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    Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

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    This document provides an overview of the evaluation and management of abnormal uterine bleeding in premenopausal women. It discusses anovulatory and ovulatory causes of abnormal bleeding and the appropriate evaluations and treatment options. For anovulatory bleeding, combinations oral contraceptives or cyclic progestin are recommended to regulate withdrawal bleeding and decrease cancer risks. For ovulatory bleeding, hormonal therapies like oral contraceptives or progestins can effectively reduce flow volume. Surgery may be indicated for structural causes. Thorough evaluation including medical history, exams, and diagnostic testing is important to identify underlying causes and guide treatment decisions.

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    Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

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    정동주
    47 views23 pages
    This document provides an overview of the evaluation and management of abnormal uterine bleeding in premenopausal women. It discusses anovulatory and ovulatory causes of abnormal bleeding and the appropriate evaluations and treatment options. For anovulatory bleeding, combinations oral contraceptives or cyclic progestin are recommended to regulate withdrawal bleeding and decrease cancer risks. For ovulatory bleeding, hormonal therapies like oral contraceptives or progestins can effectively reduce flow volume. Surgery may be indicated for structural causes. Thorough evaluation including medical history, exams, and diagnostic testing is important to identify underlying causes and guide treatment decisions.

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    Uterine Bleeding

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    This document provides an overview of the evaluation and management of abnormal uterine bleeding in premenopausal women. It discusses anovulatory and ovulatory causes of abnormal bleeding and the appropriate evaluations and treatment options. For anovulatory bleeding, combinations oral contraceptives or cyclic progestin are recommended to regulate withdrawal bleeding and decrease cancer risks. For ovulatory bleeding, hormonal therapies like oral contraceptives or progestins can effectively reduce flow volume. Surgery may be indicated for structural causes. Thorough evaluation including medical history, exams, and diagnostic testing is important to identify underlying causes and guide treatment decisions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    47 views23 pages

    Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

    Uploaded by

    정동주
    This document provides an overview of the evaluation and management of abnormal uterine bleeding in premenopausal women. It discusses anovulatory and ovulatory causes of abnormal bleeding and the appropriate evaluations and treatment options. For anovulatory bleeding, combinations oral contraceptives or cyclic progestin are recommended to regulate withdrawal bleeding and decrease cancer risks. For ovulatory bleeding, hormonal therapies like oral contraceptives or progestins can effectively reduce flow volume. Surgery may be indicated for structural causes. Thorough evaluation including medical history, exams, and diagnostic testing is important to identify underlying causes and guide treatment decisions.

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    Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

    AFP 2012;85 (1) 35-43

    R1.

    Introduction
    9 to 14 percent of women between menarche and menopause.
    Pituitary follicle-stimulating hormone estrogen proliferation of the endometrium luteinizing hormone surge ovulation corpus luteum progesterone. In the absence of pregnancy, estrogen and progesterone levels decline withdrawal bleeding (13 to 15 day postovulation) Disruption of normal physiology, anatomic changes in the endometrium, or endometrial cancer may result in abnormal uterine bleeding.

    Anovulatory and Ovulatory

    Anovulatory bleeding - irregular or infrequent periods, with flow ranging from light to excessively heavy.
    Ovulatory bleeding (menorrhagia) - regular intervals (every 24 to 35 days, excessive volume or duration of more than seven days.

    Anovulatory bleeding
    Menarche (the immature hypothalamic-pituitary-ovarian axis), Up to eight years before menopause Ovulation does not occur no corpus luteum forms to produce progesterone prolonged estrogenic stimulation excessive proliferation, endometrial instability, and erratic bleeding. Underlying disease - Polycystic ovary syndrome Uncontrolled diabetes mellitus Hypo or hyperthyroidism Hyperprolactinemia Drug - Antiepileptics (valproic acid) , antipsychotics (haloperidol, chlorpromazine, thiothixene), atypical antipsychotics (clozapine, risperidone)

    Recurrent anovulation causes an increased risk of endometrial cancer. About 14 percent of premenopausal women with recurrent anovulatory cycles develop endometrial cancer or its precursor, hyperplasia with atypia. 30 percent of cases of hyperplasia with atypia progress to cancer, and 42.6 percent of women with this pathology have undiagnosed, concurrent endometrial adenocarcinoma. High risk - advanced age, obesity, nulliparity, infertility, diabetes, family history of colon cancer, long-term unopposed estrogen therapy, or a history of tamoxifen use.

    Evaluation of Anovulatory bleeding


    History - volume or duration of bleeding , periods, intermenstrual spotting, or postcoital bleeding. Physical examination - obesity and hirsutism Pregnancy test Thyroid-stimulating hormone and prolactin levels. ACOG recommends endometrial tissue assessment to rule out cancer

    Office endometrial biopsy - inexpensive, convenient, low risk of complications. (82.3% sensitive for hyperplasia with atypia and 91 % sensitive for endometrial cancer 98 % specificity for both) Hysteroscopy structual abnormality

    Treatment of Anovulatory bleeding


    ACOG - combination oral contraceptives or cyclic progestin

    Progestin therapy and oral contraceptives routine withdrawal bleeding decrease the risk of hyperplasia or cancer correct any related excessive menstrual bleeding
    Oral contraceptives - 35 mcg or less of ethinyl estradiol Cyclic oral medroxyprogesterone acetate (Provera) - 10 mg /day for 10~14 days per month

    Hyperplasia without atypia - cyclic medroxyprogesterone acetate + continuous megestrol (Megace) at 40 mg/day or levonorgestrel-releasing intrauterine system (Mirena) F/U Endometrial biopsy - in three to six months

    Hysterectomy - adenocarcinoma

    Ovulatory bleeding

    Ovulatory abnormal uterine bleeding(menorrhagia) regular intervals , excessive volume or duration. Underlying disease - Hypothyroidism, late-stage liver disease, bleeding disorders (vWD), structural changes(submucosal fibroids or endometrial polyps) Ovulatory bleeding progesterone slough the endometrium regularly minimal risk of developing cancer.

    Evaluation of Ovulatory bleeding


    History : Duration, volume, family history of bleeding disorder, impairment of activities, underlying disease (anemia, excessive bleeding with tooth extraction, delivery or miscarriage, or surgery.) Pregnancy test, CBC (complete blood count) Prothrombin and activated partial thromboplastin time Thyroid-stimulating hormone level

    Transvaginal ultrasonography Saline infusion sonohysterography - enhanced views of the endometrium endometrial biopsy hysteroscopy

    Treatment of Ovulatory bleeding


    The goals of treatment for menorrhagia - reduce flow volume and to correct anemia. <Hormonal Therapies> Progestins - decrease excessive menstrual bleeding (21days/month) levonorgestrel -releasing intrauterine system - reduces menorrhagia more effectively than oral progestins. (the only contraceptive approved by the FDA for the treatment of menorrhagia) Oral contraceptives TOC (vWD who also desire contraception)

    <Nonhormonal Therapies>

    Nonsteroidal anti-inflammatory drugs (NSAIDs) - decrease prostaglandin levels, reducing menstrual bleeding.
    In one small study, naproxen sodium (Anaprox) and mefenamic acid (Ponstel) decreased flow volume by 46 and 47 percent, respectively. There is no evidence that one NSAID is more effective than another Tranexamic acid (Lysteda), - an antifibrinolytic, more effect than NSAID - bleeding disorders (fertility or contraindications to oral contraceptives.

    <Surgery>

    Indication - Uterine polyps and leiomyomas, submucosal fibroids


    Hysteroscopic polypectomy

    Surgical resection (maintain childbearing capacity)


    Uterine artery embolization - embolization of perifibroid vessels causing infarction of the fibroid. Hysterectomy - definitive treatment

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