Clinic visits for bothersome bleeding are an everyday occurrence and frequently lead to consults for Tami Serene Rowen, MD, MS, FACOG. In this straightforward talk, she clarifies how to distinguish abnormal from normal menses; breaks down the many reasons, both structural and hormonal, for the problem; and provides specifics on medical management – from doses to side effects – as well as surgical options and her favored techniques.
What we're gonna talk about today is abnormal uterine bleeding. This is one of the most common consults that I get, um, and that you guys probably see in your clinics as well. And so the goal today really is to come up with kind of a practical approach. I am somebody who, um, I like to think about things pathophysiologically so that if you understand the pathology of abnormal bleeding, it can help you really determine what's going on with your patients, what the next steps are, and sometimes what the treatment is. Let's see if this will let me scroll. OK. Um, so what we're gonna do today is we're gonna talk about, um, you know, what normal menstrual bleeding looks like and then what we mean by abnormal bleeding, what your differential diagnosis should be, how to do a workup, and then some of the principles for treatment. So whenever it comes to abnormal uterine bleeding, this is, this isn't my favorite slide, but I'm just kind of showing you it because it's a little pretty, but you have to understand the menstrual cycle. And I know this sounds simple, and I know people are like, Oh, but I know the menstrual cycle. Most OBGYNs don't know the menstrual cycle. I actually had an OBGYN board examiner tell me that she stopped asking people to draw the menstrual cycle during their board exams, because nobody could actually do it. So, most people really don't understand. But the way I think about the menstrual cycle is you start with the brain, and that's at the top here, A. So the hypothalamus secretes GRNH and it tells the pituitary to secrete FSH and LH. And what FSH is, is it's really the brain telling the ovary to grow a follicle, all right? And that's the way you have to think about FSH. How hard is the brain working to do that? And so, you know, we oftentimes use it to measure menopause, right? Cause the brain has to work. Really hard in menopause, so that's why you get a high FSH. If you have an incredibly low FSH, that means the brain's not working that hard. And so it either can be that something's wrong with the hypothalamus or that the, the, the pituitary is suppressed with something like a birth control pill. So you can never test these hormones when someone's on a birth control pill, for example, um, because the, the feedback mechanism from the birth control tells the pituitary to shut down. So then as FSH kind of increases, the ovary starts to grow a follicle and that has an egg inside of it and as it's doing that, so that's C, you go to D and that's where the ovarian hormones come in and estrogen is the first one that you start to see a rise in. Progesterone. very low. What estrogen does is estrogen grows the lining of the uterus. So down here at E, you see the uterine lining. At the beginning of the cycle when all the hormones are low, it sheds, that's a period, and then it starts to grow. And it's growing in response to estrogen. Halfway through the cycle, um, estrogen kind of hits its peak, you get your LH surge, right? That's from the pituitary and it tells the ovary to release an egg. Once the ovary releases an egg, what's left in the ovary is a corpus luteum. So that's over in C, the middle box, the second half of the cycle, that's the luteal phase. The corpus luteum starts secreting progesterone. And progesterone's job is to block the effects of estrogen, stabilize the lining of the uterus, and get it ready for a pregnancy. Progesterone is only produced if you ovulate. There is no role in testing progesterone in perimenopausal women, for example, when they have weird bleeding. I don't anticipate it's going to be high. They all come to me and they're like, Oh, my progesterone's low. Yes, it's low, you're not ovulating, right? People who don't ovulate don't make progesterone. Um, the corpus luteum is there to support the lining, and it only lives for about 12 to 14 days. So the luteal phase is pretty fixed because the corpus luteum shrivels up, progesterone drops, estrogen drops, and then, um, and then the, the lining sheds, and the shedding of the lining from the period is really in response to that drop in progesterone. So my favorite graph is actually the one that's on one medical, and I have this saved on my um Um, uh, this one saved like on my one medical, you know, uh, desktop basically because it's really simple. I'm like, here's the ovary, here's the pituitary, here's the ovarian hormones, here's the lining of the uterus, and I go through this with most of my patients. OK. So what is normal bleeding? So when we're talking about normal menstruation, and the normal menstrual cycle, you have to really ask about the pattern. It's not, I don't want to see like abnormal bleeding, dysfunctional bleeding. If you're sending to a gynecologist, you're, you're really talking about it, you need to describe it. How often does it come, right? Is it regular, right? Is it coming every month? Is it coming every 3 months? That's regularity. Frequency is then how close it's coming together, how heavy it is, and then how long does it last for? Um, so those are the things that you really need to be considering, right? So, pop quiz, what is considered the highest end of the normal amount of blood loss during a typical menses? I want you guys to type this into the chat or the Q&A. So what would be on the highest end of like a normal menses what we would see. I got one person who's bold enough to say, OK, uh-huh, awesome, awesome, awesome. Great. So I'm getting like one, a couple people are putting 150, 120, 120, yeah. So you guys are thinking along the right end, but it's actually lower than that. So you're thinking on the higher end here, it's actually 80. Um, so it's really not that high. There's not a lot of blood in a normal menstrual cycle. Um, so here's how we think about the criteria for normal, right? So frequency of menses, all right, so frequency, if it's, if it's, if we're considering it frequent, that's gonna be less than 24 days apart. A normal menses is 24 to 38 days and infrequent is gonna be over 38 days, all right? So that's the frequency, how quickly it's coming. Regularity, right? So that's, is it regular? There's some variation. If there's no bleeding that's absent, right? If it's regular, you're gonna have like a 2 to 20 day, right? So there can be some variation really in terms of that frequency, um, and then if it's irregular, there's a variation of more than 20 days, right? So that means one cycle is 24, um, the next one is, um, Like one cycle is 24, the next cycle is 54, um, things like that. All right, milliliters of monthly blood loss. OK, Osemi's had duration of flow. So prolonged, it should be less than 8 days, right? So but 88 days is normal. So a normal flow is actually 4.5 to 8. Shortened is less than 4.5. I don't get worried when people come to me and they're like, my menstrual flow is short. It doesn't, like, there's not really any pathology that's gonna be like, oh, now it's 3 days when it was 1. 5. The only thing I would ever worry about would be does someone have uterine scarring. So if they have a history of like a traumatic, um, uterine procedure, but most of the time, that's not what they're coming to me for. They're like, last year it was 5 days, now it's 4, now it's 3. I'm worried. If they don't have a history that makes me think scarring, I'm not particularly concerned. It's just a short cycle. And then milliliters of monthly blood loss. So normal, it's only 5 to 80. So it's actually not a lot of blood. Um, and now that people are using cups, they actually can kind of measure that. OK. So which of the following is considered reasonable in describing an abnormal menstrual pattern? So when you're sending a patient to me or to a gynecologist, what's a reasonable term, term here, uh, to, to use that we consider kind of in gynecology? I love that you guys are putting stuff in the chat. All right, so someone put in 3, so Menaraja. Meow Mecharaja? Oh, no, that person meant 2, OK. Keep going. 4 Menome, uh-huh, 234, OK. Menome 4 Menomet. OK, awesome, awesome, awesome. OK, 2345. Great. OK, so you guys have it all over and that's kind of what I oftentimes see, so I'm gonna tell you the answer is actually only oligomemenorrhea. This is the only one that is really considered a, a, a term that we in OBGYN we wanna be seeing, um. We do sometimes see people say dysfunctional uterine bleeding, but when that gets sent to me, I'm like, what does that mean? Meorrhagia is heavy menstrual bleeding, usually with a regular cycle. I can get that. Menomet, please don't use menometrorrhagia. That, that is an old term that really is like having regular periods with some bleeding in between, and then polymenorrhea is really frequent. Really, what we're trying to get away from is those descriptions. Um, but oligomemenorrhea does does still fit and that means just not a regular menstrual cycle, kind of a stretched out cycle, OK? So when you're sending people, you can say they have oligo, but menometrorrrhagia, please get away from. We don't use polymenorrhea. We don't like using the term menorrhagia. Um, instead of menorrhagia, you can say heavy menstrual bleeding. Um, that is a term that we're we're comfortable with in, in gynecology. All right. So this is a basically a description to kind of say what we want to not use menorrhagia, men or menorrhagia, hypermenorrhea, hypomenorrhea, menomeorrhagia. Um, so these are just all of these things that we're kind of just trying to get away from, all right? This ahead. OK. So what's the appropriate terminology? Abnormal uterine bleeding. That's just what I wanna hear, OK? And so when you say just say abnormal uterine bleeding and then you have to then describe what's happening. Is it, you know, are they having irregular cycles? Are they frequent cycles? Are they heavy cycles, heavy menstrual bleeding, um, are they prolonged duration of flow? So this is this graph that's very annoying, but it basically shows you like all the kind of um all the way, all the like ways you can flow into what abnormal uterine bleeding is, but it's the ways basically that we kind of want to describe it like how regular is it? What's the frequency, how heavy, what's the duration? Um, is it non-menstrual and is it bleeding outside the reproductive age, right? So that's gonna be like postmenopausal bleeding. All right. So I said abnormal uterine bleeding, heavy menstrual bleeding, you could say heavy and prolonged, you can say intermenstrual bleeding. So instead of menomeorrhagia, just tell me that they're intermenstrual. So they're having periods, but they're bleeding in between and then are they having postmenopausal bleeding, OK? And so this is basically how we think about this, prolonged, really, it's saying here, this is like a kind of the a Cog terminology over 10 days in one episode. Um, I get those a lot, which that is definitely prolonged. Frequent is gonna be more than 4 in a 90-day reference period, um, right? So that's really in that less than 24, um, day cycle range. Infrequent would be less than 2 episodes in 1 90-day reference period. So that's just infrequent and then irregular is just kind of all over the place. All right. So FIGO, so this was years ago, I think when I was in residency that the International Federation for Obstetrics and Gynecology came up with this classification system. I know it's familiar to you guys, but I need you to think about using it cause it's what's most important is how you form your differential. This is the differential for abnormal uterine bleeding. All right. So PALM, I think of as structural causes, so polyps, adenomyosis. Fibroids, leiomyoma, malignancy, and hyperplasia. And then Cohen, I think of as medical causes, coagulopathy, so a bleeding disorder, ovulatory dysfunction, and that means an endocrinopathy. All right? So people sometimes get confused, but it basically means they're not ovulating. That's where the abnormal bleeding is coming from. Endometrial is something's just wrong with the endometrium, and sometimes we rule out everything, and I'm like, we just haven't, something's wrong, endometrial dysfunction. I ia tro gen ic we gave something to them, right? So an IUD will do this, birth control pills, um, uh, uh, anticoagulation therapy, right? That's iatrogenic and then not yet classified. We don't usually do that. Usually, if I don't have, if I can rule out everything else, I say this is just endometrial dysfunction. But your job when you're seeing these patients is to think of this differential and then check things off your list of what we do or do not think this is. Um, I'll show you kind of what polyps look like here, OK? So on ultrasound, um, this is, uh, at the top of the A, you can see like the uterus is, it's, I know you guys aren't as familiar with looking at ultrasounds as me, but the calipers are around this kind of thick, there's like a thick ecogenic thing at the top of that uterus and that looks like a polyp. Below it it's nice and thin and then up at the top it's pretty thick. So that's what, that's what a polyp looks like on ultrasound. Um, on the bottom, you're gonna see these are This is what a polyp looks like on hysteroscopy. So when I look inside, it just looks like it looks like a glandular skin tag, OK? And so there's like they're saying polypoid versus sessile. Either way, it looks like a polyp. So it looks like the endometrium, but it's a growth, and that's the way to think about polyps is it's basically like a growth of the endometrium. It's glandular tissue, and that is different from fibroids, which we're gonna get to next. Oh, sorry, adenomyosis. Let's do adenomyosis first. So adenomyosis can be suggested by an ultrasound, um, and so what you can see in that top picture of the ultrasound is that the, the wall of the uterus, um, looks white and so there's like white dots through it, and that's because the end. Endometrium is basically growing into it, so you sometimes can't see like a distinction um between the endometrial lining and the um and the wall of the uterus. Sorry, I'm trying to get to the Q&A in my microcursor. There's someone I think you asked a question. Oh no, I'm not gonna, I'm gonna put that one. OK. Um. So, so that's what adenomyosis looks like. And so it looks, it looks heterogeneous, it looks irregular, it looks globular, um, and it's pretty difficult to treat, to be honest. Um, you can treat it with hormonal suppression, but it doesn't respond as well as other pathologies. Um, and so, so sometimes I'll do everything under the sun for these patients and what they need is a hysterectomy. And you can only Truly diagnose adenomyosis on a hysterectomy. Um, when patients get an ultrasound and it's like suggestive of adeno and it's like this mild and it's like very mild changes, um, that can cause some of their symptoms, but oftentimes it's an incidental finding. Usually, they have a pretty significant adeno, um, and that should be pretty obvious. If you see adenomyosis in Only, so they're getting like they have, you know, some dull pain. They had a history of an ovarian cyst or something, and you're trying to get them imaging and it shows adenomyosis. It's an incidental finding. You don't need to send them to me. You don't need to send them to a gynecologist. You don't need to go down a rabbit hole of, oh my God, they're not gonna be able to get pregnant. People with adenomyosis that causes symptoms, um, they'll be presenting with those symptoms. That's abnormal bleeding, really dysmenorrhea is pretty significant, um, and if they have really severe adenoma, I'm happy to counsel those patients, but, but if it's an incidental finding, they don't need to see a gynecologist. Um, all right, so let's move on to fibroids. OK, so fibroids are best diagnosed via imaging, um, and so I have on one side of the MRI here and on the other side, I have an ultrasound. Um, so an ultrasound is the cheapest way to do this. So you just usually start with an ultrasound and, and it looks like a ball. It just looks like a ball in the uterus, in the wall of the uterus, and it can go into the cavity, it can be sitting on top of the uterus and its shadows. So you see there's like a shadow underneath, that's the image on the right, um. An MRI is really like a, you know, it's pretty fun to look at for, for fibroids. Um, so I know this is a little tricky for you guys to see, but Basically on this MRI on the left, the, the, you see the cervix is kind of coming from the bottom, in the middle is the uterus and you can see the uterus has like a white cavity and then there's a giant ball in front of it, um, and that like in the front of it and that's a, that's a fibroid. They're, they're really much easier to see on, um, MRI's but you don't need an MRI. You really can do this with an ultrasound, um, and you can sometimes see a fibroid growing into the cavity. Again, you wanna be doing this when The lining is the thinnest. Um, if you think that there's an intracavitary component, so on the ultrasound, it says, oh, there's a fibroid, it might be in the cavity. Um, you actually wanna do a saline ultrasound. So that's like, it's called a hysterosonogram. So it's a separate procedure at radiology where they insert a catheter into the uterus, they put fluid into it, um, and then they image it. And the reason that's helpful for me as a surgeon is But if the fibroid is more than 50% in the cavity, I can actually remove it through the uterus hysteroscopically, um, and it's a really simple, great procedure. If it's not more than 50% into the cavity, then we run the risk when we're trying to remove it of actually going through the wall of the uterus, damaging the uterus, perforating, and then not getting the fibroid as well as causing other complications. Um, so whenever you see this, if it, if it, the ultrasounds like suggest intracavitary component. Send me a message if I think that we need to get a saline ultrasound. If it's 100% in the cavity, sometimes they will be able to see that, then I trust it, but oftentimes it'll say suggestive of partially intracavitary, um, yada yada, and then I really do want a saline ultrasound. If someone can't tolerate a saline ultrasound or a transvaginal probe, get an MRI. The MRI can tell me if it's in the cavity. OK. malignancy pop quiz. Which of the following confers a higher risk of endometrial cancer? So of all of these, like, not which one has the highest risk, but which one of these will increase the risk of uterine cancer. Great. I got 1135245135. Got it. So you guys are all answering it, right? The answer is basically all of them. So I put that there. Every single one of these, OK, has an odds ratio of 2 that increases the risk of uterine cancer. So when you're seeing people that have abnormal bleeding and you're worried about cancer, this is especially important for the younger patients because there is this kind of knee-jerk response to do an EMB on everybody over 45 or even younger than that. Um, and I'm a little more cautious with my EMBs. They're very painful, they're very traumatic. People don't have an increased risk. Um, I'm really not, I, I sometimes will not do an EMB because especially for perimenopausal women, if every person that had irregular bleeding got it, you know, um, got an EMB, then every single person would get an EMB. It's just part of perimenopause, right? So I usually will want to know what their risk factors are. I didn't put here an ovulation, right? If they're not ovulatory, if they have a history of not having regular periods and not on any progesterone protection. Then I'm super suspicious, and I'll do EMBs in much younger patients, cause I have found cancer in women in their 30s. Um, so these are the, this is just a chart kind of showing you those risk factors, OK, and the relative statistics. So increasing age, so, um, that, you know, unopposed estrogen therapy, obviously tamoxifen therapy twice as likely, right? So it's not the highest ever, it's literally as high as late menopause after age 55. Same with nulliparity, PCOS chronic anovulation, that's what I'm most worried about. Um, obesity. Also, um, and you're gonna see that the risk goes up to an odds ratio of 7 if they have class 3 obesity, so pretty significant. Um, diabetes is just twice as likely, so really obesity is kind of a, if they're super, if they're really obese, that's really gonna be your highest risk, but diabetes also confers an increased risk, um, and then things like Lynch syndrome, Cowden, um, Lynch is really the one I worry about the most if they have a Family history of colon cancer as well. Um, and I have diagnosed this in young patients in their 30s where the ultrasound shows a polyp. I go and I do a biopsy, they have cancer, it turns out to be Lynch. Um, family history really is not, uh, like unless it's Lynch, a family history of endometrial cancer, it's not, it's otherwise it's not genetic. Um, so unless it's Lynch, I'm not too worried if somebody has a family member that had endometrial cancer. Um, all right. OK, so basically, if we're worried about malignancy, it can be suggested via imaging. So usually you're gonna see a heterogeneous endometrial stripe and a focal mass. Now, one thing to note is in postmenopausal women, who are not bleeding, there is no criteria for how thick the lining should be. OK? So when, when you see, when your postmenopausal patient has some left lower quadrant pain and she gets an ultrasound and her lining is thick and they're like, oh, the lining is thick for a postmenopausal woman, it's not, you don't have to worry about it. The 4 millimeter cutoff is if they're bleeding. OK, because cancer and hyperplasia bleeds. If they're bleeding and their lining is above 4 millimeters, they need a biopsy. If they are not bleeding and it is 6 or 8 or even 10, they don't. Um, the, there is a UCSF study that suggests if it's like over 11 or 12 millimeters they need a biopsy. That's actually not based on any clinical data. Um, it's really like a decision tree and And I, I will say that I, I, this year had a patient with like a, she had a 4 centimeter incidentally found polyp. She was 80 years old, and I, or mass, and I was like, oh my God, this is gonna be cancer. She's 80. This is a giant mass. She did not have cancer, and I knew because she wasn't bleeding. And there were two other patients that month I diagnosed with cancer, one with like a, you know, but both of them were bleeding. So cancer bleeds. That's really my biggest concern. OK. So, um, so usually they'll be bleeding. They have a heterogeneous endometrial stripe, they have a focal mass. Um, you can pick up malignancy via an EMB, D&C, or hysteroscopy. The PiPal that you guys use in the office is highly sensitive for detecting endometrial cancer, OK? But it is contingent on how much of the cavity is affected. So if there's one polyp and you do a biopsy and you don't get any cells that look like cancer, then I actually really need to see them, um, cause I'll usually do a hysteroscopy. If they had an ultrasound that showed a polyp, I usually don't even do a biopsy. I just go straight to, to hysteroscopy. And for that reason, usually for postmenopausal people or anyone really with abnormal bleeding, I want an ultrasound first. I don't usually jump to an EMV because if there's a polyp found or a fibroid, I can spare them the office EMV and just go straight to hysteroscopy, look in with a camera, visualize the mass, and remove it. So you'll see me asking for ultrasounds most of the time before I want anyone to get an endometrial biopsy. All right. So we're gonna move over to coagulopathy. All right. So we got, we did the, the structural causes. So you only do a coagulopathy workup if the history indicates it. So they have a family history of a bleeding disorder, new onset of heavy vaginal bleeding. Um, for von Willebrand's disease, it's actually interesting, so decreasing estrogen levels um can impact von Willebrand factor synthesis. So sometimes as they get older, this will start to show up. But typically, you're gonna see this in, in menses. Um, so when they start having periods, It's really heavy. Um, you know, if they're, if they're having medications or other illnesses that can present at other age. Um, so sometimes if patients are like your young trans or non-binary patients, they're taking testosterone and their estrogen levels go down, they'll start to have heavy bleeding. You can have this in the back of your mind, but it's, it's not a, it's not super common. It's pretty rare to find von Willebrand's disease and I usually only find it in teenagers, um, who I definitely would, um, work up if they're having heavy bleeding with the onset of Mensess. This is the laboratory testing that somebody in the Q&A was asking about. So if they have, you know, abnormal uterine bleeding, initial laboratory testing, obviously, you want a CBC type and screen, obviously a pregnancy test, you guys know this, anyone with abnormal bleeding. Um, initial laboratory evaluation. So you want your coagulopathy workup, your, you know, PTT, PT, your fibrinogen. If you wanna look for von Willebrand's you need to do a von Willebrand's factor antigen, Aristoin cofactor factor 8. those are looking for von Willebrand. So these are really the coagulopathy labs that you want. Um, and then you can check other things like a TSH, you can check The iron studies, LFTs, Chlamydia is on here just because, um, people who have abnormal bleeding can sometimes have, um, chlamydia. Now it's interesting, um, and for your teenagers especially, um, I do feel like you guys are better at, at testing for STIs than a lot of gynecologists. It's often not at the top of my differential, um, but definitely for your young patients with any abnormal bleeding, um, get a chlamydia test. OK, what about ovulatory causes? So think of this as the same as endocrine, right? So anything that affects the HPO axis, the hypothalamic pituitary ovarian axis. The most common diagnosis is polycystic ovarian, but it's not always the answer. And so I just want to encourage you to really think outside of that. Um, and so, you know, are they having, if it's, if it's PCOS, then that's really oligomemenorrhea, symptoms of excess androgens, right? So the periods are, are like irregular, right? So they're just 2 months, 3 months here and there. Sometimes they never have a period, but usually they do have some sort of bleeding because they're anovulatory. And then they have symptoms of excess androgen. So that's hirsutism, that's acne, um. Sometimes people have acanthosis nigricans, which obviously is, is more of an insulin resistant symptom. I don't get ultrasounds in this setting. It just doesn't help me. If they have PCOS, I don't need to look at their ovaries to tell me. Um, so I don't think you need in, in any, in any way to get an ultrasound. I don't use ultrasounds to diagnose PCOS cause I'm not treating anything that that ultrasound is gonna find. If someone has oligomemenorrhea, I'm gonna treat the oligo. If they have symptoms of excess androgens, I'm gonna treat that. Um, the biggest risk of PCOS is endometrial cancer. If people are not having regular periods, you have to do something about it. Um, so I've had patients where they were either trying to get pregnant or they weren't trying to get pregnant, and they were having weird bleeding for years and they were in regular care, but nobody was really addressing the fact that their menses were not regular. They were anovulatory and they developed cancer in their 30s. Obviously, with PCOS you're gonna see ongoing health concerns with diabetes, so you wanna be checking for that and metabolic syndrome. But some people are just anovulatory and they don't have PCOS. So if they just don't ovulate, but they have no symptoms of excess androgens, again, I'm not a really, I'm not super keen on getting these patients ultrasounds, but if you do and the and the ultrasounds look normal, um, it's It's really just an ovulation. It's not always PCOS. And it's really about treat and I, and I always tell people with PCOS like, I don't care about the diagnosis of PCOS. I care about the treatment for the symptoms that it may, that it's causing, what it is, what is this patient complaining of? And as a gynecologist, what I'm obviously most worried about is proliferation of the endometrium and endometrial cancer. OK, so how do we think about a workup, right? Um, so I went through, I, you know, the, I didn't get into the iatrogenic, just think about any birth control that somebody's on any medications that cause excess bleeding, those are all gonna cause it. We talked about endometrios kind of this, you know, if we don't have anything, we go back to endometriosis. Let's talk about how we work this up. So if somebody has an ovulatory disorder, go back to the menstrual cycle, you need to feel confident that there's no ovulation. And so, when they're telling me their story and they're like, I'm bleeding every 2 months, I'm like, are you ovulating or not? And, and, and the most thing that I wanna know is, are you getting symptoms of ovulation? And that's really Progesterone symptoms. So that's breast tenderness, mood changes, they'll be like, oh, I get crampy. Crampy is in the uterus. That's not, that has nothing to do with progesterone. I want to know, are they having symptoms of progesterone? Do they get, you know, do they get really moody right before? Do they get moody in the two weeks before that suggests, we call those meliminal symptoms, um, that they're ovulating. OK, so if we don't think they're ovulating, then we need to figure out why. So we check a prolactin, right? So I start, so I'm showing you this graph because we started the pituitary. Is there something wrong with their prolactin? Is there something wrong with their TSH? Do they have extra 17OHP and DHEA? Are they on some sort of medication? So at the level of the ovary, if you wanna know how healthy the ovary is. You can test the FSH and LH, and again, what that's doing is it's saying how hard is the, is the brain working to get the ovary to release an egg, and what that means is if the FSH and LH are really high, the ovary is not healthy, all right? So something is wrong with the ovary and that is a sign of primary ovarian insufficiency, and we will see irregular menses in that setting. You can check testosterone and that's gonna fit into your PCOS picture, right? If you have elevated testosterone that can, um, stop you from ovulating. Anti-mullerian hormone is another way to measure, um, how, how many eggs is in the ovary. So if it's really low, that's primary ovarian insufficiency. If it's really high, it points to PCOS. It's not part of the diagnostic criteria yet for PCOS, but if the AMH is above 6 to 8, um, a lot of REIs will say, oh, that's consistent with PCOS. You can check an estradiol, but it's not particularly helpful. Um, well, I will say that in if they're bleeding, they're making estrogen. Um, so we know that if somebody's actually having bleeding, they're making enough estrogen because it's stimulating the lining. I will oftentimes do if they're having no bleeding of Provera withdrawal, you give them Provera for 10 days, that's progesterone, and see if they withdraw and that tells you that their body's making enough estrogen. But really, if they're already bleeding, you kind of know that they're making estrogen. Um, It can give you, so that's, that's really testing like how healthy the ovary is in terms of whether or not it's making estrogen. If you're looking at the level of the uterus, um, you know, you can actually do a Provera withdrawal, um, to see if there's estrogen that's built up the lining. If you think there's scarring in the uterus, so that's really a uterine. cause that's causing weird bleeding, then what you need to do is give them estrogen to see if the estrogen will build the lining, then give them progesterone and see if they bleed. If they have no bleeding, then there's actually scarring inside the uterus, um, because a normal uterus should respond to estrogen. So that's really looking for estrogens. It's a pretty rare finding and I usually can pick it up by history if they had a uterine procedure, they had normal periods that then just started getting lighter and lighter and lighter and maybe went away. Um, that makes me very concerned for Asherman's. All right. OK, so I said the rest of Cohen is endometrial dysfunction, iatrogenic, the most common are contraception and anticoagulation, and then not otherwise specified. So typically I rule out everything and then I say this is just endometrial dysfunction. I'm sorry, let's treat it, OK? Um, so how do we treat it? So the first thing is you have to establish a diagnosis, um, and that's why you just need to keep your differential broad and really just if you think about people, you know, that's why getting the history is really important. If they're having regular monthly cycles, it's not an endocrine issue. Um, so they're not, there's, they're not like you can have it like TSH could be off a little bit if they have heavy periods, but otherwise, it's not gonna be a prolactinoma issue. They're not anovulatory. You don't really have to worry about that. If it's really, um, heavy bleeding and that's it every month, then I'm really thinking a structural problem. If you find a fibroid, you need to consider type of removal. Um, not all of them need to be removed. So a lot of times people get ultrasounds, they find these fibroids, they're not near the cavity, they're like in the wall or outside. Those don't cause bleeding. So the bleeding really comes from the fibroid being in the cavity, disrupting the lining of the uterus, that's gonna cause the bleeding. And then if anyone has an endocrinopathy, treat it. Um, don't, uh, you know, don't, don't pass up like say someone has a really low prolactin, get, you know, not a low prolactin, but I mean a low elevated, right? So above, like, it's like 30, right? Typically in, in our teaching, 30 to 200 was a microaden. You don't necessarily even need an MRI if it's above 200, it's a macroadenoma. That's actually not true. 2/3 of um prolactinomas are macro um and so anybody with an, if they're having irregular periods, it seems like they're not ovulating and they have an elevated prolactin. You want two levels. You want to make sure that the second one is fasting and if it's still high, just get an MRI, um, because I've diagnosed several prolactinomas or even they're, they're not actually secreting prolactin, but it's an adeno pituitary adenoma that's compressing the pituitary and increasing, um, and causes increasing, uh, prolactin. So Q&A. OK, someone asked me to go over the dosing and timing for the estrogen progesterone withdrawal. It's a great, great, uh, question. So, OK, so if you're trying to, to, um, To see whether or not somebody's gonna have a buildup of their lining and then a withdrawal. So you can make it really easy and just give them birth control pills, like give them 3 weeks of birth control pills and then have them withdraw, but usually, um, the, I would be concerned that the progesterone might kind of block the effect of the estrogen. So my way that I prefer to do it is to give them 2 mg of oral estradiol, pure estradiol for 3 weeks. And then one week of a progestin. And so that would either be 5 mg of Ajesin or 10 mg of Provera. And so you've now built up the lining. Now you're gonna give them progesterone and you're gonna see if the lining sheds. So 3 weeks of high-dose estrogen, 2 mg and then 1 week of a progestin. Let me know if that, hopefully, that answered the question. OK. Speaking of progestins, when we are trying to treat Proliferation or abnormal bleeding, which of these is the strongest at the level of the uterus to block endometrial proliferation? All right. 1, maybe 2. I appreciate that you're asking, right? Cause people don't know this. 2, OK. 2, OK. Right, some people fear. OK, so I'll just answer. Someone asked if it's 2 or 3 weeks of estradiol. It's 3 weeks of estradiol for the, for the estrogen progesterone test. So you guys are right. So medroxyprogesterone acetate is Provera. Provera is the strongest um of the progestins, OK? Um, uh, progesterone is Prometrium. It's actually rather weak, to be honest, um. In terms of, uh, in terms of, of treating bleeding, I don't give Prometrium for bleeding. I really give it for menopausal hormone therapy. Norathindrone acetate, so that's your Agestin, it's actually really good, but it's not quite as strong, um, and then norathindrone, um, 0.35, um, is not, is not my recommendation, OK? So if you're giving somebody medication, um, you can do if you wanna give them non-hormonal, you can actually give them tranexemic acid. I love this medication. Patients don't want hormones, that's very valid if they're just having heavy regular bleeding and you've ruled out a fibroid or a polyp, just give them TXA. It's great. You take it only during your bleeding cycle, um, 3. Times a day, usually for 5 days. It is safe to use with birth control pills. The pharmacists will tell you no, there'll be an alert, yada yada. It's actually safe. This was part of my, um, my, uh, recent like recertification of my OBGYN license. They made us read through all the data, um, and the, the kind of recommendations to say that really when people are on birth control, if they're still having heavy bleeding, it's fine to throw in TXA, um. The other progestins, so medroxyprogesterone acetate, so that's your Provera. You can start at 10 mg, but you can go all the way up to 40 BID, so they can get a really high dose of this. It will make them feel pretty lousy, um, but it definitely helps with their bleeding. Nothindrone, I usually, you know, you can give it, that's your sin nothindrone acetate. It's 2.5 to 7.5. Um, you can use micronized progesterone, but I don't like it. And then, you know, an IUD is great and Depo is great. Please don't use norithindrone progesterone-only pill for abnormal uterine bleeding. Um, I see this a lot for the progesterone. Only pill is just pure norethindrone. It's in this baby dose. It, um, it is for a birth control. It is not good for abnormal bleeding. It makes people bleed. It doesn't stop ovulation. Um, so when we talk about progesterone, you know, I usually think of progesterone-only pill is the contraception, um, but these other ones are progestin pills that you can use for abnormal bleeding. I hope that makes sense. Agin norithindrone acetate is not the same, but you can see that the norithindrone acetate is 2.5 mg. So it's like, it's almost 10 times as much the dose that we start with. It's a different molecule, but it's, it's obviously much stronger either way. However, It's metabolized, it's gonna be much stronger than the norethindrone. Ajustin is not approved as a contraceptive though. So I always tell people, I'm gonna give you a justin. It's norithindrone acetate. It is, it has never been studied as a birth control method. It probably works, but it's not approved as such. Um, all right. OK, so medical management, um, sorry, starting to probably hear the crying children in the background, but I'm alone in my room, so we're OK. Um, OK, so, uh, so basically, the way to think about kind of medical management is that, um, You know, like the, the, um, birth control pills are not necessarily better than progestins, but you can also use them as a method of contraception. So OCPs are great to use. Um, I actually will oftentimes do a taper, um, and so there's no really right way to do this, but if someone's having really heavy bleeding, you wanna just head it off at the pass, give them 1 pill TID for 3, I just say 3 pills for 3 days, 2 pills for 2 days, and then every day. Um, there is data that shows you can use up to, you know, 3 pills a day for 7 days. Again, people are gonna feel kind of lousy. Obviously, if somebody is at risk of a blood clot, you're not gonna wanna do this. Um, but in, in general, I like the OCP tapers. I think they work well for acute bleeding in the operating room, we'll actually give people IV estrogen, which sounds kind of crazy, but the idea is that something's wrong with the lining of the uterus. We need to stabilize it and so we give IV estrogen for that. Surgical options. So this is why you guys send patients to me, right? So if somebody has a structural cause, I will remove it. Um, uh, but the most important is making sure that the structural cause is not just incidental. So if, if the fibroids in the wall of the uterus or they happen to have like really mild adeno, I don't, I can't really surgically remove adenomyosis without removing the whole uterus, and that will certainly cure their abnormal bleeding. Um, but really this is about whether or not I think the fibroid's causing their bleeding. Um, and so I have to just know exactly where it is. I will do endometrial ablations for patients. Um, typically what I do, so you can do a thermal, like where you put in hot water, thermal ablation, ball cautery. There's a freezing one, but the one I actually do the most of is radiofrequency, which I love. Um, it's like a, it's a device that goes in, it's like a fan that just opens in the uterus. It takes 90 seconds. I can do this in the office. Um, it's a great option for women in their forties, um, because it, its failure rate gets, uh, starts to increase after about 5 years, about 20% of people need a second procedure. So I don't do this usually in women in their thirties unless they have, I had one patient who had POI, so she was kind of, you know, perimenopausal in her thirties and was just having weird bleeding. Um, and so for her, I did it. If I think that somebody Has a high risk of endometrial cancer in the future. I don't do this. We always get a biopsy beforehand, even in patients I'm like, there's no chance it's um cancer. I always do it just to be on the safe side because after you do an ablation, you can't um safely go in and do a sample. So you can't really do a biopsy because the lining is totally scarred and so you can't really get a reliable sample. I do hysterectomies for patients if they've kind of been through everything, it's not working or they don't want medication and they're just done, um, and then I usually will counsel them about a total versus a supra cervical. There is this misunderstanding that total hysterectomy means ovaries. That is not the case. So total hysterectomy means uterus and. Cervix, um, if you take out the ovaries, that, that's an oophorectomy, so it's a totally separate procedure. Supracervical is just where we leave the cervix, um, and then, um, so that's a supraccervical hysterectomy. Um, I talk to people about their ovaries really depending on their age and their risk factors for postmenopausal women, I will, um, I will offer to take out their ovaries. All right. For route of surgery, you guys who work with me know that my preferred um route is vaginal. A lot of surgeons don't do this. They're only doing laparoscopic now with the abdominal incisions. Uh, if it's a small uterus, it's a safer, faster, much better surgery to go vaginal, and I'm really proud of the fact that I'm able to offer this to the vast majority of my patients. Um, All right. Someone asked if there's a duration of premenstrual spotting only occurring in cycle that is concerning. Um, I am not concerned about premenstrual spotting if it's in cycle prior to menses. That's really related to a decreasing progesterone level. Sometimes they might, I mean, you could, it could be a polyp. You can always get an ultrasound. Um, I'm not worried. About a malignancy doing that. Um, it's usually gonna be kind of in between and not premenstrual. If it's right before their period, it's really usually related to the decrease in progesterone. So I think it just depends on their history. I can't answer that like 100%, but most of the time premenstrual spotting, I, I really just chalk up to, uh, depending on what it is, it's really just a decreasing in progesterone. Um, Sally asked, is it standard to do a salpingectomy when someone has a hist and keeps their ovaries? That is standard now. And the reason for that is that when, um, we know that some amount of ovarian cancer starts on the tubes, and so we always, uh, recommend taking out the tubes. There's no use. For the tubes if the uterus is gone. Um, the ovaries obviously have a very important role, but not the tubes. Um, and so I always do take them out. If I'm doing, if I'm doing a laparoscopic case, it's never a problem. Sometimes when I'm doing a vaginal case, it's hard for me to reach the tube, so I won't take it out, um, but if I'm able to access it, I will. All right, we're at the very end. Last pop quiz. I learned something new today. This is like the pop quiz for who's paying attention. All right. Lastly, all right, so let's just, um, go back over everything. Um remember, AUV is the preferred terminology, abnormal uterine bleeding. It can be broken down into structural versus medical causes. Usually imaging or a procedure is needed to rule out structural causes, right? So if we think it's a polyp, fibroid, adenomalignancy, we're gonna need to do something to prove that um if it's, we think it's an ovulatory cause we wanna do labs and history, um, and the treatment really depends on the type of bleeding as well as comorbidities and patient preference, right? So you know if patients don't want hormones, we gotta work with them on that and this is why I love TXA. Um, you know, and, and also just kind of figuring out what they're concerned about, really getting a story from them. Some patients want no surgical intervention whatsoever. Some people want to jump straight to surgery. I'm really the kind of gynecologist where I really give people all of their options and I really let them make a, a decision. It's unusual for me to make a strong recommendation. Sometimes I will, but most of the time, I really don't, and I think that that's really important. Um, you can really be the savior for your patients. This is so bothersome, you guys know that, um, and so trying to figure out what it is and then helping them manage is really important. Um, so with that, I want to, I'm available for questions. I'm not sure exactly the time, um, how much time we have for questions, but I'm happy to answer any that are remaining.
