AUB Women's Health 2019-Beran for handouts...ð l ï l î ì í õ ï ³h[fhvvlyh phqvwuxdo eorrg...

$: AUB Women's Health 2019-Beran for handouts...ð l ï l î ì í õ ï ³h[fhvvlyh phqvwuxdo eorrg orvv zklfk lqwhuihuhv zlwk wkh zrpdq¶v sk\vlfdo hprwlrqdo vrfldo dqg pdwhuldo txdolw\$
4/3/2019

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Abnormal Uterine Bleeding: 20 Minute Reboot!

Benjamin D. Beran, M.D.Assistant Professor / Department of Obstetrics & GynecologyCo-Director / Fibroid ClinicMedical College of Wisconsin

PollEv.com/benjaminbera168Join our poll session!

@beranMD

Disclosures

• None


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Objectives

• At the conclusion of this talk, learners will be able to:

1. Implement a structured history process to cover most AUB etiologies

2. Select appropriate and effective laboratory and imaging evaluations for AUB

3. Personalize management plans for patients affected by AUB


Classifications

• Menorrhagia

• Metrorrhagia

• Menometrorrhagia

• Polymenorrhea

• Dysfunctional uterine bleeding

• Heavy menstrual bleeding

• Intermenstrual bleeding

• Frequent/infrequent

• Prolonged

• Irregular variation

• Unscheduled bleeding (when on hormones)


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“excessive menstrual blood loss which interferes with the woman’s physical, emotional, social, and material quality of life, and which can occur alone, or in combination with other symptoms”

1 of 10 women meet “abnormal” criteria: > 80 cc monthly

But of those with < 60cc –25% consider “heavy” flow

Matthews M.L. Abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol Clin N Am. 2015; 42:103-115

Accounts for 1/3 of gynecology office visits in reproductive years

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This Photo by Unknown Author is licensed under CC BY-NC-ND

STRUCTURALNON-

STRUCTURAL

P C

A O

L E

M I

N

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STRUCTURALNON-

STRUCTURAL

Polyps Coagulopathy

Adenomyosis Ovulatory Disorders

Leiomyoma (Submucosal or other)

Endometrial Dysfunction

Malignancy & Hyperplasia

Iatrogenic

Not OtherwiseClassified

Exceptions

• Cervical lesions

• Lower genital tract sources

• Pregnancy

• Post-menopause


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History

Menses

Bleeding

PMH

Fam Hx

Meds


History

Menses

Bleeding

PMH

Fam Hx

Meds

Menstrual History• Volume• Regularity• Frequency• Duration• Intermenstrual?• Postcoital?• Unscheduled• Dysmenorrhea


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History

Menses

Bleeding

PMH

Fam Hx

Meds

Table 1. Terminology used to accurately describe AUB symptoms when initially taking patient history

Volume Heavy Normal Light

Regularity Irregular Regular Absent

Frequency Frequent Normal Infrequent

Duration Prolonged Normal Shortened

Other Intermenstrual, Premenstrual, Post-coital, Unscheduled (in association with the use of

sex steroids)

Madhra M, Fraser IS, Munro MG, Critchley HOD. Abnormal uterine bleeding: advantages of formal classification to patients, clinicians and researchers. Acta Obstet Gynecol Scand 2014; 93:619-625


History

Menses

Bleeding

PMH

Fam Hx

Meds

If the patient says:

• Irregular cycle

• Intermenstrual bleeding

• Postcoital

• Unscheduled

• Dysmenorrhea

You should think:

Ovulatory dysfunction

Polyp / Fibroid (SM)

Polyp / Fibroid (SM)

Malignancy / Iatrogenic

Adenomyosis

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History

Menses

Bleeding

PMH

Fam Hx

Meds

• ONE of the following

• Heavy bleeding since menarche

• Postpartum hemorrhage

• Surgery-related bleeding

• Bleeding with dental work

Kouides PA et al. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with

excessive menstrual bleeding. Fertil Steril 2005; 84(5):1345-51

• TWO or more of following

• Bruising 1-2x/month

• Epistaxis 1-2x/month

• Frequent gum bleeding

• Family history of bleeding symptoms

Positive coagulopathy screen if at least 1 positive

History

Menses

Bleeding

PMH

Fam Hx

Meds

Special focus on:• Thyroid disease

• Hypertension

• Renal disease

• Anorexia/bulimia

• Psychiatric conditions



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History

Menses

Bleeding

PMH

Fam Hx

Meds

• Bleeding disorders

• Cancers (breast, colon, ovary, endometrial)


History

Menses

Bleeding

PMH

Fam Hx

Meds

• Common offenders

• Hormones

• Anticoagulants

• Fibrinolytics

• Antipsychotics


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Physical Examination

Thyroid: nodule or goiter

Breast: galactorrhea

Face: acne, hirsutism

Skin: petechiae, ecchymoses

Speculum: trauma, lesions, infection

Bimanual: uterine enlargement

Laboratory - ALWAYS

β-HCG

CBC

TSH

Prolactin


Cervical cancer screening – up to date?

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Laboratory - SOMETIMES

• If positive coagulopathy screen• PT/INR

• PTT

• Von Willebrand’s testing

• Endometrial biopsy• Age > 45

• Obesity• BMI > 30 = 4x RISK!

• Non-responsive to therapies

• Thick endometrium > 12mm

• Nulliparity

Wise et al. Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women. AJOG 2016. 215(5):598.e1-598.e8


Imaging- More than just ultrasound!

Transvaginal Ultrasonography

Saline infusion sonogram

MRI

Hysteroscopy

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Transvaginal Ultrasound

Good initial choice

Saline-Infusion Sonography

Sensitivity 100% for intracavitary lesions with 80% specificity

Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet Gynecol 1996; 174(4):1327-

Concern for intracavitary process

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MRI

Adenomyosis?

Fibroid mapping

Hysteroscopy

See and treat

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Treatment

• TREAT THE UNDERLYING PROBLEM

• Polyp Polypectomy

• Malignancy/Hyperplasia Oncology

• Coagulopathy Hematology

• Medical management of PCOS, Thyroid, Prolactin?

• Remove offending medication?

• Endometritis Antibiotics


TreatmentAUB

MEDICAL SURGICAL

Non-Hormonal

1. NSAIDs

2. Tranexamic Acid

Hormonal

1. OCPs

2. Progestin (IUD, implant, injection, pill)

3. Leuprolide acetate

Fertility-Sparing

1. Polypectomy

2. Myomectomy

3. Myolysis

4. MRgFUS

No Future Pregnancy

1. Endometrial ablation

2. UAE

3. Hysterectomy

Bulky Fibroids

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Summary

Structured History Components

• DETAILED menstrual history

• Coagulopathy screening

• Past medical history

• Current medication review

• Family history

Summary

• Laboratory Evaluation• ALWAYS

• HCG, CBC, TSH, Prolactin, Cervical cancer screening

• SOMETIMES• EMB, Coagulation studies

• Imaging• First: Pelvic US

• Concern for cavity problem?• SIS – (Diagnostic only)

• Hysteroscopy – (See & Treat)

• Numerous fibroids?• MRI

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Summary

• Management Considerations

• Treat underlying etiology!

• Typically start with medications

• Remember non-hormonal options (NSAIDs, TXA)

• Childbearing complete?

• Time for recovery?

• Surgical risk?

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