Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
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
Thyroid function tests
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
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
Type II: Pituitary
Trauma & Vascular
Type III: Ovarian
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'”
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
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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