Abnormal Uterine Bleeding

Common in women of all ages

~5% women of reproductive age seek
help annually
Life phase determines most likely
cause, and the likelihood of serious
pathology
Take your time to properly assess the
problem
Work-up and treat in a rational manner

Complications of pregnancy
Intrauterine pregnancy
Ectopic pregnancy
Spontaneous abortion
Gestational trophoblastic disease
Placenta previa
Infection
Cervicitis
Endometritis
Trauma
Laceration, abrasion
Foreign body
Malignant neoplasm
Cervical
Endometrial
Ovarian
Benign pelvic lesions
Cervical polyp
Endometrial polyp
Leiomyoma
Adenomyosis

Systemic disease
Hepatic disease
Renal disease
Coagulopathy
Thrombocytopenia
von Willebrand's disease
Leukemia
Medications/iatrogenic
Intrauterine device
Hormones (oral contraceptives,
estrogen, progesterone)
Hormonal imbalance
Anovulatory cycles
Hypothyroidism
Hyperprolactinemia
Cushings disease
Polycystic ovarian syndrome
Adrenal dysfunction/tumor
Stress
Excessive exercise

Abnormal Bleeding Cause

Pregnancy
Hormonal/Dysfunctional
Anatomic
Coagulopathy/bleeding

disorder

History
Characterize menses
Age, parity, past pregnancies, sexual
history, contraception, past gyn
problems, medications
Personal or family history of bleeding
disorder
Symptoms of thyroid disease
History of liver disease

Physical Exam
Orthostatic VS if indicated by Hx
Pelvic exam vagina, cervix,
uterus, adnexa, PAP
Skin ecchymoses, hirsutism
Thyroid gland
Liver and assoc. stigmata
Signs of virulization

Labs
CBC with Plts
Urine -HCG if reproductive age

Additional Tests (not routine)

TSH anovulatory
LFTs, coagulation studies liver dz or FHx
Complete coagulation profile consider for
non-pregnant teens
GC, Chlamydia if risk or exam suggests
Androgen excess free testosterone,
DHEA-S (PCOS evaluation)
FSH suspect premature ovarian failure
Progesterone confirm ovulation, draw in
luteal phase

Life Phase

Ovulatory Status

Etiology

R/O Pregnancy
Adolescent

Likely anovulation
Pregnancy

Consider bleeding disorder

Ovulatory
(Secretory)

Hormonal
DUB

Anovulatory
(Proliferative)

Anatomic

Reproductive age
(Usually DUB)

Coagulopathy
R/O Pregnancy
Perimenopause
Early EMB/TV Sono

Postmenopause

R/O Endometrial CA

Adolescents
Usually anovulation due to
immature Hypothal-Pit axis
Rule out pregnancy
Consider bleeding disorder
Observe or Rx with cyclic MPA or
OCs

Consider Bleeding Disorder

von Willebrands Disease

Underdiagnosed; present in 1% of population

Autosomal dominant; affects women and men
equally
Dx:
Bleeding time, Factor VIII, vW factor,
ristocetin co-factor activity
Rx:
Desmopressin (ADH) IV or intranasal
Increases vW factor, factor VIII,
plasminogen activator

Reproductive Age
H&P
Check urine -HCG
Genital tract lesionBx or refer
Enlarged uterus
r/o pregnancy
sono for anatomic cause

(e.g., fibroids)

Reproductive Age
If not pregnant and normal exam:
Usually DUB (i.e., hormonal)
Determine ovulatory status key!
Treatment: Usually hormonal

Ovulatory Cycles
Regular cycle length
Presence of premenstrual symptoms
Breast tenderness, dysmenorrhea
Mittleschmertz
Biphasic temperature curve

Anovulatory Cycles
Unpredictable cycle length
Unpredictable bleeding pattern
Frequent spotting
Infrequent heavy bleeding
Monophasic temperature curve

Anovulatory Bleeding
90-95% of reproductive age
Cause: systemic hormonal
imbalance
Always a relative progestindeficient state

Anovulatory Bleeding

Assess for secondary hypothalamic

disorder

stress, eating disorder, excessive

exercise, wt loss, chronic illness

Check TSH
Test for PCOS if indicated

obesity, hirsutism, insulin resistance

Consider chronic anovulation

Anovulatory DUB Treatment

Address underlying disorder
Treat with monthly OCs or
progesterone withdrawal every 3
months (MPA or DMPA)

Regulate cycles, protect against

endometrial CA

Clomiphene for ovulation induction

in select cases

Ovulatory Bleeding

Usually underlying prostaglandin

imbalance (DUB)
Defects in local endometrial hormonal
hemostasis
Structural lesions
Leiomyoma, adenomyosis, polyps
Systemic disease
Liver dz, renal failure, bleeding
disorder

Ovulatory Bleeding
Much less common5-10%
Consider empiric treatment
without further w/u (normal exam)

NSAIDs, OCs, progesterone IUD

If Rx fails, proceed with work up

Metabolic labs
Imaging, EMB

Ovulatory DUB Treatment

NSAIDs (prostaglandin synthetase

inhibitors) e.g., Ibuprofen, Naproxen,
Mefenamic acid
First 5d of menses

Cyclic OCs x 3-6 mos

Progesterone IUD most effective

[Tranexamic acid anti-fibrinolytic]

Evaluating endometrial cavity

Consider EMB:
Higher risk women
Prolonged exposure to unopposed
estrogen
Age > 40
Failure to respond to initial
management

Evaluating endometrial cavity

Endometrial Biopsy (EMB)
Safe, simple office procedure
Rule out endometrial CA
Confirm ovulatory status

EMB best done while bleeding

Proliferative: confirms anovulation
Secretory: confirms ovulation
Hyperplasia: chronic unopposed estrogen
Atrophy: menopause or continous OCs, HRT,
DMPA

Evaluating endometrial cavity

Dilation and Curettage (D&C)
OR procedure, less commonly used

Rule out endometrial carcinoma or

hyperplasia
Yield slightly higher than EMB, but still
blind sampling technique

Evaluating endometrial cavity

Transvaginal Ultrasonography
(TVSono)

Alternative to EMB to assess endometrium,

comparable accuracy
Endometrial stripe >5mm EMB for tissue
diagnosis
Often can detect atrophic endometrium,
leiomyomas, and endometrial polyps

Evaluating endometrial cavity

Sonohysterography

(water sono)

TVSono with saline infusion into endometrial

cavity
Enhances detection of submucosal fibroids
and polyps

Evaluating endometrial cavity

Hysteroscopy
Gold standard for endometrial assessment
Office procedure
Thorough, direct inspection of endometrial
cavity
Directed biopsy or treatment possible (e.g.,
polyp excision)

Perimenopause
H&P
Check urine -HCG
Genital tract lesionBx or refer
Enlarged uterus
r/o pregnancy
TV Sono for anatomic evaluation

(e.g., fibroids)

Perimenopause
If not pregnant and normal exam:
Consider early EMB or TV Sono

r/o edometrial hyperplasia, CA

If negative, Rx with low dose OCs

or monthly Medroxyprogesterone
Sonohysterography or
hysteroscopy if Rx fails

r/o anatomic causes

Postmenopause
5-10% endometrial carcinoma
Proceed directly to EMB or TV Sono
DDx: endometrial hyperplasia, cervical

cancer, cervicitis, atrophic vaginitis,

endometrial atrophy, submucosal
fibroids, endometrial polyps

Rx specific to cause

Treatment: Acute Bleeding

Conj. Eq. Estrogens x 21d
+ MPA last 710d

Use Estrogen IV for severe bleeding; hospitalized

High dose OC: 1 QID x 7d;

then OC daily x 3 months
or MPA x 10d q month x 2-3 more cycles

Surgical Treatment
Therapeutic D+C

fastest method to stop bleeding in unstable

patients
must follow with hormones to prevent
recurrence

Endometrial Ablation/Resection

laser or electrocautery
good option if fertility not desired

Surgical Treatment
Hysterectomy

if all else fails or patient prefers

subtotal hysterectomy is an option to preserve
optimal sexual and bladder function
hysterectomy now is rarely necessary solely
for uterine bleeding

Life Phase

Ovulatory Status

Etiology

R/O Pregnancy
Adolescent

Likely anovulation
Pregnancy

Consider bleeding disorder

Ovulatory
(Secretory)

Hormonal
DUB

Anovulatory
(Proliferative)

Anatomic

Reproductive age
(Usually DUB)

Coagulopathy
R/O Pregnancy
Perimenopause
Early EMB/TV Sono

Postmenopause

R/O Endometrial CA

Adolescents
Most likely anovulatory due to
immature Hypothal-Pit axis
Rule out pregnancy
Consider bleeding disorder
Observe or Rx with cyclic MPA or
OCs

Anovulatory Adults
Identify secondary causes of
Hypothal-Pit dysfunction, thyroid
disease, PCOS
Address underlying cause
Manage bleeding with cyclic MPA,
DMPA, or OCs

Ovulatory Adults

Causes: endometrial modeling defect,

structural lesions, systemic disease
Consider empiric Rx without further w/u
if history and exam are normal

NSAIDs, OCs, Progesterone IUD

If Rx fails, w/u with metabolic labs,

imaging, and EMB if indicated

Perimenopause
Progressive anovulation due to
declining ovarian function
Rule out pregnancy
Consider early EMB or TVSono

(esp. with endometrial CA risk factors)

Rx with OCs or monthly MPA

Postmenopause

Rule out endometrial CA (5-10%)

Evaluate for other causes

Proceed directly to EMB or TVSono

endometrial hyperplasia, cervical
cancer, cervicitis, atrophic vaginitis,
endometrial atrophy, submucosal
fibroids, endometrial polyps

Rx specific to underlying cause

Summary
Abnormal uterine bleeding is very
common
Life phase and detailed menstrual
history are key
Employ rational evaluation and
treatment strategy
You can manage it!

Cervical Cancer Screening

Todd May, MD

Cervical Cancer
12,800

cases/yr
50% never screened
Death rate 70% since 1940s

Pap introduced

Natural History
HPV

acquired in teens, 20s

Prolonged pre-malignant phase
Spontaneous HPV clearing
common
CIN peaks 20s-30s
Small number progress to
invasive cancer

Risk Factors for Neoplasia

Multiple

sexual partners

HPV
Smoking
HIV

Routine Screening Recs

Start:

Interval:

3yrs after first vaginal intercourse

Age 21 (unless virginal?)
Annually age <30
Age >30 q2-3yrs if normal x 3 annuals

Stop:

Age 65-70 if consistently normal

After hysterectomy for benign condition

High-Risk Screening Recs

Pap every 6 months x 2, then annually
for:
HIV positive
Immunocompromised by organ
transplant, chemoRx, chronic steroid
use
Prior Rx for CINII/III or cancer
Rationale: Progression to HSIL and CA
more common and more rapid

Essentials of Pap Sampling

Collect cells before bimanual exam
Gently remove cervical mucus/dc
Visualize entire portio of cervix
Use scraper for ectocervix; brush
for endocervical specimen
Fix slide immediately (<3-4sec)

Cytologic Interpretation
Adequacy

of specimen

Satisfactory or unsatisfactory

Descriptive

diagnosis

Bethesda 2001

Presence/absence

endocervical cells

of

Negative for IEL or Malig.

Benign cellular changes

Trichomonas
Fungus c/w candida sppNo action
Floral shift/BVNo action
Suspect Chlamydiacall back to test
HSVnotify patient
HPV/koilcytosismanage as LSIL
Actinomyces (IUD)Rx with Amox

Negative for IEL or Malig.

Reactive changes

InflammationNo action
Atrophy w/ inflam. (atrophic vaginitis)
Rx w/ topical estrogen, repeat if no
ECC
RadiationNo action
Reactive/reparative AtypiaNo action
Squamous metaplasiaNo action

Squamous Cell Abnormalities

ASCUSundetermined significance
ACS-Hcannot exclude HSIL
LSILlow gradeincludes HPV,
mild dysplasia/CINI
HSILhigh gradeincludes modsevere dysplasia, CINII/III, CIS
Invasive SCCa

Glandular Cells
Endometrial cellsconsider EMB if
age>40 or abnormal bleeding
Atypical Endocervical cellscolpo,
Bx, ECC
Atypical Endometrial cellsEMB,
D&C, or hysteroscopy
Endocervical, Endometrial, or
Extrauterine Cadefinitive Rx

ASC US

HIV

Repeat 4-6 months

Negative

> ASC US

HPV DNA Testing

HPV Positive
HPV Negative
(for high risk types)

Colposcopy
Routine Screening

Repeat PAP
12 months

ASCH / LSIL

Colposcopy

Neg or CIN 1

PAP q6 mos x 2

CIN 2 or 3, CIS

RX

HSIL

Colposcopy + ECC

Satisfactory

No CIN or
CINI
Diagnostic
Excision

CIN 2, 3

Rx

Unsatisfactory

Diagnostic
Excision

Bottom Line
When to refer for colposcopy:
ASC-US x 2 (x1 if HIV+)
ASC-H
LSIL
HSIL