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Menorrhagia/Metrorrhagia Bleeding and Fibroids: Evaluation and Management of Abnormal Uterine Bleeding
Edwin E Prevatte, MD, FAAFP
CME #238 Wednesday, 10:30-11:30 a.m. Location: W222A CME #239 Wednesday, 1:30-2:30 p.m. Location: W222A

The material presented at this activity is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced solely for the education of attendees. Any use of content or the name of the speaker or AAFP is prohibited without written consent of the AAFP.

FACULTY DISCLOSURE
The AAFP has selected all faculty appearing in this program. It is the policy of the AAFP that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Edwin E Prevatte, MD, FAAFP, returned a disclosure indicating that he has no affiliation or financial interest in any organization(s).

Learning Objectives
Recall the most common causes of menorrhagia Recognize symptoms commonly associated with uterine fibroid tumors, keeping in mind that fibroids also may be asymptomatic Apply a stepwise approach to evaluation Develop an appropriate management plan in consultation with the patient taking into account her preferences for definitive treatment and preserving fertility

Normal Menstrual Cycle

Length of cycle 24 to 35 days Duration of bleeding 2 to 7 days Flow < 80 ml. (avg. 30 40 ml.)

Definitions
Dysfunctional Uterine Bleeding noncyclic bleeding unrelated to anatomical lesions of the uterus or to systemic disease. (Anovulatory bleeding) Menorrhagia excessive bleeding at regular intervals Blood loss > 80 ml. per cycle and/or menstrual periods lasting longer than 7 days.

Definitions
Amenorrhea absence of bleeding for at least 3 usual cycle lengths Oligomenorrhea bleeding that occurs at an interval > 35 days Polymenorrhea Regular bleeding that occurs at an interval < 24 days Metrorrhagia light bleeding at irregular intervals Menometrorrhagia heavy bleeding at irregular intervals

Abnormal Uterine Bleeding

Menorrhagia Heavy and Regular Often results from anatomic problems of the uterus or endometrium. Menometrorrhagia Heavy and Irregular More likely from hormonal abnormalities.

Ovulating or Not?
If irregular and unpredictable Anovulatory Bleeding AUB is characterized by menometrorrhagia Causes Recent menarche Approaching menopause Others (PCOS, hypothyroidism, elevated prolactin levels)

Ovulating or Not?
IF regular and predictable..OVULATORY bleeding AUB is characterized by menorrhagia Causes: Anatomic abnormalities endometrial polyps fibroids adenomyosis Coagulopathy von Willebrand (note time of onset)

Organic Causes
Pregnancy Related Structural Pathology Benign (Fibroids, Polyps, Adenomyosis, Infection, Endometrial hyperplasia, AV malformations) Structural Pathology Malignant (Endometrial CA, Cervical CA, Ovarian CA) Systemic Disease (Coagulation/platelet disorders, Endocrine disorders, Renal/Liver failure) Obesity

Iatrogenic Causes
Trauma Foreign Body Medications Psychotropic Drugs Hormones

Evaluation History
Are there symptoms of ovulation? When did the bleeding start? (Menarche?) Precipitating factors What is the nature of the bleeding? Are there associated symptoms? Personal or family history of bleeding disorders Medications, systemic disease Sexual history Change in weight, exercise, illness, stress

Is Bleeding Anovulatory or Ovulatory?

Ovulatory AUB is cyclic but heavy or prolonged Usually due to an anatomic or physical lesion Polyp, Fibroid, Adenomyosis, Foreign Body Hemostatic defect, Infection, Trauma Anovulatory bleeding unpredictable endometrial bleeding of variable flow and duration (most common cause of AUB) PCOS, Thyroid dysfunction, Elevated prolactin

Evaluation Physical
Speculum and Pelvic Exam Determine if there is a bleeding site Size, contour, tenderness of uterus Adnexa Pain General exam Thyroid Evidence of hyperandrogenism Acanthosis nigricans Galactorrhea

Evaluation Labs
Pregnancy Test Cervical cytology Endometrial biopsy all women > age 35 Women age 1835 with risk factors (Family or personal history of uterine CA, Tamoxifen use, Chronic anovulation, Obesity, Estrogen therapy, Diabetes)

Evaluation Labs
TSH Prolactin Level (oligomenorrhea, galactorrhea) H/H Platelet count Coag. Testing if history is suggestive of a hemostatic defect (PTT, PT, factor VIII, von Willebrand factor antigen & activity) GC and Chlamydia testing Androgen levels if there is evidence of virilization

Evaluation
Pelvic Ultrasound transabdominal and transvaginal Saline Infusion Sonography Sterile saline is instilled into the endometrial cavity and transvaginal US is performed Detects small lesions, polyps, submucosal fibroids Hysteroscopy Direct visualization of the endometrial cavity Targeted biopsy or excision of lesions

Treatment
It is important to ask women about the amount of menstrual bleeding and level of fertility they will accept before any treatment recommendations are made.

Bourdrez, et al. Fertil Steril 2004;82:1606

Treatment Medical Therapy

OCPs Oral Progesterone for 21 days of cycle (526) Levonorgestrel releasing IUD Injectable Progesterone NSAIDs Danazol

Medical Therapy
OCPs Limited Evidence, reduce menstrual blood loss, not well studied in menorrhagia Oral Progestins 21 day regimen is effective Depotmedroxyprogesterone acetate may cause abnormal bleeding or amenorrhea not well studied in menorrhagia Danazol synthetic steroid that opposes progesterone and estrogen endometrial atrophy (androgenic side effects)

Medical Therapy
NSAIDs constrict uterine vasculature, reduce prostaglandins, improve platelet aggregation. Menorrhagia 30% reduction in blood loss Levonorgestrel Intrauterine System Most effective medical therapy for treating menorrhagia. (94% reduction in menstrual blood loss)

Treatment of Leiomyomata
Expectant management asymptomatic pts. LNGIUS GnRH agonists no more than 6 mos. Myolysis Myomectomy Uterine artery embolization

Surgical Treatment
Endometrial Ablation 1st generation direct visualization with hysteroscope (regional/general anesthesia) 2nd generation no hysteroscope (local anesthesia) Hysterectomy Definitive treatment Surgical morbidity, increased cost, longer recovery time

References
Apgar B, et al. Treatment of Menorrhagia. Am Fam Phys.2007;75(12):181319. Hill D. Abnormal uterine bleeding: Avoid the rush to hysterectomy. J Fam Prac.2009;58(3):13642. Evans P, et al. Uterine Fibroid Tumors: Diagnosis and Treatment. Am Fam Phys.2007;75(10):150308. Stein K, et al. A Comprehensive Approach to the Treatment of Uterine Leiomyomata. Mt Sinai J Med.2009;76:54656. Marret H, et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Rep Bio.2010;152:13337. Casablanca Y. Management of Dysfunctional Uterine Bleeding. Obstet Gynecol Clin No Am.2008;21934.