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Abnormal Uterine Bleeding

Abnormal Uterine Bleeding. Peter J. Chen, M.D. Clinical Assistant Professor Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania. What is normal uterine bleeding?. Age of patient Frequency Duration Flow. What is normal uterine bleeding?. Frequency of menses

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Abnormal Uterine Bleeding

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  1. Abnormal Uterine Bleeding Peter J. Chen, M.D. Clinical Assistant Professor Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania

  2. What is normal uterine bleeding? • Age of patient • Frequency • Duration • Flow

  3. What is normal uterine bleeding? • Frequency of menses • 21 days (0.5%) to 35 days (0.9%) • Age 25, 40% are between 25 and 28 days • Age 25-35, 60% are between 25 and 28 days • Teens and women over 40’s cycles may be longer apart Munster K et al, Br J Obstet Gynaecology

  4. What is normal uterine bleeding? • Duration of menses • 2 days to 8 days • Usually 4-6 days Hallberg L et al, Acta Obstet Gynecology Scandinavica

  5. What is normal uterine bleeding? • Flow/amount of menses • Normal volume of menstrual blood loss is 30 cc Hallberg L et al, Acta Obstet Gynecology Scandinavica

  6. Traditional terminologies • Menorrhagia • Regular intervals, excessive menstrual blood loss • amount >80mL • Metrorrhagia • Irregular intervals, excessive flow and duration • Oligomenorrhea • Interval longer than 35 days • Polymenorrhea • Interval less than 21 days Cohen BJB et al, Obstetrical and Gynecologic Survey

  7. Differential diagnosis • Pregnancy related complications • ectopic, inevitable

  8. Differential diagnosis • Disease of the cervix • Polyp, ectropian, dysplasia, invasive cancer

  9. Differential diagnosis • Disease of the uterus • Infection: endometritis • Endometrial polyp, adenomyosis, hyperplasia, adenocarcinoma • Fibroids • One third of patients with symptoms • Correlation between the severity of the bleeding and the area of endometrial surface • Sehgal N, et al American Journal of Surgery • Histologic abnormalities of the endometrium, ranging from atrophy to hyperplasia • Deligdish, et al Journal of Clinical Pathology • Endometrial venule ectasia • Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et al Journal of Obstetrics and Gynaecology Br Common W

  10. Differential diagnosis • Disease of the ovary • Germ cell tumors • Choriocarcinomas • Embryonal carcinoma • Sex cord-stromal tumors • Granulosa cell tumors(1-2% of all ovarian tumors) • Peak incidence between 50 and 55 years of age

  11. Differential diagnosis • Thyroid disease • Prolactinomas • Coagulation defects • Renal, liver failure

  12. Differential diagnosis • Trauma • Foreign bodies

  13. Differential diagnosis • Medications • Hormonal contraceptives • Hormone replacement therapy • Phytoestrogens, ginseng • SSRIs

  14. Differential diagnosis • Dysfunctional uterine bleeding • Anovulatory cycles • Loss of normal regulatory mechanism • Immaturity • Dysfunction • Psychiatric medications, stress, anxiety, exercise, rapid weight loss, anorexia nervosa • Ovarian failure • Obesity • PCOS

  15. Evaluation • History and physical • Labs • Pregnancy test • CBC • TSH • Prolactin • (Liver function tests) • (Coagulation panels) • (Androgen profile) • Testosterone, DHEAS, Hydroxyprogesterone

  16. Evaluation (cont) • Cytopathology • Pap • Endometrial biopsy • Imaging studies • Surgical • D&C hysteroscopy

  17. Treatments • Medical therapy • Hormonal • Progestin, estrogen (IV), combination OCPs • GnRH agonist • Surgical therapy • D&C • Endometrial ablation • Myomectomy/hysterectomy • Radiologic therapy • Uterine artery embolization (UAE)

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