Hitt

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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