Abnormal Uterine Bleeding (AUB)

The AUB case, discussions about management, investigations and treatment

1. Abnormal Uterine Bleeding Muhammad Redzwan 081303583 MMMC today

2. CASE Patient’s Profile Name: Puan ZA Age: 42 Parity Index: Para 4 Occupation: Teacher Address: Malim Jaya, Melaka Education: Degree LMP: 30 th March 2014 Date of Admission: 7 th April 2014 Date of Examination: 8 th April 2014

3. Chief Complaint Heavy menstruation for 6 months History of Presenting Illness Patient went to KK Cheng due to heavy menstruation for 6 months. She is apparently well and asymptomatic until 6 months ago when there is increase in flow and quantity of menstruation . Before that her flow was 4-5 days with 2 pads daily, but now it is 7-9 days with 3-4 pads daily. There is minimal blood clot . For current cycle, bleeding already stopped 2 days ago. She also experienced dysmenorrhea , but it started since menarche. Her cycle is regular of 28 days. No inter-menstrual or post-coital bleed. No similar history before. Systemic review reveals that she is lethargic and has palpitations . Other systems are unremarkable. After admission, blood was taken for investigations. She undergo abdominal and transvaginal ultrasound. IV saline has been infused, and tablet iron has been prescribed.

4. Past Obstetric History Blood Group: A Rhesus Positive Past Gynaecology History No significant. Menstrual History As mentioned in HOPI Pap’s Smear was done, twice in 2001,2008. No significant findings OCP was used after each pregnancy. Last 2010. Year Gender Birth Weight Mode of Delivery Breastfed Complications 2000 Male 2.9 kg Term SNVD 6 months nil 2002 Male 3.0 kg Term SNVD 6 months nil 2005 Female 2.8 kg Term SNVD 6 months Anaemia 2008 Female 3.1 kg Term SNVD 6 months Anaemia , GDM

5. Past Medical/Surgical History Has appendicectomy done in 1998 under GA at HTAA, no complication. No other significant history Personal History No changes in Bowel and Bladder movement. No L.O.A, L.O.W No change in sleep pattern No known drug and food allergies

6. Family History She is first of 6 siblings. Her father has diabetes mellitus and hypertension . Mother and other siblings are healthy. Her aunty of maternal side has GI carcinoma (not sure gastric/colorectal) No blood disorders and other gynaecology problems in her family/relatives. Social History Patient lives with her husband and children at Malim about 15 minutes to MGH. She owned a car. Her husband is also a teacher. They are financially and socially stable. They are not smoking, do not consume alcohol and using recreational drug.

7. General Physical Examination Patient is alert, cooperative and lethargy . IV canula inserted into her dorsum of left hand, connected to Normal Saline Vitals:- Pulse: 108 bpm , regular, low volume , no collapsing pulse, no thickening of vessel wall Blood Pressure: 110/76 mmHg, right arm supine. Respiratory Rate: 16 breaths per minute. Temperature: Afebrile Patient is pale . No koilonychia , platynychia . No cyanosis, jaundice, ulcer. No swelling of the neck, no cervical and axillary lymphadenopathy . No swelling of the breast. No pedal edema. Local gynaecological examination is unremarkable.

8. Summary 42 years old Para 4 teacher came to the hospital for menorrhagia since 6 months ago. She also experiences lethargy and palpitations. O/E she is pale; pulse is 108 bpm . She was admitted for further investigations and management.

9. Investigations FBC: Hb levels 8.1 g/ dL (7/4/2014 9.00am) 7.9 g/ dL (7/4/2014 4.00pm) 7.8 g/ dL (8/4/2014) Coagulation Profile: Normal Ultrasound: No mass in vagina, uterus, ovary. Endometrial thickness: 6 mm.

10. Discussion

11. AUB - Definitions In pre menopausal women, AUB is diagnosed when there is a substantial change in frequency, duration, or amount of bleeding during or between periods 1 . In post menopausal women, any vaginal bleeding 6 months 2 or 1 year 1 after cessation of menses is considered abnormal and requires evaluation . Approach to diagnosis and management of abnormal uterine bleeding; Canadian Family Physicians Journal

12. AUB – Causes 2,3,6 Dysfuctional Uterine Bleeding (DUB ) Pregnancy (Normal/Ectopic), Miscarriage Adenomyosis Use of birth control method (pills, IUCD) Fibroid, Polyps Endometrial Hyperplasia Polycystic Ovarian Syndrome Infection Carcinoma 3 FAQ095 AUB by The American College of Obstetricians and Gynecologists

13. How to Proceed? Primary Survey and Resuscitation 1 History taking 1,2,4,5 To identify the type of AUB [ ovulatory (cyclical), anovulatory (irregular, heavy), anatomical ( e.g fibroids/polyps)] Past obstetric/ gynaecology history – fibroids, h/o myomectomy Family history of cervical/endometrial ca. Medications: ASA, Antidepressants, Anticoagulants, HRT, etc Physical Examination 1,2,4,5 To detect systemic involvements, mass per abdomen; pelvic and bimanual examination must be done. Vaginal swabs TRO infections, cervical cytology.

14. Investigations Pregnancy Test, Complete Blood Count, CoAgulation profile 1,4 . Other blood investigations must be according to differential diagnosis 1 . Ultrasound: Abdomen and Transvaginal for Ovarian/Uterine diseases (fibroid, polyps) 1,2 Endometrial biopsy TRO endometrial cancer 1,2,4,5 Other: Diagnostic hysteroscopy, sonohysterogram and Dilation and curettage (D&C) 1

15. Dysfunctional Uterine Bleeding Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina that is due to changes in hormone levels 6 . It is a diagnosis of exclusion where other possibilities ( e.g growth, blood disorders) has been excluded 1,2,4,6 . Commonly occurs when the ovaries do not release an egg. Changes in hormone levels cause period to be later or earlier and sometimes heavier than normal 1,4,5 .

16. DUB – Symptoms and Signs 2,6 Bleeding or spotting from the vagina between periods Cycle <28 days or >35 days Cycle changes each month (irregular) Heavier bleeding (such as passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 - 3 hours in a row) Bleeding lasts for more days than normal or for more than 7 days

17. DUB – Other Symptoms 6 Due to hormonal imbalance: Excessive growth of body hair in a male pattern Hot flashes Mood swings Tenderness and dryness of the vagina Symptoms of Anaemia

18. DUB - Prognosis Hormone therapy alone usually alleviates the symptoms 4,6 . Other complications include: a. infertility 6 b. anemia (due to blood loss) c. endometrial cancer 6

19. Management In Premenopausal and Perimenopausal Women 1,4 Menorrhagia assc . with ovulatory cycles can be treated with/without hormones. NSAIDs and Antifybrinolytics . Menorrhagia assc . with anovulatory cycles need to be treated by COCP, levonorgestrel intra-uterine system (LNG-IUS) or Cyclic Oral Progestin Menorrhagia assc . with fibroids can be treated by tranexamic acid, low-dose COCPs, androgens, or GnRH agonists.

20. In Postmenopausal Women 1,4,5 Causes includes: vaginal atrophy (50%), endometrial ca. (25%) and cervical ca. (2%) Endometrial biopsy and/or Transvaginal USG must be done. F or vaginal atrophy: Topical Estrogen cream, tablet or vaginal ring; lubricans ; or moisturizers

21. Surgical Options 1,4,5,6,7 Endometrial ablation (laser, electrical, thermal or radiofrequency energy) can be suggested [85% have fewer symptoms]. 1,4,7 Hysterectomy ( permanent cure) 1,5,7 Uterine artery embolization and myomectomy can be used for fibroids. 1 Dilation and Curettage (D&C) is no longer considered as treatment. 1

22. References D. E. Telner , D. Jakubovicz (2007), ‘Approach to diagnosis and management of abnormal uterine bleeding ’, Canadian Family Physicians Journal, Vol. 53 No. 1, pp 58-64. ‘Disorders of Menstruation’ (2012), Gynaecology Today, 1 st Ed., pp.197-240. The American College of Obstetricians and Gynecologists (2012), ‘Abnormal Uterine Bleeding’, FAQ No.095 G. A. Vilos et. al. (2001), ’ Guidelines for the management of Abnormal Uterine Bleeding ’, J. Obstet. Gynaecol . Can., Vol. 23, No. 8, pp 704-709 The American College of Obstetricians and Gynecologists (2013), ‘Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women’, Committee Opinion No.557 , Obstet Gynecol 2013;121:891–6. MedlinePlus (2011) ‘ Dysfunctional uterine bleeding (DUB ) ’, National Library of Medicine National Institute of Health P. Bourdrez (2004), ‘ Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation, a levonorgestrel -releasing intrauterine device, or hysterectomy ’, Fertility and Sterility, Vol. 82 Issue 1, pp 160-166 MedlinePlus (2011) ‘ Endometrial Carcinoma ’, National Library of Medicine National Institute of Health

23. Q & A

24. THANK YOU P/s : Further reading: Gynaecology Today Chapter Disorders of Menstruation Page 197-240 Slides can be retrieved in Slideshare