Abnormal Uterine Bleeding

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Workup:

- History: menstrual, sexual, obstetric, gyn surgery, contraceptives, endometrial cancer risk factors, bleeding disorders, thyroid or celiac disease, medications.

- Physical Exam: vitals, complete pelvic, assess for current bleeding

- Labs: urine HCG, CBC, TSH, prolactin, ferritin

- Suspect Premature ovarian failure or menopause: FSH, LH, estradiol

- Heavy bleeding: consider PT/INR, PTT, von Willebrand factor

- Androgen symptoms (hirsutism, virilization) consider: DHEA-S and total testosterone

- Imaging: Transvaginal Pelvic US

*For Post-menopausal bleeding: order US, if stripe is >4mm, then hysteroscopyc D&C in OR, if <4mm, then in-office hysteroscopy and EMB.

Indications for endometrial sampling in women of reproductive-age with AUB vary by age group:

●Age 45 years to menopause – In women who are ovulatory, any AUB, including intermenstrual bleeding. In any woman, bleeding that is frequent (interval between the onset of bleeding episodes is <21 days), heavy, or prolonged (>5 days).

●Younger than 45 years – In reproductive-age women, the majority of cases of endometrial neoplasia occur in the setting of ovulatory dysfunction due to estrogenic proliferation with absent or inadequate progestational protection. Endometrial sampling is indicated if AUB is persistent, occurs in the setting of a history of unopposed estrogen exposure (obesity, chronic anovulation) or failed medical management of the bleeding, or in women at high risk of endometrial cancer (eg, tamoxifen therapy, Lynch or Cowden syndrome).

Treatment:

- If atrophic(like with Nexplanon): 1mg estradiol x5days. Repeat PRN to control bleeding. Some patient just need estrogen every few months to maintain endometrium.

- If hypertrophic: 10 mg daily for 10 days starting on day 16 of menstrual cycle. Secretory transformation of the endometrium will occur when adequately primed with endogenous or exogenous estrogen. Withdrawal bleeding may be expected within 3 to 7 days after discontinuing medroxyprogesterone.

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(UpToDate on Iron Infusions)

Typical response — An effective regimen for the treatment of uncomplicated iron deficiency with oral iron preparations should lead to the following responses:

●If pagophagia (pica for ice) is present, it often disappears almost as soon as oral or intravenous (IV) iron therapy is begun, well before there are any observable hematologic changes such as reticulocyte response. (See "Causes and diagnosis of iron deficiency anemia in the adult", section on 'Pica and pagophagia'.)

●The patient will note an improved feeling of well-being within the first few days of treatment.

●In patients with moderate to severe anemia, a modest reticulocytosis will be seen, peaking in approximately 7 to 10 days. Patients with mild anemia may have little or no reticulocytosis.

●The hemoglobin concentration will rise slowly, usually beginning after approximately one to two weeks of treatment, and will rise approximately 2 g/dL over the ensuing three weeks. The hemoglobin deficit should be halved by approximately one month, and the hemoglobin level should return to normal by six to eight weeks.

●Typically, papillation of the tongue is decreased in patients with iron deficiency and can be used as a gauge of duration of symptoms. Classically, loss of papillae begins at the tip and lateral borders, and moves posteriorly and centrally. Following iron repletion, a rapid correction (weeks to months) is observed.

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Emergent/Urgent Uterine Bleeding Treatment:

Hemodynamically Unstable:

- Fluid resuscitation and replace blood products (see table below*)

- Place urinary catheter to monitor output

- Uterine tamponade (max time to leave tamponade balloon or gauze in place is 24 hrs): Consider Gentamicin (1.5mg/kg q8h) and Clindamycin (300mg q6h) for 24 hours when using packing or balloon tamponade

- Foley balloon (approx 30ml of sterile fluid)

- Bakri balloon (up to 500ml of sterile fluid and confirm placement with US)

- Gauze packing: Kerlex (soak kerlex in 5000 to 10000 units thrombin in 5ml sterile saline)

- IV Estrogen: Premarin 25 mg in 5 mL isotonic saline injected over two minutes with a dose repeated at three and five hours from the initial dose if bleeding continued. - May take 5 hours to have significant benefit.

- Oral Estrogen: Premarin 2.5 mg q6hr until the bleeding subsides or is minimal (limit to 21 to 25 days). - After the estrogen is discontinued, a progestin should be given (Provera, 10 mg/day, for 10 days).

Hemodynamically Stable:

- Oral contraceptive pill with 35 mcg estrogen — We use two pills per day for 5 days followed by once a day for 20 days. At the conclusion of oral therapy, women will have a withdrawal bleed that may be heavy, but is likely to last less than five to seven days. *Antiemetic is needed with high-dose estrogen, patients should be prescribed routine antiemetic, possibly suppository (12.5 to 25mg promethazine) if nausea is severe. - Cascading regimen (ie, five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5) - Treatment with one pill daily of OCs should continue for at least one week after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard dose OCs may then be restarted either to prevent recurrent menorrhagia or for contraception.

- If thickened endometrium:

- medroxyprogesterone acetate (10 to 20 mg two times per day)

- megestrol acetate (20 to 60 mg two times per day)

- norethindrone (5 mg once or twice per day)

*Continued for at least 5 to 10 days. In anemic patients who can tolerate this regimen, a one- to two-month treatment period in conjunction with iron allows an increase in the hemoglobin concentration.