34F G3P3 Heavy menses for past
year
define menorrhagia, oligo/polymenorrhea and
• Menorrhagia: heabvy bleeding that interferes with
physical emotional social and material quality of life
• Oligomenorrhea: Infrequent menses (interval>38
days)
• Polymenorrhea→ <24 days apart (>4 episodes in 90
days)
• Frequency → normal 24-38
• Bleeding duration: 3-8 days
• Regularity: +/- 2-20 days
What would you like to know on history
• Age, ethnicity, GTAL, LMP
• PmHx:
– Bleeding d/o, excessive bleeding
with procedures, (ie Dentist), easy
bruising
– Liver disease
– Thyroid conditions
– Chronic disease: heart disease, lung
problems, VTE, diabetes,
hypertension
• PsHx: Fibroids, UAE, complications,
bleeding
• PObsHx: Gravidity, parity, route, RPL,
infertility, complications (esp
bleeding)
– STILL DESIRE FERTILITY?
• PGynHx:
– Cycles, REGULARITY, menorrhagia,
dysmenorrhea, premenstrual Sx
(PMS)
– Breakthrough bleeding
– STIs, Tx
– PAPs, Tx
– Contraception use (Cu-IUD)
– Sexual -> # Partners, condom use,
dyspareunia, post-coital bleeding
• FmHx: Gyne CA’s, Breast CA, Fibroids
(RF if+ 1
st
degree), Bleeding d/o, VTE
• Meds: HRT, tamoxifen, FeSO4,
coumadin, heparin, ASA
• Allergies
• Social: smoking, drugs, alcohol,
occupation, support
•
HPI
•
Menorrhagia (number of pads, pads and tampons, size of clots, changing bedsheets/clothes, missing work/school)
•
Presenting complaint for how long? Every cycle? In between cycles?
•
Associated dysmenorrhea, breakthrough, post coital bleeding
•
History of Anemia?
•
Easy bruising, nose bleeds, excessive bleeding at dentist
•
Recent weight gain/ loss
•
Thyroid symptoms (cold/heat intolerance, anxiety, fatigue, gaining wt, constipation)
•
Fatigue, SOB, syncope
•
Previous investigations & Tx tried
•
Pain/pressure symptoms
–
Change in abdominal girth
–
GI symptoms
–
GU symptoms
What would you look for on P/E?
•
VS- HR, BP, RR, temp, O2
•
BMI
•
Inspection
–
Pallor
–
PCOS: Hirsute, acne, acanthosis nigricans
–
Bleeding d/o: Bruising, petechiae
–
Liver: Jaundice, edema, spider angiomas, palmer erythema
•
Thyroid
•
Chest/CVS
•
Abdominal: Mass, tenderness, hepato-splenomegaly
•
Pelvic: Speculum, PAP, swabs (gono/chlam), CMT, bimanual (masses, tenderness)
Differential diagnosis
• PALM COEIN
• P→ polyps
• A → adenomyosis
• L→ leiomyoma
• M → malignanyc/ hyperplasia
• C→ coagulopathy
• O → ovulatory dysfunction
• E → endometrial
• I → iatrogenic
• N → NYD
What is your differential diagnosis
•
Reproductive tract disease
•
#1 cause – Pregnancy related (Do BhCG)
•
Uterine Anatomic AbN- Fibroids, polyps, adenomyosis
•
CA of reproductive tract
•
E-producing tumors (granulosa, theca cell tumors)
•
Infection (endometritis/PID)
•
Endometriosis
•
Coagulopathies
–
Menorrhagia @ menarche
–
5-20% positive in adolescents w/AUB requiring hospitalization
•
Liver Disease
–
E metabolism
–
Coagulation defects
•
Thyroid Disease
–
Hypothyroidism
•
Incidence among W with menorrhagia: 0.3- 2.5%
–
Hyperthyroidism
•
Possible amen/oligo/hypo-menorrhea
•
Dysfunctional Uterine Bleeding (DUB)
•
Typically heavy prolonged flow +/- breakthrough bleeding
•
Must R/O organic and iatrogenic causes (Dx of exclusion)
•
Anovulatory
– More common
– IRREGULAR bleeding intervals
– Mechanism:
»
No ovulation, No CL/Progesterone but continued E production (Unopposed E) so Endometrial
hyperplasia where endometrium outgrows blood supply causing Necrosis. No uniform sloughing
to basalis layer so increased Blood flow
– Intermittent ovulation
»
PCOS
»
Perimenopausal
»
Adolescent
•
Ovulatory
– ~10% of ovulating W have DUB
– REGULAR bleeding intervals
• Healthy woman, BMI 26.
• Menses - profuse, regular, about 8 days,
cramps. Worse in past six months
• First 3 days changes 1 big pad q2h, soaked.
• Tired for the last 6 months. When she
exercises SOB occurs faster than usual.
What investigations would you like to do?
•
BhCG
•
CBC +/- ferritin to determine degree of anemia
•
TSH, T3, T4
•
Coagulation profile, bleeding time (vWD)
•
LFTs
•
PAP
•
+/- Day 21-23 progesterone to verify ovulation (>5ng/mL)
•
+/- Cr, BUN, lytes
•
TVUS – Fibroids, polyps, adnexal mass, TOA, pregnancy
– Endometrial thickness may be indicative of pathology in postmenopausal W (>4mm)
– Not correlated with disease in premenopausal W
When should you do Embx?
• Age >40
• RF for endo ca: obesity, age, nuliparity, PCOs,
DM, hnpcc
• Failure of medical treatment
• Significant intermenstrual bleed
• Consider: women with infrequent menses
suggesting anovulatory cycles
• U/S revealed 3 uterine fibroids, 2 of the type
1, and one subserosal:
• Please explain the types of fibroids?
• Type 0- Pedunculated, 100% intracavitary
• Type 1- Submucosal > 50 % intracavitary
• Type 2- Submucosal < 50 % intracavitary
• Type 3- Intramural abuts endometrium no
intracavitary component
Why do fibroids cause increased
bleeding?
• Increased endometrial surface area
• Neovascularization- vascular dysregulation
• Interference with endometrial hemostasis
Approach to the management?
• Treat anemia with iron supplementation
• Control the bleeding
– Medical
– Surgical
Please outline the medical management?
•
NSAIDs (may not be effective in fibroid related menorrhagia)
–
Inhibit cyclo-oxygenase reducing endometrial prostaglandin levels
–
MBL by 20- 50%
–
Improve dysmenorrhea by up to 70%
–
Start Day 1 menses x5d, or cessation of menstruation
•
Antifibrinolytic Agents
–
Tranexamic acid (cyklokapron) 500mg-1g PO q6hrs
–
No effect on coagulation parameters, dysmenorrhea, or fertility
–
MBL by up to 40%
–
S/E: GI, leg cramps (1/3 of Pts), thrombo-embolic events have been reported (but rare)
•
Danazol
–
Synthetic steroid with mild androgenic properties
–
Inhibits ovarian steroidogenesis
–
MBL by up to 80%, bleeding interval
–
Danazol 100- 200mg PO qd x3mo
–
S/E: Weight gain (2- 6lbs in 60% of Pts), acne, voice changes
•
Progestins
•
Progestogens given in luteal phase are not effective in reducing regular heavy menstrual bleeding
–
May be useful with irregular/ anovulatory cycles when given for 12- 14d each Mo
–
Intermittent progestin
•
MPA 10mg qd x10-14d qMo
•
cOCP
– MBL by up to 40%, reduces dysmenorrhea
•
Uripristal acetate
– Progesterone receptor modulator
– 5mg PO QD for 3 months in preparation for surgery
– S/E: Constipation, H/A, hot flushes, endometrial thickening
•
LNG-IUD
– Best for ovulatory DUB who desire contraception
– MBL by up to 97% after 1yr of use
•
GnRH Agonists
– Induce reversible hypoestrogenic state; if fail other Tx
– Rapid return of Sx w/in months of Tx cessation
– S/E: iatrogenic menopause
• D&C -> Dx role, not Tx, may use in life threatening
bleed with other Tx
• UAE
– Benefits
• Decrease in menorrhagia (80%)
– Amenorrhea (8%)
• Decrease in dysmenorrhea (80%)
• Decrease in pressure symptoms – frequency (80%)
• Decrease in fibroid size (33%) – by one year 50%
• Avoid major surgery, no GA, no admission
Explain how UAE is done
– Procedure: Local anesthesia, incision in groin,
catheter inserted femoral artery, follow internal
iliac artery to Ut artery with dye, inject embolic
agent (polyvinyl alcohol) into Ut artery to block
blood flow
• @ 5 years -> 20% have surgery (myomectomy/hyst), or
rpt UAE
• Success is 90%
UAE complications
•
Hematoma
•
Infection
•
Bleeding
•
Allergy/ anaphylaxis
•
Incomplete UA occlusion
•
Misembolization of non target organs
•
Specific complications:
–
Pain
–
Post embolization syndrome 40%
–
Infections 1-2%
–
Chronic pain 5-10%
–
Ovarian dysfunction 10%
–
Menstrual dysfunction (amenorrhea 3%)
–
Transcervical myoma expulsion 5-10%
–
Hysterectomy 1-2%
UAE continued
– Absolute CI
• Current gentio-urinary infection (#1 cause serious complications)
• Malignancy
• Reduced immune status
• Severe vascular disease limiting access
• Allergy to contrast material
• Impaired renal function
• Pregnancy
– Relative CI
• Submucosal and pedunculated fibroids
• Previous int iliac/ uterine art occlusion
• Recent Gnrh agonist use
Pregnancy complications after UAE?
• SAB 30%
• PPH 10%
• PTL 20%
• CS 65%
• Increased accreta risk
Endometrial Ablation
•
1s generation (hysteroscopic ablation)
–
Amenorrhea 20-60%
–
Control bleeding 90%
–
Hysterectomy 5-20% in 1-5 years
•
2
nd
generation non hysteroscopic
–
Balloon with heat
–
Radiofrequency bipolar
–
Microwave
–
Cant treat uterine pathology
–
Large/ small cavities may be contraindicated
Similar success with both, less S/E with 2
nd
generation (fluid overload, perforation, cervical laceration, hematometra, less time, more equipment failure)
•
CI
–
Pregnancy
–
Hyperplasia, CA
–
Undiagnosed bleeding
–
Active PID, recent (<3mo)
–
Previous trans-myometrial surgery, recent perforation
–
Wants fertility
•
Counselling points:
–
Chilbearing complete
–
Need contraception
–
R/o hyperplasia/ malignancy
–
Define expectation
–
Risk of needing hyst in the future (30%)
• Hysterectomy
– Indications for hysterectomy with fibroids
• Failed conservative treatment
• Life-threatening bleeding
• Rapidly enlarging mass (esp peri/postmenopausal)
• Post-menopausal enlarging fibroid
• Completed childbearing and have associated bleeding,
anemia, pelvic pressure (bowel/bladder dysfunction)
Alternate ending 1
• Workup was normal, no fibroids or other
pathology on ultrasound and endometrial
biopsy was normal, how would you treat her?
– Same as fibroid but now AUB. No fibristal, or
myomectomy, but the rest is the same
Alternate ending 2
14F with heavy bleeding arrived in ambulance to ER
• What are you going to ask on history?
– Same as above, with emphasis on abuse and
developmental/menstrual/sexual history
• What are you going to look for on GENERAL physical
exam
– Same as above plus tanner staging
• What are you going to look for on gynecologic exam
– may need limited pelvic exam if hymen intact
– Signs of abuse, lacerations, hematomas
What are likely causes of her bleeding
• Anovulation - first two years after menarche are often anovulatory
and thus DUB is common
• Hematological abnormalities – ITP, vWdisease- check all adolescents
presenting to ER with heavy bleeding
• Infection – bleeding is associated with chlamydial infections,
adolescents with menorrhagia also have higher rates of PID
• Hyper or hypothyroidism
• Mullerian anomalies
• Cancer, ovarian tumors
• Uterine anatomical abnormalities (fibroids etc…)
What investigations would you
perform?
• If history is convincing for anovulation then a trial
with OCP/provera before further testing is
enough if not sexually active
• Pregnancy test
• TSH, T3, T4
• CBC, platelets and coags, bleeding time (vWD)
• Swabs for Clam/Gono
• +/- ultrasound
How would you treat her in ER
• Tranexamic acid 1g IV/PO Q6hrs
• 25mg IV estrogen q6h until bleeding subsides or 24 hours
• Oral estrogen or OCP- 100mcg ethinyl estradiol (2 35mg E2 OCP for
5 days then once a day)- nausea common SE give anit-nausea meds
• High dose progesin MPA 10-20 po BID or megace 20-60 mg po BID
• 30cc Foley catheter balloon for tamponade
• Surgical intervention if failed medical therapy: D&C
If you did a D&C what is the pathology
likely to show
• Abundant tissue
• No pathological abnormality
The bleeding has now settled, outline a plan of
management to try to prevent this in the future.
• If not anemic and no birth control necessary
then can watch
• Can use depot provera q 1-3months
• OCP