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Definitions:
Normal Menstrual Cycle: Regular, 3-7 days long, q21-35d, normal flow
and pain
Old classification system:
Menorrhagia: Heavy menstrual
bleeding, blood loss >80mL
Metrorrhagia: Bleeding between
periods
Polymenorrhea: Bleeding occurs more
frequently than q21d
Oligomenorrhea: Bleeding occurs
less frequently than q35d
New classification system: PALM-COEIN
Structural: PALM
-Polyp
-Adenomyosis
-Leiomyoma
-Malignancy/Hyperplasia
Non-structural:
COEIN
-Coagulopathy
-Ovulatory dysfunction
-Endometritis
-Iatrogenic
-Not yet classified
Combined
with other descriptive terms:
-Heavy
menstrual bleeding, inter-menstrual bleeding
https://obgynupdated.blogspot.com/2016/02/abnormal-uterine-bleeding-aub.html
Primary Assessment
1)
Differential Diagnosis (by age)
a.
13-18yo
i. Physiologic:
Anovulation 2/2 immaturity of HPO axis, Pregnancy
ii. Iatrogenic:
OCPs
iii. Pathologic:
Infection, Coagulopathy, Tumors
1.
~20% hospitalized adolescents have coagulopathy
b.
19-39yo
i. Physiologic:
Pregnancy
ii. Iatrogenic:
OCPs
iii. Pathologic:
Anovulatory cycles (PCOS), Endometrial hyperplasia/cancer, Structural lesion
(polyp, leiomyoma)
c.
40yo-menopause
i. Physiologic:
Anovulation 2/2 menopause or ovarian failure
ii. Iatrogenic:
OCPs
iii. Pathologic:
Endometrial hyperplasia/cancer, Structural lesions (polyp, leiomyoma)
2)
Physical Exam
a.
Full physical
b.
Speculum and Bimanual Exam
c.
PCOS
i. Obesity
ii. Hirsutism
iii. Acne
iv. Insulin
resistance: Acanthosis nigricans
d.
Thyroid
i. Nodule
3)
Laboratory Testing
a.
Pregnancy Test
b.
CBC
c.
Pap/HPV
d.
Chlamydia/Gonorrhea
e.
TSH, PRL, FSH
f.
Coagulopathy Workup:
i. Heavy
menstrual bleeding: Up to 20% may have coagulopathy
ii. History
of Medications and Herbs
1.
Anticoagulants
a.
Warfarin, Heparins, Aspirin, etc
2.
Herbs
a.
4 G’s: Gingko, Garlic, Ginger, Ginseng
b.
Motherwort
iii. Physical
Exam
1.
Petechiae, Ecchymoses, Pallor
iv. Screen:
1.
Heavy menstrual bleeding since menarche
2.
Postpartum Hemorrhage
3.
Surgery-related bleeding
4.
Bleeding with dental work
5.
Two or more of:
a.
Bruising monthly
b.
Epistaxis monthly
c.
Frequent bleeding gums
d.
Family history of bleeding symptoms
v. Patients
with a positive screen should receive evaluation, including testing for vWD
1.
Initial tests are fibrinogen, PT/INR, and PTT
2.
vWF antigen, factor VIII and ristocetin cofactor
4)
Imaging
a.
When to perform:
i. Abnormal
physical exam
ii. Symptoms
persist despite treatment in s/o normal exam
b.
TVUS
i. TAUS
may be more appropriate in adolescents
ii. Endometrial
Thickness
1.
Premenopausal
a.
Not useful for evaluation of AUB
2.
Postmenopausal
a.
<5mm
c.
Sonohysterography (saline-infused)
i. If
TVUS inadequate or further evaluation required
ii. Superior
to TVUS for detection of focal vs uniform thickening of endometrium and
intercavitary lesions
iii. Very
high sens (96-100%) and spec (94-100%)
iv. May
determine depth of myometrial involvement of leiomyomas
d.
Hysteroscopy
i. If
TVUS inadequate or further evaluation required
ii. Superior
to TVUS for detection of focal vs uniform thickening of endometrium and
intercavitary lesions
iii. Hysteroscopy:
Office vs OR
1.
Office
a.
Less expensive
b.
More convenient
c.
Faster recovery/Less time off work
e.
MRI is not recommended as primary imaging
modality
i. May
be secondary option if TVUS is inconclusive
ii. Uses
when
1.
Planning myomectomy
2.
Planning uterine artery embolization
3.
Detecting adenomyomas
a.
Best way to identify adenomyosis, but diagnosis
is histological
b.
Heterogeneous myometrium, myometrial cysts,
asymmetric myometrial thickness, subendometrial echogenic linear striations
4.
Focused ultrasound treatment
5)
Biopsy
a.
When to perform:
i. Strong
risk of endometrial cancer
1.
>45yo or postmenopausal
2.
<45yo
a.
H/o unopposed estrogen exposure
i. Obesity,
PCOS
b.
Persistent AUB or failed medical management
ii. If
cannot be performed, insufficient, or nondiagnostic, revert back to imaging
b.
Ways
i. Aspiration
ii. Hysteroscopy
w/ sampling
iii. D&C
c.
Features
i. May
miss cancer if cancer covers <50% of surface area of endometrial cavity
ii. Tests
are only an endpoint when they reveal cancer or CAH
1.
Post-test probability of endometrial cancer for
a negative test is too high (0.9%)
2.
If suspicion high enough, and imaging suggestive
(even with benign pathology on sampling), may perform hysteroscopy to take
directed biopsies
a.
Post-test probability after directed biopsy is
0.5%
6)
Therapy
a.
Use
i. Endometrial
cancer ruled out
1.
Low risk
2.
High risk who have been adequately evaluated and
found to be negative
ii. Persistent
bleeding despite therapy requires further evaluation
b.
Options
i. Hormonal
Therapy
1.
Progestins
2.
COCs
3.
Levonorgestrel IUD
ii. Tranexamic
Acid
iii. Surgical
1.
Resection
a.
Polypectomy, Myomectomy
2.
Endometrial Ablation
3.
Uterine Artery Embolization
4.
Hysterectomy
I have suffered from adenomyosis with severe cramps during and after my period. It was very painful and heavy bleeding and severe lower back pain my pain was unbearable to a point of being not able to move and a stabbing like pain on the left of my ovaries. Pain goes away when a clot comes out. But it took a while for the clot to come out. After several meetings with my gynaecologist which she suggested "Hysterectomy" but I refused I know what Hysterectomy is and how heart aching it can be then she stated that Allopathic treatment will help in pain management but it will not cure the disease. I started treatment with a drug named "endoheal 2 mg". This gave me pain relief but reduced my periods almost to no periods with numerous side effects - spotting and fluctuation in my dates. I was not mentally satisfied to bear the side effects so I came across ''Ayurvedic doctor" who started my treatment with herbs. Though I continued above drug 'endoheal 2 mg'" parallel for nine months for easy pain management. From then I continued taking the treatment. It reduced the size of my lesion but did not reduce it further after few months. And there was no relief in pain during menstruation but my Dr. Advised me to continue it during 3 months without any gap. I had noticed a quick ageing of my skin in the last 2 years. I am a smoker but for some reason I feel my quick ageing has to do with something else because I have been smoking for a long time and it's only recently that I noticed a fast decline of my skin elasticity. After then pain radiates very badly in my left leg, lower left back and left side of my vagina. The pain normally start anytime during 3, 5,6 days, but at time I had to take a painkiller for this also as it irritates whole day. Then pain disappears after fews day. My digestion was slow but Dr. Ronnie's supplements has improved it impossible situations is becoming possible miracles gradually.
ReplyDeleteI was lucky to read in the internet about a lady who was cured from Adenomyosis through Herbal Medication. I contacted Ronnie through an email address I got from a testimony shared on the internet. Without further delay I made an order, I switched over to it. I had great breakthrough, that in the first month, I was already testifying of the effective of the Herbal medication. After 3months course of taken the medicine, all symptoms were gone. It has been 1 year and four months since I became free from adenomyosis. Anyone who is not in my position would not understand what I went through, the heart break, the pain and how frustrated I was for 6 odd years. Believe me, it was hell. I am so happy; I never believed I will be this happy again in life. My story is quite lengthy, it might help you too. You may contact Dr. Ronnie to know more via his email on. ronniemd70@gmail.com