abnormal uterine bleeding tony hoang, md. abnormal uterine bleeding aub accounts for approx. 70% of...
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ABNORMAL UTERINE BLEEDINGT O N Y H OA N G , M D
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ABNORMAL UTERINE BLEEDING
• AUB accounts for approx. 70% of all gyn visits in the peri-menopause & post-menopausal years
• Menstrual disorders accounts for 20% of all gyn visits• 2 millions visits per year
• Growing popularity of Bio-Identical hormones use
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WHAT IS NORMAL BLEEDING
• AGE OF THE PATIENT (NON-PREGNANT)• ADOLESCENCE• REPRODUCTIVE• MENOPAUSAL
• FLOW• FREQUENCY• DURATION
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NORMAL BLEEDING
• FLOW (5 days)• 30 ml – 80 ml of bleeding
• FREQUENCY• Every 21-35 days
• DURATION• Bleeding for 2 – 8 days
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TERMINOLOGY
• MENORRHAGIA – heavy menstrual bleeding
• METRORRHAGIA – bleeding btwn periods
• MENOMETRORRHAGIA - combo
• OLIGOMENORRHEA – bleeding less frequent than 35 days
• POLYMENORRHEA – bleeding more often than 21 day
• AMENORRHEA – cessation of periods for 6 months
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INITIAL EVALUATION
• HISTORY
• MENSTRUAL • BLEEDING PATTERNS• ASSOCIATED PAIN SYMPTOMS• SEVERITY• FAMILY HSTORY (20%)
• PAST OR PRESENT ILLNESSES
• USE OF MEDICATIONS / Herbal Products (Ginkgo Biloba/Ginseng/ motherwort)
• USE OF BIRTH CONTROL METHODS (IUDs / IMPLANTS / INJECTIONS)
• WEIGHT, EATING HABITS, EXERCISE, STRESS LEVEL
• PAP HISTORY
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UNDERLYING BLEEDING DISORDER
• SCREEN• QUESTION ABOUT BLEEDING AT MENARCHE• HEMORRHAGE (ONE OF THE FOLLOWING)• POSTPARTUM• POST SURGICAL• BLEEDING ASSOC. WITH DENTAL WORK
• HEMORRHAGE (TWO OF THE FOLLOWING)• BRUISING ONE OR TWO TIMES PER MONTH• EPISTAXIS ONE OR TWO TIMES PER MONTH• FREQUENT GUM BLEEDING• FAMILY HISTORY
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MENSTRUAL CYCLE DIARY
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INITIAL EVALUATION
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INITIAL EVALUATION
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DIFFERENTIAL DIAGNOSIS
• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED
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DIFFERENTIAL DIAGNOSIS
• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED
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PALM-COEIN
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WHAT TO ORDER
• HCG test• CBC• vWF (IF INDICATED)• Ristocetin cofactor (IF INDICATED)• PT/INR/PTT (IF INDICATED)• TSH• CHLAMYDIA
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WORK UP TOOLS
• TRANSVAGINAL ULTRASOUND• SALINE INFUSION SONOHYSTEROGRAPHY• MRI• HYSTEROSCOPY• PAP SMEAR• ENDOMETRIAL BIOPSY• 45 YRS OR OLDER• OR RISK FACTORS: PCOS; OBESITY; FAILED RX;
PERSISTENT
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TREATMENT
• MEDICATIONS• HORMONAL• NON-HORMONAL
• SURGICAL OPTIONS• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION• UTERINE ARTERIAL EMBOLIZATION• MYOMECTOMY• ENDOMETRIAL ABLATION• HYSTERECTOMY
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MEDICATION
• HORMONAL• OCP’S (Monophasic 35 mcg pills)• 4 X 4 - 3 X 3 – 2 X 2 – 1X1 THEN STOP FOR ONE WEEK – RESUME• 3 pills for Seven days• OCP Q 6 HRS (48 HRS)• ESTROGENS (CEE) 25-40 mg IV Q 4-6hrs• PROGESTINS • PROVERA 10 mg PO Q 4 hrs or 20 mg PO TID x 7 days• PROVERA 60 -120 mg PO x 1 then 20 mg Daily x 9 days• NORETHRINDRONE 5-10 mg PO Q 4hrs
• DMPA• MIRENA IUD
• NON-HORMAL• MOTRIN 800 mg PO TID x 5 days• TRANEXAMIC ACID 500 mg – 1.3 gm PO TID x 5 days (FDA warning)• DOXYCYCLINE 100 mg PO X 10 DAYS• MEFEPREX 100 mg
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SURGICAL
• UTERINE ARTERY EMBOLIZATOIN / UFE• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION / SYMPHION• ABLATION• HTA / NOVASURE / MEA / HER OPTION / THERMACHOICE
• HYSTERECTOMY• SUPRACERVICAL• MYOMECTOMY• LAVH• LTH• TVH• TAH
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UTERINE ARTERY EMBOLIZATION
• COMPLETE CHILD BEARING• CATHERIZATION VIA FEMORAL ARTERY• IV CONTRAST • PVA (POLYVINYL ALCOHOL) • 1- 3 HRS PROCEDURE TIME• 6 HRS POST PROCEDURE BEDREST• POST OP PAIN 6-12 HRS (POSSIBLE SEVERAL MONTHS)• MAY REDUCE FIBROID BY 50%• 20% RETREATMENT OR REQUIRED SURGERY• S/E: INFECTION; PREMATURE MENOPAUSE;
PERSISTENT PAIN; SCAR TISSUE; AMENORRHEA
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ABLATIONS
• HTA• MIA• NOVASURE• HER OPTION• THERMACHOICE
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MEA
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HER OPTION
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THERMACHOICE
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NOVASURE
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HYDROTHERMAL
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OBAMACARE??
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