Abnormal Uterine Bleeding Benjie B. Mills, MD Division Director, Pediatric & Adolescent Gynecology Medical Director of Gynecology, GHS OB/GYN Center Associate Professor of Clinical Obstetrics & Gynecology University of South Carolina School of Medicine Greenville
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Abnormal Uterine Bleeding
Benjie B. Mills, MD
Division Director, Pediatric & Adolescent Gynecology Medical Director of Gynecology, GHS OB/GYN Center
Associate Professor of Clinical Obstetrics & Gynecology
University of South Carolina School of Medicine Greenville
Disclosures
• I have nothing to disclose • This presentation will discuss off-label use of
medications
Objectives
• Describe etiologies, work up, and clinical course of abnormal uterine bleeding
• Formulate a patient-centered and evidence-based treatment plan
• Focus on issues of particular importance to the PCP such as prevention, therapeutic lifestyle changes, health maintenance, and when to refer to a specialist
Etiologies
Abnormal Uterine Bleeding Heavy Menstrual Bleeding (AUB-HMB)
Intermenstrual Menstrual Bleeding (AUB-IMB)
PALM: Structural Polyp (AUB-P)
Adenomyosis (AUB-A) Leiomyoma (AUB-L)
Malignancy & Hyperplasia (AUB-M)
COEIN: Non-Structural Coagulopathy (AUB-C)
Ovulatory Dysfunction (AUB-O) Endometrial (AUB-E)
Iatrogenic (AUB-I) Not Yet Classified (AUB-N)
Structural
• Polyps
Structural
• Adenomyosis
Structural
• Leiomyomata
Structural
• Malignancy and Hyperplasia
Coagulopathy
• Inherited and acquired • Occurs in up to 20% of patients with HMB • Indications for evaluation
– Heavy menstrual bleeding since menarche, or – Postpartum hemorrhage, excessive surgical bleeding
or bleeding with dental work, or – Any two of the following
• Bruising 1-2 times per month • Epistaxis 1-2 times per month • Frequent gum bleeding • Family history of bleeding symptoms
Ovulatory Dysfunction
• Encompasses amenorrhea to frequent irregular menses and in between – Hypothalamic hypogonadotropic hypogonadism – Thyroid dysfunction – Hyperprolactinemia – Hyperandrogenemia/PCOS – Premature ovarian insufficiency – Idiopathic anovulation – Chronic illness
• Other medications – Antipsychotics – Anticoagulants – Other
Evaluation
Evaluation: History
• Age of menarche • Menstrual bleeding pattern • Severity of bleeding (clots or flooding) • Pain • Medical history • Surgical history • Family history of bleeding disorders, PCOS,
• Pregnancy – UCG – TV Ultrasound for positive UCG and bleeding
and/or pain • Pelvic infection
– GC and chlamydia NAATs – Trichomonas or cervicitis – PID
Ages 13-18 Years
• Anovulation – immaturity or dysregulation of the hypothalamic-pituitary-ovarian axis – Irregular cycle length – Within 3 years of menarche (80% in a regular pattern) – Plan:
• R/O pregnancy • Cyclic medroxyprogesterone acetate 10 mg x 10 days per
month or OCPs if desires treatment • TSH in patients with other symptoms of thyroid dysfunction • Coagulopathy workup if heavy since menarche • Assess for anemia if heavy or prolonged bleeding
Ages 13-18 Years
• Coagulopathies – Prolonged, heavy menses – May be irregular due to immature HPO axis – Plan: