Abnormal uterine bleeding

Question 1

Expected patterns and amounts of menstrual bleeding

Answer 1

• Normal cycle: 21-35 days
• Normal period length: ≤8 days
• Nl blood loss per menstrual cycle: 20-80ml
• Abnormal bleeding: deviations from an individual’s own established patterns of bleeding

Question 2

Ovulatory vs anovulatory bleeding

Answer 2

• Abnormal ovulatory bleeding (menorrhagia): ≥80ml of blood loss per menstrual period, must be occurring at predictable monthly intervals to be considered ovulatory
• Possible etiologies: fibroids, polyps, other reproductive tract lesions, drugs
• If a women who just started having her period is bleeding excessively think vWD
• Dysfxnal uterine bleeding: excessive bleeding that occurs sporadically/randomly and is not in a predictable monthly interval (anovulatory bleeding)
• 90% of abnormal bleeding is anovulatory

Question 3

Work-up for AUB 1

Answer 3

• Adolescents: think inherited coagulopathies (vWD) and STI (chlamydia) especially if bleeding follows sex
• Must ask if menstrual Hx is regular or irregular
• Organic (ovulatory) bleeding would have the characteristic prodrome of menstruation: moodiness, breast tenderness

Question 4

Work-up for AUB 2

Answer 4

• Causes of ovulatory bleeding: polyps, fibroids (leiomyoma), adenomyosis
• Adenomyosis: endometriosis w/in myometrium, which may bleed at various times (may present as long and painful periods)
• > 35 most often is anovulatory bleeding (CA, hyperplasia, adenomyosis): no bleeding punctuated by massive bouts of hemorrhage (not predictable)

Question 5

Testing and indications for endometrial Bx

Answer 5

• CBC, TSH, PT, STI, pregnancy
• Bx indications: new onset of unexplained excessive bleeding, spotting btwn menstrual periods
• Low thresholds in women w/ risk factors: age >35, obese, anovulatory cycles/PCOS, family Hx of lynch syndrome
• Endometrial CA: must be considered in any women w/ stigmata of PCOS for ≥2yrs

Question 6

Rx options for AUB

Answer 6

• Medical Rxs promote coagulation: NSAIDs (promote clotting by inhibiting PG synthesis), tranexamic acid, COCs (OCPs/patch/vaginal ring), progestin only contraceptives (oral, injection, IUD), GnRH agonists
• Surgical options: endometrial ablation/resection, uterine artery embolization, hysterectomy

Question 7

NSAIDs and tranexamic acid

Answer 7

• 20-25% reduction in bleeding, should be used prior to or on first day of menses and should take them for 3-5 days (3x/day)
• Tranexamic acid: inhibits conversion of plasminogen to plasmin preventing clot lysis, also increases collagen synthesis and preserves the fibrin matrix
• Contraindicated in women taking COCs

Question 8

Contraceptive Rx

Answer 8

• COC: 50% reduction in bleeding and makes it more predictable
• Oral progestin-only medications are not as good as COCs
• DMPA (progestin shot): once every 90 days, very effective at minimizing bleeding, may experience weight gain
• GnRH have too many side effects
• LNG-IUS (progestin IUD) has significantly less blood loss than copper IUD (copper IUD showed more blood loss than control)
• LNG-IUS is most effective Rx

Question 9

Effectiveness and side effects of Rx

Answer 9

• NSAIDs: modest decrease in blood loss, GI irritation is side effect, no contraception
• Tranexamic acid: modest decrease in blood loss, side effect is allergic rxn, no contraception
• OCs: modest decrease in blood loss, side effects are hormonal, good contraceptive
• DMPA: dramatic decrease in blood loss, side effect is hormonal, highly effective contraception
• LNG-IUS: dramatic decrease in blood loss, side effects are minimal (occasionally hormonal), highly effective contraception