Abnormal Uterine Bleeding
Anne Whitworth, M.D.
Learning ObjectivesLearning Objectives
– Identify the causes of abnormal uterine bleeding
– Demonstrate a knowledge of the evaluation of abnormal uterine bleeding
– Describe the treatments for the different causes of abnormal uterine bleeding
– Identify the causes of abnormal uterine bleeding
– Demonstrate a knowledge of the evaluation of abnormal uterine bleeding
– Describe the treatments for the different causes of abnormal uterine bleeding
Abnormal Uterine Bleeding
Definition:
Bleeding outside of normal physiologic menstruation
Includes both dysfunctional uterine bleeding & structural bleeding
Normal Menstrual Cycle
Proliferative Phase/Follicular (8-14 d) Predominance of estrogen over
progesterone and a build up of endometrium
Secretory Phase/Luteal(14 d) Begins after ovulation triggers
progesterone production Marked by a reaction to the combination
of estrogen and progesterone and stabilization in the thickness of the endometrium
Normal Menstrual Cycle
Pituitary gonadotropin secretion is stimulated by the GnRH
Estradiol results in increased secretion of LH and decreased secretion of FSH
Leading to release of the egg
Corpus luteum has negative feedback on LH and FSH
Normal Menstrual Cycle
Normal Menstrual Cycle
Interval 28 days +/- 7 days
Duration 4-6 days (3-5 pads/tampons per day)
Blood loss 25-69 ml (average 35 to 40 ml) no clots, no mid cycle bleeding
Normal Menstrual Cycle
The average female will have around 400 menstrual cycles in her life
Up to 20% of women will present to the office with the complaint of excessive blood loss
Definitions of Abnormal Uterine Bleeding Menorrhagia
Prolonged or excessive uterine bleeding at regular intervals
Metrorrhagia Uterine bleeding at irregular but frequent
intervals, amount is variable Menometrorrhagia
Prolonged uterine bleeding at irregular intervals
Definitions of Abnormal Uterine Bleeding
Intermenstrual bleeding Bleeding of variable amounts between
regular menstrual periods Polymenorrhea
Uterine bleeding at regular intervals of less than 21d
Oligomenorrhea Uterine bleeding in which the interval
between bleeding episodes may vary from 35 days to 6 months
Amenorrhea No uterine bleeding for at least 6 months
Causes of Abnormal Uterine Bleeding
Disruption of regularity, frequency, volume and duration of menstrual flow
The cause can be physiologic, pathologic or pharmocologic
Causes of Abnormal Uterine BleedingDifferential
Complications of Pregnancy
Pelvic Pathology
Systemic Ovulatory vs. anovulatory
Iatrogenic (pharmacologic)
Causes of Abnormal Uterine BleedingDifferential
1. Complications of Pregnancy
Ectopic pregnacy Miscarriage Placenta previa Gestational trophoblastic disease
Causes of Abnormal Uterine BleedingDifferential
2. Pelvic Pathology
Benign Pregnancy, myoma, adenomyosis,
endometriosis,endometrial/cervical polyp, PID, infection,trauma, vascular abnormality, foreign body
Malignant Carcinoma of the reproductive tract Endometrial hyperplasia (pre- malignant
changes)
Uterine Fibroids
Causes of Abnormal Uterine BleedingDifferential
3. Systemic Ovulatory
Coagulation disorder Thrombocytopathy, von Willibrand’s disease,
Leukemia Systemic Lupus erythematosus Cirrhosis
Anovulatory Hypothyroid, hyperprolactenemia, PCOD,
hypothalamic dysfunction
Causes of Abnormal Uterine Bleeding
4. Iatrogenic
Hormone therapy Contraceptive devices and injections Medications
Antidepressants, anticoagulants, steroids
Causes of Abnormal Uterine Bleeding
If no etiology in above categories then by exclusion the diagnosis is dysfunctional uterine bleeding--it applies not only to menorrhagia but also menometrorrhagia
Causes of Abnormal Uterine Bleeding
Dysfunctional Uterine Bleeding
Causes 80% of menorrhagia
Bleeding is UTERINE and mechanism is HORMONAL
Causes of DUB
DUB is usually related to one of four hormonal-imbalance conditions
Estrogen breakthrough bleeding
Estrogen withdrawl bleeding
Progesterone breakthrough bleeding
Progesterone withdrawl bleeding
Causes of DUB
Estrogen breakthrough bleeding:
This occurs when excess estrogen stimulates the endometrium to proliferate in an undifferentiated manner--if there is insufficient progesterone to provide structural support the endometrium will slough at irregular intervals
Causes of DUB
Estrogen withdrawl bleeding:
This results from a sudden decrease in estrogen levels, such as occurs after bilateral oophorectomy, cessation of exogenous estrogen therapy or just before ovulation in the normal menstrual cycle
Causes of DUB
Progesterone breakthrough bleeding:
This occurs when the progesterone:estrogen ratio is high. (progesterone only contraception)
The endometrium becomes atrophic and is prone to frequent, irregular bleeding.
Causes of DUB
Progesterone Withdrawl Bleeding:
This occurs only if the endometrium is initially proliferated by exogenous or endogenous estrogen
Evaluation of Abnormal Uterine Bleeding Obtain a History
Menstrual history Recent cycle length and duration, blood flow,
and pattern Color and character of flow (pain, discharge,
odor) Estimate of amount of blood loss Use of contraception
Medical history Thyroid disorder Current medications
Evaluation of Abnormal Uterine Bleeding Physical Exam
Height, weight, vital signs Body fat distribution Tanner staging Pelvic examination
External-bruising, laceration, discharge, cervix
Bimanual exam- uterine size, adnexal mass or pain
Evaluation of Abnormal Uterine Bleeding Laboratory assessment
Rule out pregnancy!
CBC, PAP, cultures
Maybe TSH, Prolactin level
Maybe coagulation studies
Evaluation of Abnormal Uterine Bleeding Further evaluation is based on
menopausal status
Premenopausal--look for cause of anovulatory bleeding
Peri and postmenopausal--need to evaluate for endometrial hyperplasia or cancer
Evaluation of Abnormal Uterine Bleeding Tests to rule out endometrial
hyperplasia or carcinoma
Endometrial Biopsy
Ultrasound
Hysteroscopy
Evaluation- Endometrial Biopsy
Treatment
Goal of treatment is to control bleeding, prevent recurrence, and preserve fertility (if desired)
Treatment
Acute, heavy bleeding
Hemodynamically unstable: High dose IV estrogen, or D& C
Hemodynamically stable: oral estrogen
Treatment
Chronic abnormal bleeding—medical Rx
observation NSAIDS Oral contraceptives Progesterones Hormone replacement Inhibit GnRH stimulation Danazol
Treatment-Medical
Drug/Class
Efficacy Side effects Mechanism/other
NSAIDs 20-30% GI upset Decrease cyclooxygenase and increase thromboxane to prostaglandin
OCPs 50% H/A, nausea, edema, wt gain, mood changes,
50 micrograms ethinyl estradiol
Progestins 15% Same Days 15-26, blood loss reduction 88% with IUD by month 3
Treatment –Merina IUD
Treatment- Medical
Drug/class Efficacy Side effects Mechanism/other
Danazol 60% Androgenic, endometrial atrophy
Alters pulsitile gonadotropin release, higher doses inhibits ovulation
GnRH Agonists
100% Hypoestrogenic/ bone loss deplete further pituitary of bioactive goanadotropins and desensitize it to further GnRh stimulation
Antifibrin-olytic agents
80% H/A, Gi upset, vertigo, possible increased thrombotic activity
Decrease blood loss by 84% by preventing the activation of plasminogen