Upload
norma-banks
View
235
Download
1
Embed Size (px)
Citation preview
Unit II
ABNORMAL UTERINEBLEEDING
Dr. Sony Singh, MD, FRCSC Director of Minimally Invasive Gynecology
The Ottawa Hospital
Dr. Mina Wesa, MD, FRCSC Fellow in Minimally Invasive Gynecology
The Ottawa Hospital
Dr. Shahid Islam, MD, PhD, FRCPCAssociate Professor and Program Director , Lab Medicine-Anatomical Pathology, University of Ottawa Staff Physician, Ottawa Hospital
Disclosure
Unit II – AUB – Dr. Sony Singh
You may only access and use this PowerPoint presentation for educational purposes. You may not post this presentation online or distribute it without the permission of the author.
Describe menorrhagia, metrorrhagia, menometrorrhagia, oligomenorrhea
Classify abnormal uterine bleeding in ovulatory and anovulatory bleeding
Categorize abnormal uterine bleeding into anatomical, medical/pharmacological and biochemical hormonal causes – using PALM-COEIN nomenclature!
Elaborate a clinical approach to abnormal uterine bleeding inpremenarchal, reproductive, peri and post-menopausal women
Unit II – AUB – Dr. Sony Singh
Objectives
Elaborate a clinical approach to abnormal uterine bleeding and briefly discuss available treatment options
Compare the normal menstrual cycle with anovulatory conditionssuch as PCOS, POF and menopause
Formulate a differential diagnosis of vaginal bleeding with respect topre-menarchal, pre-menopausal and post-menopausal causes
Describe pharmacological and surgical management of menorrhagia
Describe the etiology and presenting signs and symptoms of anovulatory vaginal bleeding (including menopause, PCOS and ovarian tumors)
Unit II – AUB – Dr. Sony Singh
Objectives
(Live speaker)
Unit II – AUB – Dr. Sony Singh
Case Presentation
Abnormal Uterine Bleeding (AUB)
Refers to menstrual bleeding of abnormal quantity, duration, or schedule
Common gynecologic complaint, accounting for over 30% of outpatient gynecologic visits
Wide differential Structural uterine pathology (fibroids, polyps, adenomyosis) Anovulation Disorders of hemostasis Neoplasia
ALWAYS RULE OUT PREGNANCY!!!
INTRODUCTION
TERMINOLOGY - Traditional
• Amenorrhea: absence of menstruation for at least three usual cyclic lengths
• Oligomenorrhea: cyclic length> 35 days
• Polymenorrhea: Cyclic length <24 days
TERMINOLOGY - Traditional
• Menorrhagia: regular, normal intervals with excessive volume and durations of flow
• Metrorrhagia: irregular intervals with normal or reduced volume and duration of flow
• Menometrorrhagia: Irregular intervals and excessive volume and duration of flow
Malcolm G. Munro MD, FRCS(c), FACOG
Professor, Department of Obstetrics & Gynecology
David Geffen School of Medicine at UCLA
Director of Gynecologic Services
Kaiser Permanente Los Angeles Medical Center
Ian S. Fraser MD, FRCOG, FRANZCOGProfessor in Reproductive Medicine Department of
Obstetrics & Gynaecology
Queen Elizabeth II Research Institute for Mothers and Infants
University of Sydney
Hilary O. D. Critchley MD, FRCOG, FRANZCOGProfessor of Reproductive Medicine Section of Obstetrics &
Gynaecology
Head, Division of Reproductive and Developmental Sciences
University of Edinburgh
TERMINOLOGY - Revised
FIGO Classification System for
Abnormal Uterine Bleedingin the Reproductive Years
For the “Menstrual Agreement Process”:
FIGO Classification System for Causes of Abnormal Uterine Bleeding in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Up to 30% of women in Canada will seek medical assistance for this problem during their reproductive years
Significant health care burden for women, their families, and society
Major impact on women’s quality of life, productivity, utilization of healthcare services
PREVALENCE
Perimenarche Perimenopause Postmenopause
Menarche Menopause
10 - 14
Reproductive
14 - 45 40 - 60
Early
50 - 65
Late
60 - DeathBirth - 10
Premenarche
The Cultural Context of Menstruation
The Affected Populations
The Cultural Context of MenstruationImpact of Heavy Menstrual Bleeding
Quality of Life
Regulation of Normal Menstruation
Characteristics of Normal Menstruation
NORMAL ABNORMAL
Duration of flow 4 – 6 days <2 days or >7 days
Volume of flow 30 mL >80 mL
Length of cycle 24 – 35 days
ETIOLOGY OF AUB
Neonatal period
Prepubertal period
Adolescence Reproductive years Peri- menopause
Post- menopause
Estrogen withdrawal
Foreign body
Infection
Blood dyscrasia
Hypothalamic
Anovulation (central, intermed, gonadal)
Carcinoma (uterus, cervix)
Atrophic vaginitis
Sarcoma immaturity Functional (blood dyscrasia, hypothyroid,
Climacteric Carcinoma (uterus,
botryoides
Ovarian tumor
Inadequate luteal function
luteal dysfunction)
Iatrogenic (contraception,
Polyps ovarian)
EstrogenTrauma Psychogenic
(including anorexia, bulemia)
anticoagulation,hemodialysis)
Pregnancy (abortion, ectopic, RPOC, GTD)
replacement
Uterine
ETIOLOGY OF AUB – Reproductive years
Neonatal period
Prepubertal period
Adolescence Reproductive years
Peri- menopause
Post- menopause
Estrogenwithdrawal
Foreign body
Infection
Sarcoma botryoides
Ovarian tumor
Trauma
Blood dyscrasia
Hypothalamic immaturity
Inadequate luteal function
Psychogenic (including anorexia, bulemia)
Anovulation (central,intermed, gonadal)Functional (blood dyscrasia, hypothyroid, luteal dysfunction)
Iatrogenic (contraception, anticoagulation, hemodialysis)
Pregnancy (abortion, ectopic, RPOC, GTD)
Uterine
Carcinoma(uterus, cervix)
Climacteric
Polyps
Atrophicvaginitis
Carcinoma (uterus, ovarian)
Estrogenreplacement
FIGO Classification System for Causes of Abnormal Uterine Bleeding in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Common cause of abnormal genital bleeding in pre- and postmenopausal women
Hyperplastic overgrowths of endometrial glands and stroma around a vascular core, sessile or pedunclulated
Single, multiple, variable size and location, may beasymptomatic
Prevalence rises with increasing age, premenopausal > postmenopausal
Risk factors: Tamoxifen, obesity, HRT
95% benign
POLYPS: AUB-P
Malignancy Risk Factors:Size > 1.5 cm Tamoxifen use Postmenopausal
All symptomatic polyps should be removed
Asymptomatic polyps:
Premenopausal women – remove if:o Polyp > 1.5 cm diametero Multiple polypso Polyp prolapsed through cervixo Infertilityo Risk factors for endometrial cancer
Postmenopausal women – remove all endometrial polyps
TREATMENT - Polyps
Hysteroscopic Polypectomy - Scissors
Hysteroscopic Polypectomy – Electrosurgical Loop Resectoscope
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Ectopic endometrial glands and stroma within the uterine musculature
Hypertrophy and hyperplasia of surrounding myometrium, diffusely enlarged uterus “globular”
True incidence unknown as definitive diagnosis based on histopathology (following hysterectomy)
Pathogenesis – endometrial invagination versus mullerian rests.
Pathology: Uniformly enlarged, boggy uterus Thickened myometrium
ADENOMYOSIS: AUB-A
PATHOGNOMONIC on microscopy: Presence of endometrial tissue within the myometrium
Clinical Manifestations: Heavy menstrual bleeding Painful menstruation Chronic pelvic pain Enlarged, globular uterus on exam, may be tender
Symptoms typically noted in women 40-50 years old, given traditional diagnosis by hysterectomy.
Newer MRI criteria for diagnosis suggest disease may cause dysmenorrhea and chronic pelvic pain in adolescents and younger reproductive-age women as well.
Often the diagnosis of “pure” adenomyosis may be obscured by other pathology McElin TW, Adenomyosis of the uterus, Obstet Gynecol Annu. 1974;3(0):425.
Kunz G et al., Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging, Hum Reprod. 2005;20(8):2309.
ADENOMYOSIS: AUB-A Clinical Manifestations
Definitive diagnosis only by histopathology (hysterectomy)
Preoperative diagnosis by characteristic clinical manifestations (menorrhagia,
dysmenorrhea, enlarged uterus)
MRI is best imaging technique Increased signal in areas of adenomyosis Exclude malignancy Distinguish adenomyosis from fibroids
Transvaginal ultrasound up to 83% sensitive and 85% specific (Meredith SM, 2009)
ADENOMYOSIS: AUB-A Diagnosis
Hysterectomy – definitive treatment
Hormonal options Progestins (Levonorgestrel IUD) Gondaotropin releasing hormone (GnRH) analogs Aromatase inhibitors ? Combined hormonal contraception
Conservative surgery Endometrial ablation or resection Laparoscopic myometrial electrocoagulation Excision of adenomyosis – no plane, “woody” tissue consistency
Uterine artery embolization (UAE) – some success Kim MD et al., Long-term results of uterine artery embolization for symptomatic
adenomyosis, AJR Am J Roentgenol. 2007;188(1):176.
ADENOMYOSIS: AUB-A Treatment
Recurrent symptoms within 6 months after cessation of hormonal therapy
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Most common pelvic tumor in women
Benign, originate from myometrial smooth muscle
Women of reproductive age
Symptoms: AUB Pelvic pain or pressure Infertility or adverse pregnancy outcomes
Clinically apparent in 12-25% women, noted on pathological exam in approx. 80% of uteri
LEIOMYOMA (Fibroids or Myomas): AUB-L
LEIOMYOMA: AUB-L Terminology
European Society of Hysteroscopy Classification System for
Submucosal Fibroids
LEIOMYOMA: AUB-L
INCREASED RISK•Incidence is 2 to 3 fold greater in black women than in white womenBaird DD et al., Am J Obstet Gynecol. 2003;188(1):100
•Early menarche (< 10 yrs old)
•Red meats
•Alcohol (beer)
•Other – hypertension, family history
DECREASED RISK•Higher parity
•Green vegetables, fruits
•Dietary vitamin A
•Smoking
Risk Factors
Abnormal uterine bleeding
Pelvic pressure and pain
Reproductive dysfunction
LEIOMYOMA: AUB-L Clinical Manifestations
Abnormal uterine bleeding
Pelvic pressure and pain
Reproductive dysfunction
LEIOMYOMA: AUB-L Clinical Manifestations
Abnormal uterine bleeding
Pelvic pressure and pain
Reproductive dysfunction
LEIOMYOMA: AUB-L Clinical Manifestations
Abnormal uterine bleeding
Pelvic pressure and pain
Reproductive dysfunction
LEIOMYOMA: AUB-L Clinical Manifestations
PHYSICAL EXAMINATION:Bimanual pelvic examination – enlarged uterusSpeculum examination – prolapsed submucous fibroid, cervical contour
LEIOMYOMA: AUB-L Diagnosis
IMAGING:Transvaginal Ultrasound (TVS)
95-100% sensitive Most widely used modality – accessible, cost-effective
Saline Infusion Sonography (Sonohysterography) Improved assessment of intracavitary fibroids
LEIOMYOMA: AUB-L Diagnosis
Fibroid in 53 yo womanwho presented with PMBJoizzo, JR et al., AJR Am J Roentgenol 2001
TVS SIS
Diagnostic HysteroscopyCan be performed in officeSaline or CO2 distension media? accuracy compared to ultrasound
LEIOMYOMA: AUB-L Diagnosis
LEIOMYOMA: AUB-LDiagnostic Hysteroscopy
Magnetic Resonance Imaging To distinguish among leiomyomas, adenomyosis, and adenomyomas Expensive Reserved for complex surgical planning Also to distinguish fibroids from leiomyosarcomas, before uterine artery embolization
(UAE)
LEIOMYOMA: AUB-L Diagnosis
Post UAE
No role for prophylactic treatment – Exceptions: planning pregnancy, hydronephrosis
Treatment choice based on: Type, severity of symptoms Size Location Patient age Reproductive plans
Options: Expectant Medical management Surgical management
LEIOMYOMA: AUB-L Treatment
Hormonal therapiesEstrogen–progestin contraceptives
Levonorgestrel–releasing intrauterine system (“Mirena IUD”)
Progestin injections (Depot Medroxy Progesterone Acetate – DMPA)
Progestin pills
Gonadotropin-releasing hormone (GnRH) agonists, antagonists
Selective progesterone receptor modulators (“SPRMs” – Ulipristal acetate)
Antifibrinolytics (?)
Danazol - ++ side effects
LEIOMYOMA: AUB-L Medical Management
LEIOMYOMA: AUB-L Surgical Management
UAE
Hysteroscopy
Myomectomy
Laparoscopy/Laparotomy
AUB-L
Hysterectomy
Vaginal
Laparoscopic
Abdominal
LEIOMYOMA: AUB-L Hysteroscopic Myomectomy
LEIOMYOMA: AUB-L Laparoscopic Myomectomy
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Endometrial hyperplasia Proliferation of endometrial glands that may progress to or coexist with endometrial
cancer Result of chronic UNOPPOSED estrogen stimulation without balancing effects of
progesterone Women present with abnormal uterine bleeding Histologic diagnosis – ENDOMETRIAL BIOPSY
MALIGNANCY / HYPERPLASIA: AUB-M
MALIGNANCY / HYPERPLASIA: AUB-M
Normal endometrium
HISTOLOGY % RISK OF COEXISTING CA
Simple hyperplasia without atypia 1
Complex hyperplasia without atypia 3
Simple hyperplasia with atypia 8
Complex hyperplasia with atypia 29
Normal proliferative endometrium
MALIGNANCY / HYPERPLASIA: AUB-M Treatment
Atypicalhyperplasia
(often complex)
Pre-menopausal
Fertility desired High dose Progestintherapy
Childbaringcompleted Total
Hysterctomy
Post-menopausalTotal
Hysterectomy Bilateral salpingo-
oophorectomy
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Initial screening for an underlying disorder of hemostasis in patients with excessive menstrual bleeding should be structured by medical history.Positive screen comprises any of the following:
COAGULOPATHY: AUB-C
Von Willebrand disease identified in 13% of women with HMB.
Screening for bledding disorders in women with HMB
Heavy menstrual bleeding (HMB) since menarche
One of the following:Postpartum hemorrhageSurgery-related bleedingBleeding associated with dental work
Tow or more of the following symptoms:Bruising one to two times per monthEpistaxis one to two times per monthFrequent gum bleedingFamily history of bleeding symptoms
CONSULT HEMATOLOGY!!
Options:No desire for pregnancy:Combined oral contraceptivesLevonorgestrel-releasing IUSEndometrial ablation
If pregnancy desired:AntifibrinolyticsFactor replacement therapydDAVP at the onset of menses
COAGULOPATHY: AUB-C Treatment
FIGO Classification System for Causes of AUB in the Reproductive Years
Structural abnormality No structural abnormality
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Unpredictable bleeding pattern Variable amount of flow Absence of cyclic production of
progesterone
OVULATORY DYSFUNCTION: AUB-O
FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Predictable cyclic menses, normal ovulation No other causes of AUB identified
Possible mechanism (s): Disorder of endometrial hemostasis – deficient vasoconstrictos (PGF2α, endothelin-1),
accelerated fibrinolysis Endometrial inflammation, infection Abnormal local inflammatory response Abnormal vasculogenesis
DIAGNOSIS OF EXCLUSION!
ENDOMETRIAL: AUB-E
FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
IATROGENIC: AUB-I
FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp
Adenomyosis
LeiomyomaMalignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Rare entities
Arteriovenous malformations (AVMs)
Myometrial hypertrophy
Other disorders not yet identified
NOT YET CLASSIFIED: AUB-N
(To be added)
Lets run through a case to consolidate all this
Evaluation of AUB in Premenopausal Women
Unit II – AUB – Dr. Sony Singh
Evaluation of AUB in Perimenopausal Women
Unit II – AUB – Dr. Sony Singh
Evaluation of AUB in Postmenopausal Women
Unit II – AUB – Dr. Sony Singh
AUB – Normal Cavity, No Malignancy
Endometrial Ablation
Non-hysteroscopic
Hysteroscopic
Hysterectomy
Vaginal
Abdominal
Laparoscopic