GYN

CMECNE

Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the lab tests that should be ordered when a woman presents with irregular, prolonged menstrual bleeding
2. Summarize the clinical situations that would warrant an endometrial biopsy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Abnormal uterine bleeding in the setting of anovulation or oligoovulation (AUB-O) results from chronic estrogen stimulation of the endometrium. In the setting of irregular, prolonged bleeding (menorrhagia)

Perform an age appropriate history and physical exam
Appropriate lab tests include
- Pregnancy test
- Thyroid function tests
- Prolactin level
- PT/aPTT
- Sexually transmitted disease testing
- Complete blood count if bleeding is prolonged and heavy
Endometrial biopsy should be performed in women over age 45 or those of any age with risk factors for endometrial hyperplasia or malignancy
- Nulliparity, hypertension, obesity, irregular menses and family history of endometrial cancer
Saline infusion sonohysterography (SIS), hysteroscopy or transvaginal ultrasound may be used to rule out an anatomic abnormality
ACOG states that

Failure of medical management requires further investigation, including imaging or hysteroscopy

SYNOPSIS:

Ovulatory menstrual cycles generally occur between 21 and 45 days, are predictable, and last about 5 days reflecting sequential stimulation of the endometrium first by estrogen alone, then by a combination of estrogen and progesterone and finally by withdrawal of both hormones. The cause of AUB-O can be an abnormality at any level of the hypothalamic-pituitary-ovarian axis. Consequences can include blood loss anemia due to heavy bleeding, as well as endometrial hyperplasia and endometrial cancer.

FIGO Subclassification System

The 4 types can be referred to by the acronym ‘HyPO-P’ | Last ‘P’ separated because it does not track to a single anatomic location

Type 1: Hypothalamic
- Genetic
- Autoimmune
- Iatrogenic
- Neoplasm
Type II: Pituitary
- Functional
- Infectious/Inflammatory
- Trauma & Vascular
Type III: Ovarian
- Physiologic
- Idiopathic
- Endocrine
Type IV: PCOS
- Diagnosis and categorization and recommended by the International PCOS network

Note: According to FIGO, “The new system provides practical utility and a second layer, or sub-classification, for each of the three anatomically defined entities, including discrete pathophysiological categories. These can be remembered using the acronym ‘GAIN-FIT-PIE'”

KEY POINTS:

The levonorgestrel IUD is effective in treating AUB-O and can be offered to all age groups
Progestin and combination birth control pills are common medical options
Weight loss and exercise should be strongly recommended for overweight anovulatory women
Surgical therapy, such as hysterectomy, is rarely indicated but can be considered in women who have failed medical therapy or in whom medical therapy is contraindicated
Hysterectomy with removal of the cervix can be offered to women who meet above criteria and have completed childbearing, or who have significant intracavitary pathology
Endometrial ablation is not recommended as a first line therapy for AUB-O as traditional methods of endometrial surveillance may not be possible after the procedure
ICD 10 code: N93.9

Learn More – Primary Sources:

ACOG Practice Bulletin 136: Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction

AAFP: Review of ACOG Practice Bulletin No. 136

FIGO: Ovulatory Disorders Classification System

Evaluation of Amenorrhea, Anovulation, and Abnormal Bleeding

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