Abnormal Uterine Bleeding Common in women of all ages Common in women of all ages ~5% women of reproductive age seek ~5% women of reproductive age seek help annually help annually Life phase determines most likely Life phase determines most likely cause, and the likelihood of cause, and the likelihood of serious pathology serious pathology Take your time to properly assess Take your time to properly assess the problem the problem Work-up and treat in a rational Work-up and treat in a rational manner manner
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Abnormal Uterine Bleeding Common in women of all agesCommon in women of all ages ~5% women of reproductive age seek ~5% women of reproductive age seek
help annuallyhelp annually Life phase determines most likely Life phase determines most likely
cause, and the likelihood of serious cause, and the likelihood of serious pathologypathology
Take your time to properly assess the Take your time to properly assess the problemproblem
Work-up and treat in a rational mannerWork-up and treat in a rational manner
Coagulopathy R/O PregnancyPerimenopause Early EMB/TV Sono
Postmenopause R/O Endometrial CA
Adolescents Usually anovulation due to Usually anovulation due to
immature Hypothal-Pit axisimmature Hypothal-Pit axis Rule out pregnancyRule out pregnancy Consider bleeding disorderConsider bleeding disorder Observe or Rx with cyclic MPA or Observe or Rx with cyclic MPA or
Underdiagnosed; present in 1% of populationUnderdiagnosed; present in 1% of population Autosomal dominant; affects women and men Autosomal dominant; affects women and men
equallyequally Dx:Dx: Bleeding time, Bleeding time, Factor VIII, vW factor, Factor VIII, vW factor,
ristocetin co-factor activityristocetin co-factor activity Rx:Rx: Desmopressin (ADH) IV or intranasalDesmopressin (ADH) IV or intranasal
Reproductive Age H&PH&P Check urine ß-HCGCheck urine ß-HCG Genital tract lesion—Bx or referGenital tract lesion—Bx or refer Enlarged uterusEnlarged uterus
r/o pregnancyr/o pregnancy sono for anatomic causesono for anatomic cause
(e.g., fibroids)(e.g., fibroids)
Reproductive Age If not pregnant and normal exam:If not pregnant and normal exam:
Usually DUB Usually DUB (i.e.,(i.e., hormonal) hormonal) Determine ovulatory status Determine ovulatory status key!key! Treatment: Usually hormonalTreatment: Usually hormonal
Ovulatory Cycles Regular cycle lengthRegular cycle length Presence of premenstrual symptoms Presence of premenstrual symptoms Breast tenderness, dysmenorrhea Breast tenderness, dysmenorrhea MittleschmertzMittleschmertz Biphasic temperature curve Biphasic temperature curve
Anovulatory Cycles Unpredictable cycle length Unpredictable cycle length Unpredictable bleeding pattern Unpredictable bleeding pattern Frequent spotting Frequent spotting Infrequent heavy bleeding Infrequent heavy bleeding Monophasic temperature curveMonophasic temperature curve
Anovulatory Bleeding 90-95% of reproductive age 90-95% of reproductive age Cause: Cause: systemicsystemic hormonal hormonal
imbalance imbalance Always a relative progestin-Always a relative progestin-
deficient statedeficient state
Anovulatory Bleeding Assess for secondary hypothalamic Assess for secondary hypothalamic
Anovulatory DUB Treatment Address underlying disorderAddress underlying disorder Treat with monthly OCs or Treat with monthly OCs or
progesterone withdrawal every 3 progesterone withdrawal every 3 months (MPA or DMPA)months (MPA or DMPA) Regulate cycles, protect againstRegulate cycles, protect against
endometrial CAendometrial CA Clomiphene for ovulation induction Clomiphene for ovulation induction
in select casesin select cases
Ovulatory Bleeding Usually underlying prostaglandin Usually underlying prostaglandin
imbalance (DUB)imbalance (DUB) Defects in Defects in locallocal endometrial hormonal endometrial hormonal
Safe, simple office procedureSafe, simple office procedure Rule out endometrial CARule out endometrial CA Confirm ovulatory statusConfirm ovulatory status
EMB best done while bleedingEMB best done while bleeding Proliferative: confirms anovulationProliferative: confirms anovulation Secretory: confirms ovulationSecretory: confirms ovulation Hyperplasia: chronic unopposed estrogenHyperplasia: chronic unopposed estrogen Atrophy: menopause or continous OCs, HRT, Atrophy: menopause or continous OCs, HRT,
DMPA DMPA
Evaluating endometrial cavityDilation and Curettage (D&C)Dilation and Curettage (D&C)
OR procedure, less commonly usedOR procedure, less commonly used
Rule out endometrial carcinoma or Rule out endometrial carcinoma or hyperplasiahyperplasia
Yield slightly higher than EMB, but still Yield slightly higher than EMB, but still “blind” sampling technique“blind” sampling technique
TVSono with saline infusion into endometrial TVSono with saline infusion into endometrial cavitycavity Enhances detection of submucosal fibroids Enhances detection of submucosal fibroids
““Gold standard” for endometrial assessmentGold standard” for endometrial assessment Office procedureOffice procedure Thorough, direct inspection of endometrial Thorough, direct inspection of endometrial
cavitycavity Directed biopsy or treatment possible (e.g., Directed biopsy or treatment possible (e.g.,
polyp excision) polyp excision)
Perimenopause H&PH&P Check urine ß-HCGCheck urine ß-HCG Genital tract lesion—Bx or referGenital tract lesion—Bx or refer Enlarged uterusEnlarged uterus
r/o pregnancyr/o pregnancy TV Sono for anatomic evaluation TV Sono for anatomic evaluation
(e.g., fibroids)(e.g., fibroids)
Perimenopause If not pregnant and normal exam:If not pregnant and normal exam: Consider early EMB or TV SonoConsider early EMB or TV Sono
r/o edometrial hyperplasia, CAr/o edometrial hyperplasia, CA If negative, Rx with low dose OCs If negative, Rx with low dose OCs
or monthly Medroxyprogesteroneor monthly Medroxyprogesterone Sonohysterography or Sonohysterography or
hysteroscopy if Rx failshysteroscopy if Rx fails r/o anatomic causesr/o anatomic causes
Postmenopause 5-10% endometrial carcinoma5-10% endometrial carcinoma Proceed directly to EMB or TV SonoProceed directly to EMB or TV Sono DDx: DDx: endometrial hyperplasia,endometrial hyperplasia, cervical cervical
Treatment: Acute Bleeding Conj. Eq. Estrogens x 21d Conj. Eq. Estrogens x 21d
+ MPA last 7–10d+ MPA last 7–10d Use Estrogen IV for severe bleeding; hospitalizedUse Estrogen IV for severe bleeding; hospitalized
High dose OC: 1 QID x 7d; High dose OC: 1 QID x 7d; then OC daily x 3 months then OC daily x 3 months or MPA x 10d q month x 2-3 more cyclesor MPA x 10d q month x 2-3 more cycles
Surgical TreatmentTherapeutic D+CTherapeutic D+C
fastest method to stop bleeding in unstable fastest method to stop bleeding in unstable patientspatients
must follow with hormones to prevent must follow with hormones to prevent recurrencerecurrence
Endometrial Ablation/ResectionEndometrial Ablation/Resection laser or electrocautery laser or electrocautery good option if fertility not desiredgood option if fertility not desired
Surgical TreatmentHysterectomyHysterectomy if all else fails or patient prefersif all else fails or patient prefers subtotal hysterectomy is an option to preserve subtotal hysterectomy is an option to preserve
optimal sexual and bladder functionoptimal sexual and bladder function hysterectomy now is rarely necessary solely hysterectomy now is rarely necessary solely
for uterine bleedingfor uterine bleeding
Life Phase Ovulatory Status Etiology
R/O Pregnancy
Adolescent Likely anovulation
Consider bleeding disorder Pregnancy
Reproductive age
(Usually DUB)
Ovulatory(Secretory)
Anovulatory (Proliferative)
HormonalDUB
Anatomic
Coagulopathy R/O PregnancyPerimenopause Early EMB/TV Sono
Postmenopause R/O Endometrial CA
Adolescents Most likely anovulatory due to Most likely anovulatory due to
immature Hypothal-Pit axisimmature Hypothal-Pit axis Rule out pregnancyRule out pregnancy Consider bleeding disorderConsider bleeding disorder Observe or Rx with cyclic MPA or Observe or Rx with cyclic MPA or
OCsOCs
Anovulatory Adults Identify secondary causes of Identify secondary causes of
structural lesions, systemic diseasestructural lesions, systemic disease Consider empiric Rx without further w/u Consider empiric Rx without further w/u
if history and exam are normalif history and exam are normal NSAIDs, OCs, Progesterone IUDNSAIDs, OCs, Progesterone IUD
If Rx fails, w/u with metabolic labs, If Rx fails, w/u with metabolic labs, imaging, and EMB if indicatedimaging, and EMB if indicated
Perimenopause Progressive anovulation due to Progressive anovulation due to
declining ovarian functiondeclining ovarian function Rule out pregnancyRule out pregnancy Consider early EMB or TVSono Consider early EMB or TVSono
(esp. with endometrial CA risk factors)(esp. with endometrial CA risk factors) Rx withRx with OCs or monthly MPAOCs or monthly MPA
Postmenopause Rule out endometrial CA (5-10%)Rule out endometrial CA (5-10%)
Proceed directly to EMB or TVSonoProceed directly to EMB or TVSono Evaluate for other causesEvaluate for other causes
Rx specific to underlying cause Rx specific to underlying cause
Summary Abnormal uterine bleeding is Abnormal uterine bleeding is veryvery
commoncommon Life phase and detailed menstrual Life phase and detailed menstrual
history are keyhistory are key Employ rational evaluation and Employ rational evaluation and
treatment strategytreatment strategy You can manage it!You can manage it!
Cervical Cancer Screening
Todd May, MDTodd May, MD
Cervical Cancer 12,800 cases/yr12,800 cases/yr 50% never screened50% never screened Death rate Death rate 70% since 1940s 70% since 1940s
Pap introducedPap introduced
Natural History HPV acquired in teens, 20sHPV acquired in teens, 20s Prolonged pre-malignant phaseProlonged pre-malignant phase Spontaneous HPV clearing Spontaneous HPV clearing
commoncommon CIN peaks 20s-30sCIN peaks 20s-30s Small number progress to Small number progress to
invasive cancerinvasive cancer
Risk Factors for Neoplasia Multiple sexual partnersMultiple sexual partners HPVHPV SmokingSmoking HIVHIV
Routine Screening Recs Start:Start:
3yrs after first vaginal intercourse3yrs after first vaginal intercourse Age 21 (unless virginal?)Age 21 (unless virginal?)
Interval:Interval: Annually age <30Annually age <30 Age >30 q2-3yrs if normal x 3 annualsAge >30 q2-3yrs if normal x 3 annuals
Stop:Stop: Age 65-70 if consistently normalAge 65-70 if consistently normal After hysterectomy for benign conditionAfter hysterectomy for benign condition
High-Risk Screening RecsPap every 6 months x 2, then annually Pap every 6 months x 2, then annually
for:for: HIV positiveHIV positive Immunocompromised by organ Immunocompromised by organ
Prior Rx for CINII/III or cancerPrior Rx for CINII/III or cancerRationale: Progression to HSIL and CA Rationale: Progression to HSIL and CA
more common and more rapidmore common and more rapid
Essentials of Pap Sampling Collect cells before bimanual examCollect cells before bimanual exam Gently remove cervical mucus/dcGently remove cervical mucus/dc Visualize entire portio of cervixVisualize entire portio of cervix Use scraper for ectocervix; brush Use scraper for ectocervix; brush
Cytologic Interpretation Adequacy of specimenAdequacy of specimen
““Satisfactory” or “unsatisfactory”Satisfactory” or “unsatisfactory” Descriptive diagnosisDescriptive diagnosis
Bethesda 2001Bethesda 2001 Presence/absence of Presence/absence of
endocervical cellsendocervical cells
Negative for IEL or Malig.Benign cellular changesBenign cellular changes TrichomonasTrichomonas Fungus c/w Fungus c/w candida sppcandida spp—No action—No action Floral shift/BV—No actionFloral shift/BV—No action Suspect Suspect ChlamydiaChlamydia—call back to test—call back to test HSV—notify patientHSV—notify patient HPV/koilcytosis—manage as LSILHPV/koilcytosis—manage as LSIL ActinomycesActinomyces (IUD)—Rx with Amox (IUD)—Rx with Amox
Negative for IEL or Malig.Reactive changesReactive changes Inflammation—No action Inflammation—No action Atrophy w/ inflam. (“atrophic vaginitis”)Atrophy w/ inflam. (“atrophic vaginitis”)
—Rx w/ topical estrogen, repeat if no —Rx w/ topical estrogen, repeat if no ECCECC