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Abnormal Uterine Bleeding in Perimenopausal Women

OB/GYN Rotation

Katie Miller

on 4 October 2013

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Transcript of Abnormal Uterine Bleeding in Perimenopausal Women

Abnormal Uterine Bleeding in Perimenopausal Women
Kathryn Miller MS3
Obstetrics and Gynecology Rotation
University of Central Florida College of Medicine
Mrs. SB
CC: 49yo G3P3003 female with painful and heavy uterine bleeding

HPI: Patient had been experiencing painful cramping associated with menstruation since December 2012.

In June and July, patient had no period.

In August, experienced light spotting which lasted for 2 weeks.

LMP began 9/23 and has continued since - now on day 10. Associated with extremely heavy bleeding and intense abdominal pain. Patient states that she has used 3 boxes of tampons and is waking up 3+ times a night due to bleeding through pad.

Today, experienced dizziness and nausea and decided to come in.
Mrs. SB Continued
Bilateral ovarian cysts
Acid reflux

Tubal ligation - 1993

3 uncomplicated pregnancies delivered at term via SVD

Regular periods until Dec 2012. No hx of STIs or abnormal pap


Medical history

Physical exam

Lab tests


Consideration of age factors

History and Physical
Bleeding patterns, severity, family hx
20% of women (any age) will have bleeding disorder
Meds - warfarin, heparin, NSAIDs, hormones, ginkgo, ginseng, motherwort

Mrs. SB Continued
VS: T 98.7 HR 79 BP 118/60 RR 15 O2 100% RA BMI 25.7

NECK: Supple, no masses, no thyroid enlargement.
HEART: Regular rate and rhythm. No murmurs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended.
GU: External genitalia normal. Cervix difficult to visualize due to bleeding.

Hg 7.3

TVUS shows thickened endometrial
lining at 22mm; large clot over internal
cervical os; b/l ovarian cysts; polyp in endometrial cavity

Alternatives to Hysterectomy in the Management of Leiomyomas. ACOG Practice Bulletin No. 96. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008; 112:201-7.
Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. ACOG Practice Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012.
Pinkerton JV. Pharmacological therapy for abnormal uterine bleeding. Menopause 2011; 18:453-61
UptoDate. "Postmenopausal Uterine Bleeding".
Answer - B
Mrs. SB Revisited
VS: No orthostatic hypotension

Repeated stat hemoglobin

Patient did not want to be admitted although a hysteroscopy was scheduled for the following morning

Structural Causes:
Malignancy & hyperplasia
Laboratory Tests and Imaging
Answer - B
Important to rule out malignancy
Endometrial sampling is indicated in patients older than 45
High overall accuracy
Hysteroscopy - good for diagnosis of cancer but not hyperplasia

Medical options

Pharmacological Therapy
Combined hormonal contraceptives can reduce excessive menstrual bleeding by 40-50%
Extended cycle and continuous combined, progestin-only (IUD, implants, pills)
Levonorgestrel intrauterine system equal to endometrial ablation
Effects on leiomyomas poorly understood
Tranexamic acid inhibits plasminogen activator with a 40% to 60% reduction in menstrual blood loss

In women with leiomyomas, gonadotropin-releasing hormone agonists lead to 35-65% reduction in leiomyoma volume within three months of treatment
Temporary effects
Bone loss - low-dose steroidal add-back therapy if more than 6 months
Aromatase inhibitors
Progesterone modulators - decrease in volume of 26-74%, slower growth
Endometrial hyperplasia without atypia, elevation of transaminases


Uterine artery embolization

Endometrial ablation

Preoperative adjuvants:
Gonadotropin-releasing hormone agonists
Vasopressin decreases blood loss
New classification system - PALM-COEIN
Ovulatory dysfunction
Not yet classified
Age Factors
Mother - Uterine cancer
Grandmother - Breast and ovarian cancer

Works at a research firm. Lives at home with husband, all three children out of the house. Denies tobacco use, drinks 3 glasses of wine per week.
Medical History
Physical Examination
Obesity, signs of insulin resistance, thyroid disease, or PCOS
Signs of bleeding disorder
Pelvic examination
A 50-year-old G2P2 has a history of menorrhagia, pelvic pain, dyspareunia, dysmenorrhea, constipation and occasional spotting in between periods. She has a three-year history of urinary urgency and frequency. The patient is concerned that she has fibroids, as her close friend was recently diagnosed with fibroids. What is the symptom most commonly associated with leiomyomas?

A. Intermenstrual spotting (metrorrhagia)
B. Menorrhagia
C. Dyspareunia
D. Dysmenorrhea
E. Urinary symptoms
The major symptom associated with myomas is menorrhagia, thought to be secondary to: 1) an increase in the uterine cavity size that leads to greater surface area for endometrial sloughing; and/or 2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea. Other relatively frequent symptoms include pain and pressure symptoms related to the size of the tumors filling the pelvic cavity, as well as causing pressure against the bladder, bowel and pelvic floor.
Laboratory Testing
Pregnancy test
CBC - w/platelets, PT and aPTT
Pap smear
Transvaginal ultrasound
Anovulatory cycle
Pelvic infection
Ages 13-18
Ages 19-39
Polyps, myomas
Anovulatory cycle
Endometrial hyperplasia
Anovulatory cycle
Endometrial hyperplasia/CA
A 49-year-old G0 reports that her periods have become heavier over the last year. The patient’s physical exam is notable for her having a slightly enlarged, irregularly shaped uterus. A pelvic ultrasound confirms the presence of two 2 x 2 cm intramural uterine fibroids. The patient’s friend recently had a hysterectomy due to uterine fibroids and menorrhagia. The patient would like to avoid having surgery. She has tried NSAIDs which did not seem to help much. Her endometrial biopsy is negative. She is interested in the medical options for treating symptomatic uterine fibroids. What is the next best step in the management of this patient?
A. Aspirin
B. Methotrexate
C. Estrogen
D. Gonadotropin-releasing hormone agonists
E. Indomethacin
Answer - D
Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size. This treatment is commonly used for three to six months before a planned hysterectomy in an attempt to decrease the size of the uterus, which may lead to a technically easier surgery and decreased intraoperative blood loss. In patients who are not yet menopausal, once the gonadotropin-releasing hormone agonist therapy is discontinued, the fibroids may grow again with re-exposure to endogenous estrogen. Thus, this therapy may be most useful for women who are close to menopause, as this patient is at age 49. Aspirin and Methotrexate are not effective treatments for fibroids. Methotrexate is used in ectopic pregnancies. Aspirin and Indomethacin will likely not help, as she did not respond to NSAIDs.
A 50-year-old G3P3 complains of menorrhagia. Physical examination is notable for a 14-week size irregularly shaped uterus. Her hematocrit is 35%. Which of the following is the next most appropriate step in this patient’s management?
The majority of patients with uterine fibroids do not require surgical treatment. If patients present with menstrual abnormalities, the endometrial cavity may be sampled to rule out endometrial hyperplasia or cancer. This is most important in patients in their late reproductive years or postmenopausal years. If the patient’s bleeding is not heavy enough to cause iron deficiency anemia, reassurance and observation may be all that are necessary.

Treatment with GnRH analogue can also be used in perimenopausal women as a temporary medical therapy until natural menopause occurs.

Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.
A. Hysteroscopy
B. Endometrial sampling
C. Treatment with GnRH analogue
D. Hysterectomy
E. Myomectomy
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