Vaginal Bleeding in the Perimenopause (Age 35-50)

Vaginal Bleeding in the
Perimenopause
(Age 35-50)
Ralph Anderson, M.D., F.A.C.O.G., F.R.C.S. (C)
Chairman and Professor
Department of Obstetrics and Gynecology
University of North Texas Health Sciences Center
Fort Worth, Texas
1
Classification of Abnormal Uterine Bleeding
• Menorrhagia: heavy bleeding; loss of more
than 80 mL of blood and/or increased duration
of flow (> 7 days) at regular intervals.
• Menometrorrhagia: increased loss or duration
of bleeding occurring at irregular intervals.
2
• A 40-year-old female presents with irregular bleeding over the
past year.
• Menstrual history
• 1st period age 15
• Bleeding q 25-28 x 3-5 days until 1 year ago
• Now bleeding is heavy and very irregular (menometorrhagia)
• Gen Px normal
• Pelvic – no abnormalities
• Hb – 9.5 Hct 28
• What is the first step in the management?
• Pregnancy test
• Pregnancy Related Complications
•
•
•
•
•
Threatened abortion
Incomplete abortion
Complete abortion
Missed abortion
Trophoblastic disease
3
• A 40-year-old female presents with irregular bleeding over the past year.
• Menstrual history
• 1st period age 15
• Bleeding q 25-28 x 3-5 days until 1 year ago
• Now bleeding is heavy and very irregular (menometorrhagia)
• Gen Px normal
• Pelvic – no abnormalities
• Hb – 9.5 Hct 28
• What is the first step in the management?
• Pregnancy test negative
• What is the next step in the management?
• Endometrial biopsy
• Proliferative endometrium
• Ultrasound
• Normal uterus, tubes and ovaries
• What is the likely diagnosis?
• Anovulatory cycles
4
• Menometorrhagia (Heavy bleeding at Irregular
Intervals)
• Excessive estrogen production and
domination
• Anovulatory cycles
• Polycystic ovaries
• Obesity
• Hypothalamic Dysfunction
• Anorexia
• Exercise
5
6
Management of Perimenopausal Patient with
Menometorragia Due to Anovulatory Cycles
1. Observation
2. Oral contraceptives
3. Oral progesterone
• Provera 5mg daily
• Provera 5mg for 14 days of each month
4.
5.
6.
7.
Depoprovera
Progesterone IUD
D&C
Hysterectomy
7
Management of Perimenopausal Patient with
Menometorragia Due to Anovulatory Cycles
1. Observation
2. Oral contraceptives
3. Oral progesterone
• Provera 5mg daily
• Provera 5mg for 14 days of each month
4.
5.
6.
7.
Depoprovera
Progesterone IUD
D&C
Hysterectomy
8
• A 43-year-old g3p3 female presents with a history of
having had heavy normal periods her entire life until 1 year
ago when they began to be heavier and have progressively
become heavier until now she bleeds heavily for 9-10 days
and uses approximately 8 pad 1 day.
• General Physical Examination normal
• Pelvic examination
• Uterus enlarged to 8 week size
• Hb 9.2 Hct 26
• Pregnancy test negative
• Endometrial biopsy shows secretory endometrium with the
evidence of hyperplasia or malignancy.
• What is the next step in the management?
• Transvaginal ultrasound
• Saline Infusion Transvaginal ultrasound
9
Heavy Bleeding with Regular Menstrual Cycles
(Menorrhagia)
• Benign gynecologic disease
• Endometrial polyp
• Fibroids
• Adenomyosis
• Neoplasm of uterus
• Hyperplasia
• Cancer
10
Benign Conditions of the Uterus
11
• A 43-year-old g3p3 female presents with a history of having had
heavy normal periods her entire life until 1 year ago when they
began to be heavier and have progressively become heavier
until now she bleeds heavily for 9-10 days and uses
approximately 8 pad 1 day.
• General Physical Examination normal
• Pelvic examination
• Uterus enlarged to 8 week size
• Hb 9.2 Hct 26
• Pregnancy test negative
• Endometrial biopsy shows adenomatous hyperplasia with
atypia.
• What is the management
A.
B.
C.
D.
D&C
Progesterone IUD
Provera or Megace
Hysterectomy
12
Hyperplasia of Endometrium
• Oral progesterone
• Progesterone IUD
(Mirena)
1% risk of cancer
• D&C
• Hysterectomy and
Bilateral salpingo
oophorectomy
1-3% risk of cancer
13
15-20% risk of cancer
Cancer of the Endometrium
14
• A 43-year-old g3p3 female presents with a history of
having had heavy normal periods her entire life until 1 year
ago when they began to be heavier and have progressively
become heavier until now she bleeds heavily for 9-10 days
and uses approximately 8 pad 1 day.
• General Physical Examination normal
• Pelvic reveals a normal size uterus and no pelvic
pathology.
• Hb 9.2 Hct 26
• Pregnancy test negative
• Endometrial biopsy reveals secretory endometrium
• Transvaginal ultrasound reveals normal uterus and
ovaries.
• What are your thoughts?
15
• In a reproductive age woman with menorrhagia or
menometorrhagia not related to
• Pregnancy
• Benign uterine pathology
• Hyperplasia or cancer
• Think of Systemic Disorders
• Endocrine
• Hyperthyroidism
• Liver Disease
• Renal Disease
• Obesity
• Hypothalamic Disorders
• Anorexia
• Exercise
16
Abnormal Uterine Bleeding
Medications Associated with Menorrhagia
• Antidepressants
• Antipsychotics
• Interferes with stimulatory and inhibitory nervous impulses that control
hypothalamic function resulting in anovulation and abnormal uterine
bleeding
• Anabolic steroids
• Amenorrhea or irregular vaginal bleeding due to the androgenic effects
of the steroids.
• Aspirin and other prostaglandin synthase inhibitors inhibit
platelet function
• Heparin and warfarin interferes with clotting mechanisms.
• Digoxin
• Propranolol
• Corticosteroids
17
Iatrogenic Causes of Menorrhagia and
Menometorrhagia in the Perimenopausal Female
•
•
•
•
•
Oral contraceptives
Depot medroxyprogesterone acetate
Post menopausal therapy
Anticoagulants
Herbal supplements
18
Vaginal Bleeding in the Perimenopause
(35-50)
• Pregnancy Related Problems
• Heavy bleeding at Irregular Intervals
• Anovulatory cycles
• Heavy bleeding with Regular Menstrual Cycles
• Benign gynecologic disease
• Polyp ∙Fibroids ∙ Adenomyosis
• Neoplasm of the uterus
• Hyperplasia ∙Cancer
• Metabolic Disorders
• Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity
• Medications associated with Menorrhagia
• Antidepressants ∙Antipsychotics ∙ Aspirin
19
Vaginal Bleeding in the Perimenopause
(35-50)
• Pregnancy Related Problems
• Heavy bleeding at Irregular Intervals
• Anovulatory cycles
• Heavy bleeding with Regular Menstrual Cycles
• Benign gynecologic disease
• Polyp ∙Fibroids ∙ Adenomyosis
• Neoplasm of the uterus
• Hyperplasia ∙Cancer
• Metabolic Disorders
• Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity
• Medications associated with Menorrhagia
• Antidepressants ∙Antipsychotics ∙ Aspirin
20