Chapters Transcript Abnormal Uterine Bleeding: A Review of Evaluation, Diagnosis, and Management Dr. Aneesh Chawla, MD, MS walks through the causes, diagnostics, evaluation and management of abnormal uterine bleeding. Welcome back everybody. So I'm gonna go ahead and introduce our next speaker. We have hi, Doctor Chala. We have Doctor Anish. Is it Anish? Yeah, Tala. He earned his medical degree at Wake Forest University School of Medicine in Winston, Salem, North Carolina. He then completed his residency in obstetrics and Gynecology at Southern Illinois University School of Medicine in Springfield, Illinois. Doctor Chala is currently an assistant professor of obstetrics and gynecology with the washi physicians at Barnes Jewish Hospital. He also sees patients at the Center for Advanced Medicine in South County. Is that correct? I saw that on the website. I just wanna make sure. Well, thank you so much for your time today and we look forward to hearing your talk on abnormal uterine bleeding. So I will let you have the floor. Ok, perfect. Thank you for having me. Um Really excited to give this talk especially uh just coming out of training. You used to get a lot of consults and residency, especially on the inpatient side of what to do for these patients as well as on the outpatient side of just questions on how to evaluate and manage patients with uh abnormal uterine bleeding. Um So we'll go through a couple of things um to start with. I have no financial disclosures or conflicts of interest. Um So we'll go through a couple of things this afternoon. We'll review the causes of abnormal uterine bleeding, review the diagnostic evaluation for abnormal uterine bleeding, um discuss management options and then talk about evaluation management of acute abnormal uterine bleeding. So, uh abnormal uterine bleeding also called A UB. It seems like something, hey, won't come up very often, but it's actually about a third of the visits um that we see on a gynecologic side and accounts for about 70% of the inpatient uh gynecologic consults um that we get for patients, especially in the per post menopausal age group. Um So just to make sure that we're all in the same sort of baseline. Um I like to do a little bit of review of the menstrual cycle. Um Typically, we think about the menstrual cycle being on average about 28 days uh with a split down the middle, with the 1st 14 days being the follicular phase and the second half being the luteal phase during that follicular phase. What we're seeing is increased levels of FSH, follicle stimulating hormone acting on um the follicles within the ovary to cause maturation so that the egg with the follicle will ultimately be released um with our luteinizing hormone surge at about midway through the cycle, with the hope that you know, there'll be um you know, meeting of the egg and the sperm to create a embryo that will implant in the uterus um when that doesn't occur. Um you know, we have our corpus luteal cyst that remains after the follicle ruptures, it'll create progesterone, um which helps to continue creating a thickened lining um for implantation but should pregnancy not occur. Um There'll be a decrease in that progesterone and especially, you know, the enemy treatment is very sensitive to that. And as a result, um we get menstruate uh menses, which is the equivalent to having a progesterone withdrawal bleed, but it's, you know, um being managed by the body itself. Um a couple of definition, things that I think are important, especially for talking to patients about what's normal, what's abnormal uh variation of a normal menstrual cycle can vary from 21 to 35 days in length. So we're talking about day one of Menzies to day one of the next Menzies. So patients who come in uh may have concerns about that, but having that sort of range in mind can definitely give a little bit more ease to patients. On average menses last about five days. Patients who are having menses greater than about eight days in duration typically do warrant for their evaluation. We talk about poly menorrhea. So bleeding, that's sooner than every 21 days that uh oligomenorrhea, which will then be bleeding greater than every 35 days, some other sort of just housekeeping nomenclature, things which are important um when talking about patients, especially probably in the last decade or so. Um ACOG the governing body for a strict gynecology has pushed for a change in nomenclature. Um that things like dysfunctional uterine bleeding that can be um switch to abnormal uterine bleeding, menorrhagia, um be referred to as heavy menstrual bleeding and menorrhagia be referred to as intermenstrual bleeding. And so using that overarching term of abnormal uterine bleeding, um we then refer to it as abnormal uterine bleeding with heavy menstrual bleeding or intermenstrual bleeding. Uh The other thing that we take a look at and keep in mind is potential causes for abnormal uterine bleeding. Um We typically break that down into structural and nonstructural causes using the 2011 ego classification system. Um Our structural causes can be polyps which tend to be benign overgrowths within the endometrial tissue adenomyosis. Uh which sorry, let me go to this next graphic makes a little bit easier to sort of visualize. So, uh polyps that can arise within the endometrium can cause abnormal bleeding, especially just when you look at where they're located, it can affect the actual endometrium itself uh and disrupt it for normal menses, adenomyosis, which the best way to describe it would be similar to endometriosis, but of the uterus itself where you have imagination of the endometrium growing into the uterine muscle and the myometrium um that can cause heavy and painful menses. Um leom myomas, so, fibroids um which depending on their location can again disrupt the endometrial lining and cause heavy bleeding. The other structural thing that we worry about is malignancy and hyperplasia um which can be pretty worrisome for patients from a nonstructural standpoint. Um Our acronym which is the structural and coin, which not even spelled like the word coin, but close enough for what we're talking about today. Uh Our nonstructural causes include coagulopathy. Um So on Willebrand's dysfunction would be a major one that we consider ovarian dysfunction for patients. So those who have an ovulatory cycles related to endocrine dysfunction, whether it be hyperthyroidism, hypothyroidism, including subclinical hypothyroidism and Polycystic Ovarian syndrome, endometrial issues, whether it be hyperplasia from a cycles can also be a component there. Their iogen causes that uh it's important to keep in mind. Um you know, in some cases, their abnormal meaning may be a result of their birth control, whether it's an IUD the next one on implant OCPs. Um as well as if there are other medications. One of the biggest reasons I've seen consults on an inpatient setting is abnormal uterine bleeding and the setting of new anticoagulation. Keeping in mind that that can be an androgenic cause for this type of abnormal bleeding. And then last but not least we have our n category which is not otherwise classified. Um It's less common but just sort of our catch all for hey, it's not fitting into any other category. So when we look at abnormal uterine bleeding, our biggest, biggest, biggest thing that we need to do is a history and physical exam, getting all this information for patients to get a good differential and where to go from there. Um really stems at the heart of the history and physical exam. So looking at their age of monarchy, if they're having bleeding after menopause, so we have an idea of how long they've been menopausal, getting idea of their menstrual bleeding patterns. How long do they have between menstrual cycles? How many days their cycles are lasting? How much bleeding they're having? Uh are they passing clots? How many pads tampons they're going through? Are they fully soaking them? Are they just changing them for comfort sake? Um Associated pain. So also known as dysmenorrhea. How bad is it on a scale of 1 to 10? Does it affect their life in a way that it prevents them from being able to go to work and do their normal activities of daily living? Take a look at other medical conditions that could be contributing to their symptoms, evaluating for a surgical history. Um You know, if we have a patient, she's had a hysterectomy and she's having abnormal bleeding less likely to be coming from the uterus, but does give us concern for where there may be issues with the vaginal cuff and other things that may be going on with the vagina um medications, especially looking at herbal supplements, um such as Saint John's Wart, uh Ginko Ginseng, um as well as medication, anticoagulants are important to have an idea of what else could be contributing, looking for signs and symptoms of hemostatic disorders. So, do they have CT I do they bruise easily. Those things are important for the general physical exam other than listening to heart and lungs um for patients that come in with this issue, we do recommend doing a physical exam um that includes a pelvic exam. So take a look with the speculum, examining the cervix, looking for active bleeding, looking for any abnormalities, lacerations. Um If they are not up to date with their pap smear, making sure pap smear has been collected ST I testing that can be collected as well as a bimanual exam to appeal for any abnormalities within the uterus as well as bilateral N sub. It is important um in these patients no matter their age to really do a good family history as well for any bleeding or clotting disorders. But percent of patients with abnormal uterine bleeding will have some sort of coagulopathy that's inherited. Uh Most often we'll see this in patients who are having heavy menstrual bleeding at the initiation of menses. And this will be the first time they've had really any sort of abnormal bleeding. Uh And when you do that sort of evaluation, we tend to find that those patients are more likely to have issues with Von Willow Brand's disease. So, um again, looking for the disorders of hemostasis. Uh The other things we keep in mind are if they've been having heavy menstrual bleeding since monarchy. Um history of postpartum hemorrhage, which is defined as greater than a leader of blood loss at time of delivery, re regardless of vaginal or cesarean delivery, uh excess bleeding with surgery, dental work or uh specifically, if they have two or more uh uh bruising 1 to 2 times a month, that's unexplained, nosebleed, frequent gum bleeding, especially with brushing their teeth or family history of bleeding issues. So from a lab work up standpoint, first and foremost, always get a pregnancy test for these patients just because we wanna make sure that this bleeding is not uh change due to implantation or early pregnancy related bleeding that may be related to placental location. Uh We do recommend starting with a complete blood count to evaluate for anemia um as well as coags for the patients. Typically, I'd start with just a PT and A P TT. Um If there are further concerns for things like Von Willebrands, um doing more of a deep dive into things like a risk, wrist ace assay. Um And when you start getting into that nitty gritty, that's typically from my standpoint, not my comfort level, but that's typically when I would involve in technology, but to each provider's preference. Um We recommend checking a TSH, just because hyperthyroidism, hypothyroidism, whether overt or subclinical can also affect menstrual cycles and regularity. Um while not included on the sort of these A R recommendations, uh we also do recommend evaluating for elevated levels of prolactin, the patient who may have uh a slightly elevated prolactin. We do recommend repeating that test as a fasting uh lab just to evaluate for if there's prolactin dysfunction, that could also be altering the uh hypothalamic pituitary ovarian access to cause issues with ovulation and um uterine bleeding. Um As well, we do recommend ST I testing. Um Recommendation is to at least get chlamydia testing more often than not. The swabs that you that from the office include a combined gonorrhea and chlamydia swab. I also recommend checking for trichomonas, bacteria, vaginitis, yeast infections, whether doing through PC R swabs or doing uh wet prep in the office. Um From a imaging standpoint imaging is an important guideline for us to figure out if there's a structural cause to the bleeding that a patient is having. Uh more often than not. I do recommend just starting with a transvaginal ultrasound. It typically, especially with the improvements in imaging. Uh You can get a lot of information from it that helps you guide your decision making and management. Um Occasionally, it may be helpful to do what we call an S isa saline infusion son of his gray. So, uh Saline ultrasound, which is a transvaginal ultrasound where we put a tiny catheter into the cervix into the uterus um and inject some saline while we're doing imaging with the ultrasound, just to evaluate for structural issues like polyps and fibroids. Um that may be pedunculated more often than not. We do not recommend doing CT or MRI as a first line of imaging. Besides the cost itself, the amount of information is not gonna be much different from what we'll get from a transvaginal ultrasound, um which tends to be more helpful for what we're looking at. If you're unable to do any sort of imaging like that, you know, from a gynecologic standpoint, we're happy to do potentially in office hysteroscopy, which is a procedure where doing our pelvic exam, we would go in with a very, very tiny camera through the cervix end of the uterus to do a visual evaluation of the endometrium. The other things that we do consider are doing endometrial biopsies for patients, particularly if they are over the age of 45 with abnormal bleeding or they have significant risk factors such as and obvious cycles with PC os or obesity and it is just due to increased risk of endometrial cancer. Um When this cannot be performed in the office setting, we do recommend taking the patients from our standpoint to the or where we perform a hysteroscopy with a dilation heritage just to do a little teaching about uterine fibroids and how they can relate to heavy menstrual bleeding. Um when we look at locational fibroids and how these can affect bleeding. Our biggest concern is gonna be with what we call type zero. So pedunculated fibroids and those that are gonna be type one and type two, which are affecting uh the uterine cavity shape as well as the endometrium. Uh And as a result can really cause increases in bleeding. Just because of that distortion, we can still see some increase in bleeding with type three through six fibroids. Um Once we get to more of the subserosal or uh fibroids that are not really within the uterine cavity themselves, less likely to be the major cause of bleeding for our patients. So next, we're just gonna break down what we should consider for our differential diagnosis for these patients based off of age and treatment recommendations. So a lot of our younger patients, especially we're talking about age 13 to 18. So just getting started with their menstrual cycles, there may be some irregularity for that 1st 12 to 18 months, typically after three years of menstruation. Though, if we're still seeing irregularities, that is about the time when we start talking about what else we could do and what evaluation needs to be done. And so this is the situation where we're worrying about an ovulation. Uh that's potentially physiologic or if there's something else going on, we do keep in mind other things such as the female athlete triad where they are, you know, the very, very skinny patients who are exercising significantly to the point that they're not going to have a cycle as a result of sort of that shutdown of that HPO access. Uh We also do look at, are they on any sort of contraception that could be affecting their cycles? Are they pregnant? Do they have infection? The recommendations are for all patients under the age of 25 to really be routinely screened for gonorrhea and chlamydia. Um And if we see that type of infection, making sure that it's appropriately treated, their partner is appropriately treated can really have a big impact on the bleeding that we're noticing again. Like I mentioned earlier, coagulopathy are usually first well diagnosed in these patients when they start having the first menstrual cycles. Um they, from my experience, um they tend to end up in a hospital with such heavy bleeding that they require IV medications to help stop acute bleeding as well as potential uh blood transfusions. This is when we really wanna make sure that we're doing a f full coagulopathy, work up and evaluating what can be done. Um That's very rare, but we do also try and make sure that we're not missing any sort of tumor like a rhabdomyosarcoma. So our treatment plan for our younger patients tends to be very focused heavily on oral contraceptive pills, uh particularly combined oral contraceptive pills, uh making sure that they don't have any contraindications, which tends to be much lower in our younger patient population. Um especially those with wop of these being on these medications, especially with doses that contain 20 to 35 mcg of ethanol estradiol. Um will see increases in factor eight and on Willebrand factor, which can help with some of that copy uh for our patients where there are concerns with PC OS and they're having excess sort of androgen manifestation whether it be terminal hair um or acne. Um you know, being on OCPs can help suppress that ovarian and adrenal uh androgens as well as increase the sex hormone binding globulin um to decrease the amount of circulating androgens. Um I do caution that it's very uncommon for us to make a formal diagnosis of Polycystic O bearing syndrome in patients, especially under the age of 21. When we get imaging, the thing that we keep in mind is they may have polycystic appearing ovaries at that age, but it's not uncommon for that to occur in the setting of normal physiology. And so we do want to be careful about not giving them that label and diagnosis when it could just be normal physiology and waiting till they're a little bit older and cycles are established to talk about that. Now, in our patients who are ages 19 to 39 again, always concerned for pregnancy. This is where our imaging um is gonna be helpful and it's important to keep in mind the type of imaging our patient will be able to tolerate, especially our younger patients who have not started having sexual activity. Uh and our young teenage patients, a transvaginal and pelvic ultrasound is not gonna be well tolerated. And in those patients highly recommend just trying to do transabdominal imaging first. Um And using that as an opportunity to look for any structural concerns like fibroids or polyps. Um when we get into this age range, this is where we start to consider an ovulation, whether it's related to PC OS. There are a whole slew of labs that we can talk about for evaluating that. Um But that is typically are less common concern with abnormal bleeding in this age range. Um There is a low concern for endometrial hyper, but especially our patients who may be having an ovulatory bleeding where they may be having a cycle every 23 months. Uh Our concern is that thickened endometrium because it's not being shed, that continued growth can increase their risk for developing endometrial intra neoplasia um at an earlier age. And so we wanna make sure that we're evaluating for that and then talking to them about treatment options, whether it be on combined uh birth control or doing cyclic Progeston so that they're having regular withdrawal bleeds. Um Again, in this patient population under the age of 40 we're gonna be less concerned for uh any sort of malignancy. Um So again, we're looking at talking to our patients about starting OCPs. Uh We do wanna really make sure that they don't have contraindications such as uncontrolled hypertension, tobacco use. Uh while a relative conation are patients where we do not recommend estrogen contain birth control are gonna be those who are tobacco users over the age of 35. Uh patients who have migraines with aura due to the increased risk of stroke on estrogen containing birth control patients with a history of DVTs PE S hepatic and renal dysfunction. We want to be very careful about giving them combined birth control options. Uh We do have non estrogen containing birth control options, which there are plenty of, they're very well tolerated. Um I thought of doing progesterone pills and the Depo Provera shot the ones that I routinely counsel my patients about our um intrauterine devices that contain uh progestin such as the Mirena IUD, which is actually approved for five years of use um for heavy menstrual bleeding and uh abnormal bleeding as well as up to eight years for contraception. And because it's long acting reversible contraception, it's great for our patients who really do not want an unintended pregnancy. And when they desire pregnancy as a matter of just removing their IUD uh being their cycles coming back pretty quickly for them to be able to attempt to conceive um for patients with concerns for PC OS and and ovulatory bleeding. Um even weight loss of 5 to 10% can really make a drastic difference in their overall reading pattern um and can cause them to return to having a more normal menstrual cycle. Um This is especially important uh when we talk to our patients who have an obvious reading who are interested in attempting to conceive. Um this can make a big difference in ensuring that they're having regular ovulation that can help them to become pregnant. Lastly, we talked about our patients who are age 40 above getting close to menopause um with the average age of menopause being 51.8 years old. Um and that permenopausal period lasting up to four years with hot flashes and changes in their bleeding and formal menopause being diagnosed as 12 months. Um in that age range without a menstrual cycle. Uh Again, we're tending to see in these patients more of that and obvious word of bleeding just due to changes in their ovarian function. This is where we do become a little bit more concerned about other issues such as endometrial hyperplasia and rethel neoplasia. So specifically the recommendations that we're gonna be providing to our patients are if they're coming from another provider who started a work up, they're over the age of 45 we're gonna start with a biopsy just so that we can rule out that very small, you know, 5% chance of cancer in those patients. Um As we get closer to menopause, you know, we do find that patients tend to continue to develop endometrial polyps. Uh and that a lot of the bleeding that we see in those patients can be related primarily due to atrophy, whether it's the endometrium or even just pulver and vaginal atrophy. That tissue as the estrogen levels decrease in menopause can really cause atrophy of the skin that makes it more likely to have small bresick tears with intercourse and just activities of dating. Nothing. We also do take into consideration Liam Myomas uh depending on their size and location. We wanna make sure that they're being appropriately managed to best help control those symptoms for patients. So for uh age 40 plus patients again, were considering OCPs proge therapies like an IUD um cyclic progestins if they do not want contraception. Um and particularly just want to make sure that they're getting that regular withdrawal bleed. And then the, this is the each population where we start talking about things like endometrial ablation. Um And the reason it's important that we give more of an age cut off when we talk about this is that endometrial inflation as a procedure, we think of it as a stop gap to help us control bleeding and um heavy menstrual bleeding symptoms. So the patient can get to menopause um and doing a procedure like this on a patient who's in their twenties, early to mid thirties, it's a temporizing effect, but it can have unintended consequences of side effects that ultimately cause the patient to end up having a hysterectomy at a younger age than would typically otherwise plan for if they had had an ablation at a later age. It's also important for these patients to be well counseled that they must be done with their child bearing and have a very permanent form of contraception. And this is because with an endometrial ablation, we are burning the endometrial lining to the base salas. And as a result of that, it's an inhospitable environment for um implantation of a pregnancy. So, should these patients become pregnant, it very much increases their risk of developing an ectopic pregnancy. So, moving on, um we'll talk real quick about some of the management and evaluation from the inpatient side of things for abnormal uterine bleeding, especially in an acute setting. Um So these are the patients that come into the hospital, they're in the er and especially if you're in a location where there's not a gynecologist available. Um You may get called in patient, it's just not doing great. They may have some hypovolemia chemo demic instability. And so the key things that you wanna go to right away are making sure that we're getting adequate IV access. At least one, if not two large bore 1618 gauge ivs on these patients, so that we can uh you know, give them a large amount of crystalloid to help hyperemia and hemodynamic instability. And then being able to check labs, particularly you wanna check your blood count your coags and especially making sure depending on how the patients presenting, getting a type and cross for potential transfusion. Very similar to in the outpatient setting. These patients who present with acute A UB, we want to be doing a very thorough history looking for any family history, getting an idea of what their cycles are like if there are any precipitating events, changes in medications as well as doing a repeat exam. Um, This is especially important so we can get an idea and quantify the bleeding. I do recommend to providers that are seeing patients um in an acute setting that if you're doing a speculum exam, that you particularly use procto swabs to really clear out um the vaginal vault, evaluate for any areas that might be actively bleeding just because in a patient who comes in that may have recent trauma to um the vulva vagina, the cervix itself. If that's your root cause, being able to uh create excellent hemostasis will really create a great impact on those patients. Um It also gives us an idea of how much bleeding they may be having, especially a patient who's in uh uh supine position, that blood may be just accumulating there within the vaginal vault. And the minute they get up, they'll pass a large clot. So being able to clear that out. So we have an idea of the bleeding as well as I do recommend um for those patients to get pad counts um, so that we're able to quantify the amount of bleeding by weighing the pads themselves and seeing sort of a quantified number of blood loss. Lab wise is gonna be very similar checking a pregnancy test. CBC Coags. Um TSH, I do recommend checking a prolactin as well if they've not had recent ST I screening, making sure that they're getting uh gonorrhea chlamydia testing performed. Uh This can be done by uh endocervical vaginal swabs. It can also be collected by urine um and making sure that they have a recent set of uh a recent C MP. So you can make sure that there's no uh renal or coptic dysfunction before talking about medication management. Our goals with acute abnormal bleeding are to really control the bleeding so that the patient is able to remain stable and not require emergent uh intervention within the or and then to discuss what may be going on so that we can reduce menstrual blood loss in subsequent cycles. Um Again, a lot of this is gonna be dependent on their clinical stability, the overall acuteness of the bleeding, what the suspected etiology is. Uh you know, from an inpatient setting, you know, when we get consulted for these patients, depending on the amount of bleeding that's going on, especially in patients who we are typically consider doing an endometrial biopsy on. Um So those are age 45 plus or have risk factors such as obesity and ove cycles. Um it may be difficult for us to actually perform that evaluation to see what's going on just because of the severity of the bleeding. Um that creates a nondiagnostic sample for us. Um We also wanna get an idea of just the patient desire future fertility in rare instances and it tends to be more obstetric than gynecologic in nature. Such heavy bleeding can result in emergency hysterectomy. Um and then take a look at what other medical problems the patient has their understanding of their health literacy, especially when it comes to their medications, how they're taking them. Um and any recent procedures they've had when it comes to acute management. Um Once sort of that workup's been started, um I do recommend that patients have imaging just so we have an idea of what's going on and make sure that we're not missing any structural causes that can be immediately identified and treated. Um What we look for is starting them on high dose IV estrogen. So, uh this will be IV uh Premarin 25 mg every 4 to 6 hours for about 24 hours before switching them to another form of estrogen. Typically, we consider doing high dose OCPs. The other option is depending on the availability of things like Premarin doing monophasic, uh combined oral contraceptive pills for these patients. Uh This can typically be done as taking three pills. Um Oh uh sorry, this can be done by taking one pill three times a day for seven days as an acute uh starting dose and then doing a taper from that point on. So, taking um three pills daily for three days, two pills daily for three days and then one pill daily to finish their pack, skipping the placebo and then starting their next pack of birth control. Um It is important to evaluate for contraindications for these patients. One of the nice things that I do recommend that, um, there's a free app from the CDC that talks, uh about contraception. Um, and it tells you the mec criteria to let you know the risks depending on the patient's comorbidities, uh, using particular, um, contraceptive medications for patients who are not candidates for estrogen. We do recommend using medroxyprogesterone acetate, uh, Provera IV. Um, you can go up to 20 mg IV every eight hours for seven days and then switch over to Po Provera, um, 10 to 20 mg anywhere from 1 to 3 times a day. I do not recommend starting patients on Depo Provera, um, during acute bleeding and it's just because our ability to control and titrate, um, that as a medication is not as good as doing other forms of IV medications or oral medications. Um, another option that we have available for our patients is Tranexamic acid TX A. Um, it's another great option for patients who are just not good candidates for these other, uh, medications containing estrogen or progesterone. Um, and that's can be given IV can be given po you can give either 600 mg being the max dose dose at 10 megs per keg every eight hours IV or giving patients um 1300 mg po every eight hours for about five days. Um Again, you wanna make sure that these patients aren't at increased risk for thrombosis before starting them on TX A. There are a couple of other options. These are less common for us to use on the acute side. Um using intranasal depressant for patients who have on Will Brand's disease. Um is an option. It's not something that I've actually ever seen done before. It's more of a theoretical uh keeping in mind that using this can cause hyponatremia in these patients as well as fluid retention um which is not great in a patient who's having active hemorrhaging. Um You can do recombinant factor eight and B. Von Willebrand factor um in severe hemorrhage. Um We do recommend avoiding nsaids for patients during these acute bleeds um just due to changes in platelet function or dysfunction, um especially with aggregation um as well as interaction with the liver and kidneys, um especially when starting OCPs at the same time in the rare circumstances that you call us for a consult. And we say, hey, this patient's so severely bleeding that we've tried medications. It's not really helping. Um We want to think about our temporizing solutions which can include placing uh a 26 inch a catheter within the uterus uh and filling it up with 30 cc of saline. And that can create an intrauterine tampon on is very similar to uh from an centric side, we use something called a Bakary balloon for postpartum hemorrhage, which very similar idea just filling that uterine cavity with uh saline and creating tampon by pressing against the uterine lining and creating hemostasis from that standpoint from a surgical standpoint, assuming a patient is stable, um We can talk about doing AD and C uh typically in the acute setting, it's not gonna be very feasible for us to do a hysteroscopy to evaluate for structural abnormalities. And it's just because with very heavy active bleeding, we're not gonna be able to visualize and it makes it a very difficult procedure and that in itself has a lot of risks. Um You know, our goal would be preferred to get the patient stabilized um to potentially do a more controlled hysteroscopy DNC. Um Routinely, we do not recommend doing endometrial ablation for acute bleeding while it's an option. Um It's typically not preferred just because again, we wanna make sure that when we're doing an endometrial ablation that we are really getting um good sampling to make sure we're one ruling out any sort of neoplasia that might be underlying as well as uh making sure that we're really able to well um upl the endometrium um in rare circumstances depending on the type of bleeding as long as it's not so cute that the patient's hemodynamically unstable, we can consider um consultation to interventional radiology to discuss uterine artery embolization, which I will talk about a little bit more in a couple of slides. Um And in rare circumstances, our last resort would be proceeding with a hysterectomy for patients in these situations where it's so cute that we do talk about hysterectomy. These patients tend to end up with a total abdominal hysterectomy. So overall long term management, just to sort of review recommendations and things that are reasonable for starting. Um depending on your comfort level with insertion, placing uh lemon, oral IUD. So the Mirena Loleta kyla sina, all find options. I typically do recommend especially for abnormal uterine bleeding, uh placement of the Mirena just because from an FDA standpoint, it is the only one that is FDA approved for heavy menstrual bleeding. Um doing combined oral contraceptive pills with estrogen and progesterone. Um There are definitely options depending on what the bleeding is like. Even on OCPs, patients may benefit from having fewer cycles. And that may be a discussion with gynecology of saying, hey, would it be better for the patient to do OCPs and take a placebo week or skip that placebo week, do 22 to 4 packs of their OCPs and then take the placebo week to have uh a normal menstrual cycle. Similarly, we can do proge therapies with De Provera, which would be an intramuscular injection every three months, typically about every 11 to 18 weeks, uh sorry, 11 to 13 weeks. Um as well as oral progestins such as Provera No Ayro um and one which is a little bit newer to the market and not as easily available due to just how many options there are and cost would be risperiDONE, which the brand name goes by. Sly is another option um from an outpatient standpoint for patients who have abnormal bleeding. Um It's reasonable to try them on TX A. Um starting with 1300 mg every eight hours. Um up to five days once their menstrual cycle starts, uh we can also talk to patients about doing scheduled and a lot of patients tend to become a little bit more hesitant when you tell them that you recommend doing Ibuprofen or Naproxen, but these definitely have great efficacy. Um We recommend starting it on the first day of their cycle and continuing until 2 to 3 days after their mends ends. We're talking about doing Ibuprofen 600 mg every 6 to 12 hours. Naproxen either doing 500 mg with a repeat dose in 3 to 5 hours and then about uh every 12 hours or twice daily or the other one, which is an option which you tell patients that there's another medication and it's something that they've never heard of. They may be um more likely to try is methane acid. Um It's another type of NSAID, doing 500 mg every eight hours or 500 mg as a loading dose with 250 mg every six hours is another option. Uh Just mind that if your patient also has dysmenorrhea and they're keeping really good track of their cycles. And you have an idea of when their cycle will be. Um, these same medications can be used to help prevent dysmenorrhea, uh by starting them about 1 to 2 days before their cycle begins and then continuing until about day three of their cycle. Um And the thought process is, it helps with the spiral arterials. Um within that endometrium being uh a little bit less active and uh less release of prostate glands that can cause discomfort for these patients. Um So, lastly, uh we'll just quickly talk about some of the more invasive procedures that uh we typically counsel patients about. Um, and just so that you guys have some idea of what is going on with these procedures and what the thought process is. Um, when we talk about your artery emulation, it's a procedure performed by interventional radiology. Just take a look at graphic here. Uh Typically they're gonna be going in through the uh femoral artery um with a guide wire following it all the way up and trying to get to the uterine arteries themselves. This procedure is gonna be best to indicate for patients who have fibroids. Um And what they'll do is they will put uh material within the venous and arterial blood flow that will prevent blood flow from going to the fibroids. As a result, the fibroids are gonna lose their blood supply becoming a product and to decrease in size. Uh it does have really good success rate for the right candidate. 90% improvement in bleeding and those who have associated pelvic pain will see an 80% improvement in those symptoms. Um The absolute contraindications are gonna be patients who have uh current active pregnancy, um active uterine or an excellent infection, whether it's P ID, gonorrhea, chlamydia, um tube ovarian abscess as well as suspected gynecologic malignancy. Um that's not been worked up. Um because more often than not, these patients do need to have an endometrial biopsy and imaging performed before this procedure can be done. It is also important for these patients to understand that pregnancy is contraindicated with the uterine artery embolization. So they should be fairly certain that they are done with their child bearing. Um Just to give a little bit more insight into endometrial ablation. There are several options. Uh what me and my partners do offer for patients is what's called the novasure endometrial ablation. Um There is also the option for the minerva endometrial ablation which is very similar. Um and other institutions, they may offer a uh thermal ablation, um a hydrothermal ablation or uh the serene endometrial um which instead of using hot fluid, freezes the tissue. Um to essentially cause the same result, which is destruction of the uterine lighting all the way to the ailis layer, which is about 4 to 6 millimeters deep. Um Again, the greatest success for these patients is gonna be when they're over the age of 40 it has an 86 to 99% satisfaction. Um 70 to 80% of these patients will have decreased bleeding and 15 to 35% will become amenorrheic. Um Just to sort of go through the infographic of the No. Sure. Um Again, we wanna make sure that we're ruling out any sort of potential uterine malignancy for these patients. And so the procedure itself is typically started with a hysteroscopy D and C to make sure we're getting a good sampling of the endometrium, preferably having an endometrial biopsy in the office first to rule out any sort of malignancy so that they can be properly referred if one is identified. Um Essentially what happens is depending on the patient's endometrial cavity size and shape. The novasure device is a gold plated mesh that um once inserted uh fits to the shape of the endometrium. Uh As a result, uh the device itself creates a vacuum seal uh and uses thermal energy through the uh mesh itself to burn lining of the uterus. And this can last for up to 100 20 seconds. It does stop after it reaches a particular impedance of about I believe, 50 ohms. Um and then we remove the device, we go back and we take a look with our hysteroscope just to make sure that the lining of the endometrium is well burned and that there are no areas that are not burned. Um, again, it's really important for these patients because of that increased risk of ectopic pregnancy to make sure that they have a permanent form of contraception. And we're not talking about just an IUD or LAN on. We're talking about making sure that they've had a tubal ligation. Their partner has a vasectomy to reduce those risks. Um, last but not least. Um, we talk about hysterectomy whether it's an abdominal approach, which is less often for us, more often we're doing vaginal and minimally invasive laparoscopic hysterectomies, whether it's straight sick laparoscopy or robot assisted um, hysterectomies. Uh We do typically try and reserve this for patients who have failed medical management. Uh The key thing that's really important to talk to patients with from our standpoint is when we do hysterectomies, uh, patients get very easily confused about the difference between a partial hysterectomy, a total hysterectomy and radical hysterectomy. Um, and what we're moving, what we're not removing and the majority of cases when we're doing hysterectomies, my partners and myself will err on the side of doing what we call a total hysterectomy, whether it's a vaginal abdominal or laparoscopic approach, that means we are taking out the uterus, the cervix and typically at the same time we're doing a bilateral salpingectomy. And it's important that we talk for patients that doing the bilateral salpingectomy. Because as a procedure, the thought process is we're reducing their risk for developing ovarian cancer because the majority of ovarian cancer is thought to start at the femrite ends of the fallopian tubes rather than the ovaries themselves. Um And by doing the self inject Andy, we can reduce that risk of future ovarian cancer by anywhere from 30 to 60% depending on the study reviewed. Uh depending on the case, uh the patient's age risk factors such as if they have uh carrier mutation for BRC A one or Lynch syndrome, we may also recommend a oophorectomy at that same time, but that's definitely a discussion that we'd have more in depth with our patients before doing any sort of surgical planning. Um With that being said that is all of the information I have. Uh what questions do people have? Thank you so much, Doctor Chalo. That was a great presentation if anybody has any questions. Um The Q and A and the chat are open. OK. Um So the first question I have um is why would someone want a partial total abdominal hysterectomy? It's a very good question. Um It's actually very rare that we do that uh any sort of partial hysterectomy with the retention of a portion of the cervix these days. Um The few instances that we consider our, their controversial evidence about whether or not um removal of the cervix really affect sexual function. Um And in those cases, patients may request uh what we call a super cervical hysterectomy. So taking everything except the cervix itself, um really the one medical indication where we consider discussing just doing a super cervical hysterectomy uh is in the cases of patients who have pelvic organ prolapse depending on the severity of their symptoms, doing a super cervical hysterectomy in conjunction with our lovely colleagues in neuro gynecology, um are able to place mesh over the remnant of the cervix and the vaginal cuff and can actually attach that mesh to um the sacro itself and that'll help prevent future prolapse. Ok. Um Next question using nsaids in a patient already with abnormal uterine bleeding. How risky. So this does sort of come with the clinical judgment and evaluation of the patient depending on how severe their bleeding is. The things we wanna keep in mind are, are they hemodynamically unstable or is it a case of the patient has a period every 45 days, it lasts for five days, but they're going through, you know, a whole box of tampons in two days. It's definitely a reasonable option to talk to those patients about starting it and said beforehand. Um as an option, typically, it's not my first line recommendation for those patients. I do try and counsel them about taking OCPs, but there are always patients who are very resistant to taking any sort of contraceptive. Uh And that's ok. So it gives us an alternative option. Um The other thing to keep in mind, which I don't know if I really discussed much is a lot of patients will come in and say, hey, my cycles are abnormal but aren't really tracking them. And in the age of smartphones, I highly recommend to every single patient if they have an iphone and it's just purely from my experience of what I've been able to find the built in health app has an option for tracking when your cycle is. Everyone does worry, especially in the post Rovi Wade era. How secure is that it should be typically secure if that's, you know, a safety privacy concern for patients. Um, definitely keeping just a little paper chart, even just an index card of when their cycle started when it ended, when their next cycle started. Uh, an idea of how many tampons or pads that they're using and blood clots that they're passing can be really helpful from a diagnostic standpoint. The other thing I also recommend to all my patients is that when starting birth control, as with any other medication, I myself have not excluded. It's really hard to remember to take medications, even vitamins on a daily basis, um, and using your phone to set an alarm to make sure that they're taking their medications, especially if they're on a progesterone therapy, taking it around the same time every day. Typically, we want them to be taking it within about 30 to 60 minutes of the same time frame every day. Any other questions, you all have any other questions that you think of later on after this presentation? You're more than welcome to email me. Um I will be sending once again, I'll be sending out an email with uh follow up information and uh contact information uh in case you need to contact their office. So, um but thank you so much, Doctor Tala. We really appreciate your time and your, your information today. Yeah, of course. Thank you for having me. Uh Again, our office is always happy to see patients for consults whether it's obstetric gynecologic, um especially abnormal bleeding. If you see those patients and you start that work up at a minimum. We do really like seeing that CBC TSH prolactin um from an imaging standpoint. We have a lovely imaging uh team over here at the main campus at Barnes Jewish Hospital um within our office. They do really great imaging. We're typically able to get patients in with same day imaging before they see us. So if you send us over all, just let us know and we can get that always set up for patients before they come in. Great. Thank you so much. Thank you for having me. Have a good rest of your day. You too. Bye bye. Thanks. Bye bye. Created by Presenters Aneesh Chawla, MD Assistant Professor, Ob/Gyn View full profile
