AUB Flashcards
Menorrhagia
Blood loss of >80mL per cycle
FREQUENTLY PRODUCES ANEMIA
Metrorrhagia
Bleeding between periods
Polymenorrhea
Bleeding that occurs more often than every 21 days
Oligomenorrhea
Bleeding that occurs less often than every 35 days
Labs for AUB
- CBC
- UPT
- Thyroid tests
- Coagulation studies in adolescents with + heavy bleeding or adults with + screening hx
- Vaginal or urine sample (rule out Chlamydia)
PALM-COEIN
P - Polyp
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
C - Coagulopathy O - Ovulatory dyscfunction E - Endometrial I - Iatrogenic N - Not yet classified
Dx of AUB
- Hx of duration and amount of flow
- Hx of systemic infections, thyroid disease, weight change
- Medications: warfarin, heparin, exogenous hormones
- Herbal remedies: ginkgo, motherwort, ginseng
- Hx of coagulation disorders
- Complete physical exam (look for excessive weight, PCOS, thyroid disorder, insulin resistance)
- Pelvic exam: rule out vulvar, vaginal, or cervical lesions; pregnancy; uterine myomas; adnexal masses; adenomyosis; or infection
Adolescents with AUB
- Often occurs as a result of persistent anovulation due to immaturity of the HPO Axis and is normal physiology
AUB Causes
Ages 19-39
- Pregnancy
- Structural lesions
- Anovulatory cycles
- Use of Hormonal contraceptive
- Endometrial hyperplasia
Taking a Menstrual History
- All Patients
- Age of menarche
- Cycle Length
- Duration of bleeding
- Perception of flow: light, medium, heavy
- Menstrual product use
- First day of LMP
- Dysmennorrhea
Taking a Menstrual History
- Patients reporting HMB
- Soaking through pad/tampon in 1h for 2-3hr in a row
- Passing blood clots >1 inch in diameter
- Double protection: pad and tampon or 2 pads
- Flooding or gushing sensation
- Frequent “accidents” or leaking through protection
- Diagnosed with anemia in past?
Treatment for AUB
- Mild (<3 months and Hgb normal)
- Observation
- Keep calendar
- Use antiprostaglandin meds (NSAIDS and Mefenamic Acid) to decrease menorrhagia
Treatment for AUB
- Moderate (Heavy menses, q1-3 weeks, mild anemia)
- If not currently bleeding: Cyclic OCP
- Medroxyprogesterone Acetate 10mg QD x 10 days
- Norethindrone Acetate 5mg QD x 10 days
Treatment for AUB
- Severe (Prolonged/Heavy bleeding, Anemia Hgb <9)
- Admit to hospital if orthosis present or Hgb <7
- Hgb 8-10: Tapering OCPs (30mg ethinyl estradiol/0.3mg norgestrel) use q4h until bleeding stops
- Iron supplement to improve anemia
Tranexamic Acid
- Used to tx heavy menses for women who may desire to conceive and wish to not have their fertility negatively affected.
Contraindications of Tranexamic Acid
- Use caution in women with a personal hx of thromboembolism
Mefenamic Acid SE
- GI Effects
- Not suitable for women who have previously had PUD or who are thought to have HMB d/t coagulation disorder
- If beneficial, may be continued indefinitely
NSAIDS in Management of AUB
- Limitation of inflammatory mediators is helpful to treat AUB
Hormonal Tx of AUB
- Maintenance of progesterone exposure limits endometrial inflammation and prevents menstruation
- These are the MOST EFFECTIVE txs available for HMB
Injectable Progesterone
- Offers women alternative to pills or IUD
- Excellent for women who experience frequent or irregular HMB
- CAUTION: slight reduction in bone mineral density with long-term use
GnRH Agonist
Delivery system and Dose
- IM, SQ, Intranasal
- 5mg TID from day 5-26 of menstrual cycle
GnRH Agonist
MOA
- Decreases LH/FSH -> Hypogonadal State -> MEDICAL MENOPAUSE
- Reduces amenorrhea rate of up to 90%
GnRH Agonist
Uses
- Tx of uterine fibroids (leiomyoma) -> reduce size when hormone level suppressed
GnRH Agonist
SE
- Flushing
- Vaginal Dryness
- HA
- Decreased libido
Oral Progesterone
Most Common
- Norethisterone
Oral Progesterone
Dose
- 5mg tablet TID from day 5-26 of menstrual cycle
Levonorgestrel-releasing Intrauterine System
MOA
- IUD
- decreases menstrual loss by up to 96% after 1 year of use; tx of HMB for 5 years -> remove and replace with new device
Levonorgestrel-releasing Intrauterine System
Pros
- Does not require patient compliance
- Reduction of dysmenorrhea
Levonorgestrel-releasing Intrauterine System
Potential Complications
- Unscheduled bleeding: most common during first 3-6 months of use
- Infection: increased risk first 3 weeks after insertion; DO NOT USE TAMPONS
- Expulsion of IUD: highest risk during first 6 weeks after insertion; higher in nulliparous women
- Perforation: rare, occurs 1:1000 cases
SPRMs Ulipristal Acetate (UPA)
- Restricted to 3 months pretreatment of fibroids prior to surgical intervention
- Effective in treating HMB associated with uterine fibroids (3-10cm in size)
- Control of HMB achieved significantly quicker than with GnRH Agonist
- SE limited to HA and breast complaints
- No publications currently about clinical utility of SPRM in women who do not have fibroids
COCs
Estrogen and Progestogen
- On 3 weeks, Off 1 week
COCs
Pros
- Excellent for women experiencing frequent or irregular HMB
- Produces estimated reduction of blood loss of 50%
- Regulation of bleeding
COCs
Contraindications
- Women with BMI >35
- Smokers over 35 yo
- HTN
- Vascular disease
- Migraines with aura
- Current/Recent breast cancer
- Personal or strong fam hx of venous thromboembolism
Progesterone Only Pill
- Not recommended for HMB treatment
