Transcript
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AbnormalUterineBleeding
Causes, Evaluation and Treatment
PALMCOEIN Introduced by FIGO Supported by ACOG Create consistency in research Help define roles in diagnosis and
treatment Help standardize the approach
TermsabandonedintheFIGOnomenclaturesystem
Dysfunctional uterine bleeding Epimenorrhagia Epimenorrhea Functional uterine bleeding Hypermenorrhea Hypomenorrhea Menometrorrhagia Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia,
primary menorrhagia, functional menorrhagia, ovulatory menorrhagia, anovulatory menorrhagia)
Metrorrhagia Metropathica hemorrhagica Oligomenorrhea Polymenorrhagia Polymenorrhea Uterine hemorrhage
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Clinicaldimensionsofmenstruationandmenstrualcycle
Frequencyofmenses,d
Frequent 38
Clinicaldimensionsofmenstruationand
menstrualcycle
Regularityofmenses:cycletocyclevariationover12months,d
Absent Nobleeding
Regular Variation 220
Irregular Variation>20
Clinicaldimensionsofmenstruationand
menstrualcycle
Durationofflow,d
Prolonged >8.0
Normal 4.58.0
Shortened
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Clinicaldimensionsofmenstruationand
menstrualcycle
Volumeofmonthlybloodloss,mL
Heavy >80
Normal 580
Light
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PALMNonstructural
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
PALMCOEINNo place for dysfunctional uterine bleeding
DUB
PALMCOEIN PALM are most common Polyp Adenomyosis Leiomyomas Malignancy
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Workup
History Use descriptive scheme Pain Family history of AUB or bleeding
disordero20% will have an underlying bleeding
disorder Meds Herbs
Meds Warfarin Heparin NSAID OCPs
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Herbs Ginko Ginseng Motherwort
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Exam Overweight PCOS signs
oAcne oHirsutism
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Exam Overweight PCOS signs
o Acne o Hirsutism
Thyroid nodule
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Exam Overweight PCOS signs
o Acne o Hirsutism
Thyroid nodule
Insulin resistanceo Acanthosis nigricans on neck
Exam Overweight PCOS signs
o Acne o Hirsutism
Thyroid nodule Insulin resistance
o Acanthosis nigricans on neck
Signs of bleeding disordero Petechiaeo Ecchymoseso Skin palloro Swollen joints
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Pelvic Cervical or vaginal lesions
oBiospy? Uterine size Uterine contour
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Lab UPT CBC Screening for bleeding disorders (when
indicated) TSH Chlamydia
Imagingetc US Saline infusion US MRI Hysteroscopy EMB
AgeBreakdown 13-18
oHypothalamic-Pituitary-Ovarian access immature
oOCPoPregnancyoPelvic infectionoCoagulopathies oTumor
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AgeBreakdown 19-39
oPregnancyoPolypoLeiomyomaoAnovulation (PCOS)oHormonal contraceptivesoHyperplasiaoLess commonly cancer
AgeBreakdown 40
oAnovulatory bleedingoHyperplasiaoCanceroEndometrial atrophyoLeiomyoma
Imaging No clear advantage in initial
workup TVUS if persistent Endometrial thickness in
premenopausal patient is not helpful
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Imaging TVUS great for myometrial evaluation SIS great for evaluation of endometrial cavity 46% have something abnormal about the cavity 3D some evidence that it helps determine the
depth of myometrial invasion of leiomyoma MRI weigh cost and benefits
o Prior to myomectomy?o Prior to UAEo HIFU
Biopsy Over 45 - definitely Younger
o If unopposed estrogen PCOS Obese
o Failed medical management o Persistent AUB
Positive predicative value better than negative predicative value
Biopsy Only an endpoint if
oCancer oAtypical hyperplasia
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AUBP Polyp Hysteroscopy
AUBA Adenomyosis MRI US
oHeterogeneous oMyometrial cystsoAsymmetrical myometrial thicknessoSubendometrial echogenic linear
striations
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AUBE Abnormal prostaglandin synthesis Prostaglandin receptor upregulation Increased fibrinolytic activity Increase tissue plasminogen activity
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Rx Low risk patients
o Trial of meds NSAIDs Progestins OCPs Levonorgestrel IUD Tranexamic acid
ProbabilityofHysterectomyAfterEndometrialAblation
Mindyn K.Longinotti,MD,GavinF.Jacobson,MD, YunYiHung,PhD,andLeeA.Learman,MD,PhD
N ~ 4000 Kaiser patients Did not include laser or Cryo 26% went to hysterectomy Eight year follow up
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Fig.1
Copyright 2012 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 49
Leiomyomas Hysterectomy OR
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Leiomyomas Contraceptive steroids NSAIDs GnRH agonists Aromatase inhibitors Progesterone modulators
Leiomyomas Myomectomy
oOpenoLaparoscopyoRobotoHysteroscopy
UAE mrHIFU
Caveats Preop GnRH agonist GnRH antagonist
oNo steroid flare Vasopressin
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Myomectomy CS??????
Myomectomy CS?????? No clinical trials 1 rupture in 750 pooled laparoscopic
myomectomies Maintain a high index of suspicion
Myomectomy Help with future conception? Myomas present in 5-10% of infertility
patients Sole identifiable factor in 1-2.4% IVF patients with submucous myomas
seem to benefit
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Myomectomy Recurrence Adhesions
UAE Ovarian failure Increased risk with age 12% placentation problems
oPreviaoAccreta
mrHIFU Studies comparing to
myomectomy ongoing
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Highintensityfocusedultrasoundtreatmenton70uterinefibroids:efficacyand
safetyMayinuer Niyazi,Haiyan Sun,YanLi,Shuhua Huang,WeiWangGynaecology,PeoplesHospitalofXinjiangVvgur AutonomousRegion,China
mrHIFU Actually 70 patients FDA approved Trial going on in patients desiring future
pregnancy Myomectomy is comparison group Results may be a year or more
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ExperimentalTherapy
FIGURE2Transvaginalsonogramguidanceofaneedleinsertionintothefibroid Arrows marktheneedlepathway.Theiceballisgeneratedfromthetipbackwardandextendsbeyondthetipbyonlyapproximately23mm.Ther...
MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028
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FIGURE1LaparoscopicvisualizationofcryoandthermalneedlesLaparoscopicvisualizationofcryoandthermalneedles(17 g,IceRod;GalilMedical,Yokneam,Israel)insertedintoafibroid.Eachneedleismarkedat1cmlengths.Theneedlesare...
MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028
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FIGURE3TransvaginalvisualizationoftheiceballTransvaginalvisualizationoftheiceballgeneratedfromimagesinFigure2.Thefrontedgeoftheiceballisdemarcated,butthebackedgeisnot...
MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028
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Prevalence
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