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AUB

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by

Tome Erasmus

on 28 October 2016

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Transcript of AUB

Abnormal Uterine Bleeding
Dr Tome Honing
MMed O&G, FCOG
Aug 2015
P
A
L
M
Polyps (AUB-P)
Endometrial / endocervical
Epithelial proliferations:
Vascular, glandular, fibromuscular, connective tissue
Usually benign
Might have atypical/malignant features
Esp if size >1,5cm, hpt, tamoxifen

Polyps (AUB-P)
History:
AUB (intermenstrual spotting/post coital spotting)

Dx: ultrasound (SIS) or hysteroscopy

Mx: polypectomy (histology)
Office hysteroscopy
Resectoscopic polypectomy

AUB-P
AUB-P
AUB-P
AUB-P
Adenomyosis (AUB-A)
Adenomyosis U/S criteria
AUB-A
Focal adenomyosis
AUB-A
Globular uterine enlargement

obscure endom/myom junction
AUB-A
Anechoic cystic lacunae
AUB-A
AP asymmetry
Leiomyoma (AUB-L)
AUB-L
Subclassification
AUB-L
linear striations
outer capsule
AUB-L
SIS - cavity distortion
AUB-L
Hysteroscopy
AUB-L
Malignancy/ Hyperplasia (AUB-M)
Risk for endometrial ca:
6,2% in women age 35 -44y
13,6 -24/ million woman-years for age group between 40-50y

Endometrial sampling:
All women above 45y
Family history of non-polyposis colorectal CA (lifetime risk 60%, mean age 48-50y dx)

AUB-M
Risk factors for endometrial CA
Age >40
Weight > 90kg
Anovulatory cycles
Nulliparity
Infertility
Tamoxifen use
Family hx

WHO classification (2014)
Coagulopathy (AUB-C)
ACOG screening - ADULT
ACOG screening - Adolescent
Menses greater that 7 days/ ‘flooding’ or ‘gushing’ sensation/ bleeding through pad/tampon in 2h

History of anaemia

Family hx of bleeding disorder

Bleeding disorder after hemostatic challenge (tooth extraction, surgery etc)

AUB-C Medical Rx
AUB-C Medical Rx
(AUB-O)
Spectrum menstrual abnormalities

Endocrinopathies
PCOS
Hypothyroidism
Hyperprolactinemia
Mental stress, anorexia, extreme exercize
Obesity


(AUB-O)
Drugs:
Impact Dopamine metab (Phenothiazines, tricyclic antidepressants)

Extremes of reprod age
Ovulatory dysfunction (AUB-O)
Endometrial dysfunction (AUB-E)
Normal ovulatory function (predictable and cyclical)

No other definable cause identified

Primary endometrial dysfunction of local hemostasis

AUB - E
Deficiency of local vasoconstrictors:
Endothelin-1
Prostaglandin F2 alpha

Accelerated lysis of endometrial clot
Excessive plasminogen activator

Increased local production of vasodilators
Pg E2 and prostacyclin (I2)

AUB-E
Incomplete repair of endometrium at menses

Due to infection or inflammation (esp Clamydia trachomatis)

Iatrogenic (AUB-I)
AUB-I
Other drugs causing AUB:
Antidepressants (SSRI’s, TCAs)
HRT
Tamoxifen
Corticosteroids
Thyroxine
Herbs: ginseng, ginko, soy products

Not yet classified
(AUB-N)
E
I
N
C
Bleeding from uterine corpus:

abnormal in regularity, volume frequency or duration
absence of pregnancy

Acute AUB:
episode of heavy bleeding, requiring immediate intervention

Chronic AUB:
present for the majority of last 6 months


Definitions
HPO axis
Duration of flow: 4,5 – 8 days
Frequency of cycle: 24-38 days (+_2 to 20days)
Volume: 5 – 80ml


Normal menstrual cycle
NB:
Pathology of lower reproductive tract
not included in classification

Previously inconsistent and confusing nomenclature
undermine the investigative leverage of meta-analysis
FIGO Menstrual Disorders Working group 2011
approved new classification
international group of clinician-investigators
17 countries
from 2005 - 2009
living document (periodic revision)

Terminology
Nomenclature
O
Medical Mx AUB
Acute AUB
Chronic AUB (HMB)
Definition
Heterotopic endometrial tissue present in myometrium
Myometrial hypertrophy

Prevalence: 5 – 70%

Diffuse or focal

Hx: AUB, dysmenorrhoea, dyspareunia, chr pelvic pain

Dx: u/s, MRI (hysterectomy histology)

Rx: surgical
Medical (similar to Leiomyoma)


Globular uterine enlargement
Cystic anechoic spaces
(doppler to excl veins)
Subendometrial echogenic linear striations
Uterine wall thickening (AP asymmetry)
Heterogenous echo texture
Obscure endometrial/myometrial border
Thickening of transition zone

Sensitivity and specificity >80%
Benign fibromuscular tumors of myometrium

Submucosal, intramural, subserosal (other)

Dx: ultrasound (SIS), hysteroscopy

Mx: myomectomy/ hysteroscopic resection

Medical Rx:
LNG-IUS
CHC’s
NSAIDS, Tranexamic acid

13% of women with HMB have biochem haemostasis disorders

Also includes anti-coag meds (Warfarin)

HMB since menarche

One of following:
PPH
Surgery related bleeding
Dental work associated bleeding

Two of following:
Epistaxis 1 or 2x/month
Frequent gum bleeding
Family hx of bleeding sx

Inherited bleeding disorder

Tranexamic acid
CHC
LNG-IUS
DMPA

(GnRH agonist, Danazol)
Desmopressin (vWD)

Anti-coagulation therapy

LNG-IUS
Oral progestins
Depo-Lupron


breakthrough bleeding’ (unscheduled bleeding)
Medicated or inert intrauterine systems
Combined hormonal contraception
Dopamine metabolism drugs (phenothiazines, tricyclic antidepressants)

Compliance issues
(missed pill, erratic use)
Rare and ill defined causes of AUB
Chr endometritis
Arteriovenous malformations
Myometrial hypertrophy

Future
entities

IV conjugated estrogen (CEE)
25mg IV q4-6h X 24h

Oral tranexamic acid
1,3g tds PO x 5 days

COC (35ug EE)
1T tds po x 7 days/ until bleeding decreases, then taper

Oral progestin
MPA 20mg tds PO x 7 days
Noresthisterone: 5-10mg q4h until bleed stops, then qid x 4 days, then bd for up to 2 weeks, then daily

GnRH agonist
with aromatase inhibitor or antagonist to prevent initial estrogen flare

Intra-uterine Foley’s
balloon tamponade
(3 or 10ml)

NSAID
Mefenamic acid 500mg bd x 4-5 days
Naproxen 250mg – 500mg bd x 4-5 days
Ibuprofen 600mg to 1200mg dly x 4-5 days

Tranexamic acid
1,3g tds PO x 5 days

COC
Cyclical, extended or continuous

Oral progestin
MPA 5 -10mg dly for 12- 14 days
Norethisterone 5mg dly x 5-10 days

DMPA
LNG-IUS

SIS
Hysterosocpy
Polypectomy
AUB-A
Venetian blinds / linear striations
Hysteroscopic
resection
Hyperplasia without atypia
Atypical hyperplasia (endom intraepith neoplasia)
(AUB-O) TREATMENT
References
mixed echogenicity
Laparoscopic myomectomy
Full transcript