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 path a physiologically 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. It's a sort me scroll. Okay. 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 work up and then some of the principles for treatment. So whenever it comes to abnormal uterine bleeding this is this isn't my favorite slide. And I'm just kind of showing you 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 O. B. G. Y. N. S. Don't know the menstrual cycle. I actually had a O. B. G. Y. N. 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 gr. NH 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. Alright. 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? Because the brain has to work really hard and 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 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 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 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. U. C. 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 in it tells the ovary to release an egg once the ovary releases an egg, what's left in the ovary is a corpus Lucia. So that's over and see the middle box the second half of the cycle that's the ideal phase. The corpus ludie um starts secreting progesterone. And progesterone is 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 is low. Yes it's low you're not ovulating right? People who don't ovulate don't make progesterone. Um The corpus ludie um is there to support the lining and it only lives for about 12 to 14 days. So the lucio phases pretty fixed because the corpus ludie um 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 this one saved like on my one medical, you know, desktop basically because it's really simple. 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. Okay so what is normal bleeding? So when we're talking about normal menstruation, 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 three months? That's regularity frequency. Is that 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 menaces? I want you guys to type this into the chat or the Q. And 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 Okay. Uh huh, awesome, awesome, awesome. Great. So I'm getting like one, A couple of people are putting 1 51 21 20. 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 Menzies. Alright 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 Menzies is 24-38 days and infrequent is going to be over 38 days. Alright so that's the frequency, how quickly it's coming regularity. Right? So that is it regular? There's some variation if there's no bleeding that's absent, right? If it's regular you're going to have like a 2 to 2020 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 20 for um the next one is um like one cycles 20 for the next cycle is 50 for um things like that. Alright milliliters of monthly blood loss. Okay, awesome. Is that duration of flow? So prolonged, it should be less than eight days right? But 88 days is normal, so 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 three days when it was one five. The only thing I would ever worry about would be just someone have uterine scarring. So if they have a history of like a traumatic uterine procedure, but most of the time, that's not what they're coming to me for. Their like last year was five days. Now it's four. Now it's three, 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. Okay, 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 use that? We consider kind of in gynecology. I love that you guys are putting stuff in the chat. Alright, so someone put in three, so maharajah meta meta raja, that person meant to okay, keep going for men I met. Uh huh. 234. Okay, no Metformin? Ahmet. Okay, awesome, awesome, awesome. Okay. 2345. Great. Okay 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 Allah go Maria. This is the only one that is really considered a term that we in O. B. G. Y. N. We want to 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? Mena raja is heavy menstrual bleeding usually with a regular cycle. I can get that. Men Ahmet please don't use many metro raja. That that is an old term that really is like having regular periods with some bleeding in between and then parliamentary is really frequent really what we're trying to get away from is those descriptions. Um but all ago Maria does does still fit and that means just not a regular menstrual cycle, kind of a stretched out cycle. Okay, so when you're sending people you can say they have all ago, but Meno Metro raja, please get away from, we don't use parliamentary a we don't like using the term mena raja. Um instead of maharaja, you can say heavy menstrual bleeding. Um That is a term that we're we're comfortable with in gynecology. All right, so this is basically a description to kind of say what we want to not use mena raja. Metro raja. Hyper Maria. Hi palminteri a Metro Metro raja. Um So these are just all of these things that were kind of just trying to get away from? all right, just ahead. Okay so what's the appropriate terminology, abnormal uterine bleeding. That's just what I want to hear. Okay. And so when you say just say abnormal uterine bleeding and then you have to then describe what's happening. Is that you know, are they having irregular cycles? Are they frequent cycles? Are they heavy cycles? Heavy menstrual bleeding. 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 minstrel? 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 can say heavy and prolonged. You can say inter menstrual bleeding. So instead of Menno Metro raja just tell me that their inter menstrual. So they're having periods but they're bleeding in between. And then are they having postmenopausal bleeding? Okay and so this is basically how we think about this prolonged really? It's saying here this is like a kind of the take terminology over 10 days in one episode. Um I get those a lot. Which that is definitely prolonged frequent is going to be more than four in a 90 day reference period. Um Right so that's really in that less than 24 day cycle range infrequent would be less than two episodes in 1 90 day reference periods. That's just infrequent. And then irregular is just kind of all over the place. Alright 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 because it's what's most important is how you form your differential. This is the differential for abnormal uterine bleeding. Alright so palm I think of his structural causes. So polyps endometriosis, fibroids, leo my oma malignancy and hyperplasia. And then cohen I think of as medical causes kogelo empathy. So bleeding disorder ovulate torrey dysfunction and that means an endocrine apathy. Alright 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 have some things wrong. Endometrial dysfunction. I am estrogenic. We gave something to them. Right? So an I. U. D. Will do this birth control pills. Um uh anti coagulation therapy. Right? That's why a transgenic 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 an immaterial 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 kinda what polyps look like here. Okay so on ultrasound um this is 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 academic 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 that's what a polyp looks like on ultrasound. On the bottom you're gonna see these are this is what a polyp looks like on history Oscar peace. And when I look inside it just looks like it looks like a glandular skin tag. Okay and so there's like they're saying pollock versus cecil. 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 politics 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 adam aosis. Let's do adam aosis first. So adam aosis can be suggested by an ultrasound. Um And so what you can see in that top picture of the ultrasound is that the wall of the uterus um looks white and so there's like white dots through it and that's because the end of petroleum is basically growing into it. So you sometimes can't see like a distinction between the endometrial lining and the and the wall of the uterus. Sorry I'm trying to get to the Q. And A. And my someone, I think you asked a question oh no I'm not gonna I'm gonna put that one. Okay. Um So so that's what adam Aosis 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 diagnosed adam aosis on a hysterectomy. Um When patients get an ultrasound and it's like suggestive of ad Anno and it's like this mild and it's like very mild changes um that can cause some of their symptoms but often times it's an incidental finding. Usually they have a pretty significant ad. No. Um And that should be pretty obvious if you see addendum aosis. Yeah at least they're getting like they have you know some dull pain. They have a history of an ovarian cyst or something and you're trying to get them imaging and it shows adam aosis. It's an incidental finding. You don't need to summon to me. You don't need to someone 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 endometriosis that causes symptoms. Um They'll be presenting with those symptoms. That's abnormal bleeding. Really. Dismantle area is pretty significant. Um And if they have really severe add, no 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 let's move on to fibroids. Okay so fibroids are best diagnosed to be a imaging. Um And so I have on one side of the M. R. I. 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 going 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 M. R. I. 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 M. R. I. On the left this 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 fiber. They're they're really much easier to see on um MRI's but you don't need an M. R. I. You really can do this with an ultrasound. Um And you can sometimes see a fiber growing into the cavity again you want to be doing this one, the lining is the thinnest. Um If you think that there's an intra cava terry component. So on the ultrasound it says oh there's a fibroid that might be in the cavity. Um You actually want to do a saline ultrasound so that's like it's called a history of sonogram. 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 history topically. 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 the ultra sounds like suggests inter cavatelli 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 intra cava torrey um yada yada. And then I really do want a saline ultrasound. If someone can't tolerate a saline ultrasound or a trans vaginal probe. Get an M. R. I. The M. R. I can tell me if it's in the cavity. Okay 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. Okay has an odds ratio of two 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 E. And B. On everybody over 45 or even younger than that. Um And I'm a little more cautious with my E. M. B. S. They're very painful, they're very traumatic. It people don't have an increased risk. Um I'm really not. I sometimes will not do an E. M. B. Because especially for perimenopausal women, if every person that had irregular bleeding got you know, got an E. M. B. Then every single person would get an E. N. B. 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 ovulate torrey, 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 E. M. B. S. In much younger patients because I have found cancer in women in their thirties. Um So these are this is just a chart kind of showing you those risk factors. Okay? 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 mila parity pcos chronic and ovulation. 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 seven if they have class three obesity, so pretty significant. Um diabetes is just twice as likely. So, really obesity is kind of their super, 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 lynch is really the one I worry about the most if they have a hist family history of colon cancer as well. Um And I have diagnosis in young patients in their thirties where the ultrasound shows a polyp, I go and I do a biopsy they have cancer. It turns out to be lynched. Um Family history really is not like unless it's lynch a family history of endometrial cancer, it's not 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, okay. So basically, if we're worried about malignancy, it can be suggested via imaging. So usually you're going to 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. Okay. So when when you see when you're post menopausal patient has some left lower quadrant pain and she gets an ultrasound and her lining is six and they're like, oh the lining is sick for a postmenopausal woman, it's not you don't have to worry about it. The four millimeter cut off is if they're bleeding, okay because cancer and hyperplasia bleeds. If they're bleeding and they're lining is above four millimeters. They need a biopsy. If they are not bleeding and it is six or eight or even 10, they don't um 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 I I will say that I I this year had a patient with like a she had a four centimeter incidentally found polyps she was 80 years old and 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. Okay so um so usually they'll be bleeding. They have a heterogeneous endometrial story. If they have a focal mass. Um you can pick up malignancy V. And E. N. B. D. N. C. Or hysteria Skopje. The pipe, all that you guys use in the office is highly sensitive for detecting endometrial cancer okay 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 because I'll usually do a hysteria Skopje. If they had an ultrasound that's showed a polyp, I usually don't even do a biopsy, I just go straight to hysteria Skopje. 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 E. M. B. Because if there's a polyp found or a fibroid I can spare them the Office CMB and just go straight to hysteria Skopje, looking 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. Alright, so we're gonna move over to kogelo apathy. Alright, so we got we did the structural causes. So you only do a coagulant Kathy work up if the history indicates it. So they have a family history of bleeding disorder. New onset of heavy vaginal bleeding. Um For Von Will Brandt's disease, it's actually interesting. So decreasing estrogen levels. Um can impact von gillibrand factor synthesis and sometimes as they get older this will start to show up but typically you're going to 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 another age. Um So sometimes if patients are like you're 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 it's not super common. It's pretty rare to find Von Will Brandt's disease and I usually only find it in teenagers who I definitely would work up if they're having heavy bleeding with the onset of Betsy's. This is the laboratory testing that somebody in the Q. And A. Was asking about. So if they have you know abnormal uterine bleeding, initial laboratory testing obviously you want a C. B. C. Type and screen obviously a pregnancy test. You guys notice anyone with abnormal bleeding. Um initial laboratory evaluation. So you want your kogelo empathy work up your you know Ptt Ptt fibrinogen. If you want to look for Manuela brands you need to do a Von Will Brandt's factor anti generous to cede and Co factor factor eight. Um Those are looking for Manuela brand. So these are really the kogelo apathy labs that you want. Um And then you can check other things like a. TSH. You can check the iron studies. LFTs claim ideas on here just because 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 testing for stds 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 comedy a test. Okay. What about ovulate torrey causes to think of this as the same as endocrine? Right. So anything that affects the H. P. O. Access the hypothalamic pituitary ovarian access, 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 P. C. O. S. Then that's really ah ligament area symptoms of excess androgens. Right so the periods are like irregular, right? So they're just two months, three months here and there. Sometimes they never have a period but usually they do have some sort of bleeding because they're an ambulatory and then they have symptoms of excess androgen. So that's here statism that's acne. Um Sometimes people have a can't assist micro cans which obviously 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 any in any way to get an ultrasound. I don't use ultrasound to diagnose Pcos because I'm not treating anything that that ultrasound is gonna find if someone has Allah gonorrhea. I'm gonna treat the ala go if they have symptoms of excess androgens, I'm going to 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 leading for years and they were in regular care but nobody was really addressing the fact that their menses were not regular. They were an ambulatory and they developed cancer in their 30s. Obviously with PCOS you're gonna see ongoing health concerns with diabetes. So you want to be checking for that and metabolic syndrome. But some people are just an oval A torrey 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 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 really just an ovulation. It's not always PCOS and it's really about. 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 be that it's causing, what is what is this patient complaining of? And as a gynecologist, when I'm obviously most worried about is proliferation of the endometrium and endometrial cancer. Okay, so how do we think about a work up, right. Um So I went through, you know I didn't get into the yatra genic 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 endometriosis 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 ovular Torey 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 two months I'm like are you ovulating or not? And and and the most thing that I want to 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 cramp cramp 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 they get moody in the two weeks before that suggests we call those liminal symptoms um that they're ovulating. Okay 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 17 H. P. And D. H. E. A. R. They on some sort of medication. So at the level of the ovary, if you want to 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. Alright 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 stop you from ovulating. Anti malaria and 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 A. M. H. Is above 6 to 8. Um A lot of R. E. I. S. 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 is actually having bleeding they're making enough estrogen because it's stimulating the lining? I will often times do if they're having no bleeding. A pro vera withdrawal. You give them pro vera for 10 days. That's progesterone and see if they withdraw and that tells you that their bodies 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 taking estrogen. If you're looking at the level of the uterus. Um You know, you can actually do a pro vera 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 come 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 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 and then just started getting lighter and lighter and lighter and maybe went away. Um That makes me very concerned for Ashley Evans. All right, okay. So I said the rest of cohen is endometrial dysfunction. I estrogenic the most common or contraception and anti coagulation 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. Okay. Um So how do we treat it? So the first thing is you have to establish a diagnosis and that's why you just need to keep your differential abroad 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 they're not 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 prolactin oma issue. They're not an ambulatory. You don't really have to worry about that. If it's really 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 and 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 there 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 endocrine apathy 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 pro active but I mean a low elevated right? So above like it's like 30 right? Typically in our teaching 32 200 was a micro adenoma. You don't necessarily even need an M. R. I. If it's above 200 it's a macro adenoma that's actually not true. Two thirds of prolactin omagh's our macro um And so anybody with if they're having irregular periods it seems like they're not ovulating and they have an elevated prolactin you want to levels you want to make sure that the second one is fasting even if it's still high just get an M. R. I. Because I've diagnosed several prolactin omagh's or even they're not actually secreting prolactin but it's an adenoma pituitary adenoma that's compressing the pituitary and increasing um and causes increasing prolactin. So Q. And A. Okay the someone asked me to go over the dosing and timing for the estrogen progesterone withdrawal. It's a great great question. So okay so if you're trying to to um to see whether or not somebody is gonna have a build up of their lining and then a withdrawal so you can make it really easy and just give them birth control pills like give them three 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 two mg of oral estradiol pure estradiol for three weeks and then one week of a progestin. And so that would either be five mg of a Justin or 10 mg of pro vera. And so you've now built up the lining. Now you're gonna give them progesterone and you're going to see if the lining sheds. So three weeks of high dose estrogen, two mg and then one week of a progestin. Let me know if that. Hopefully that answered the question. Okay. Speaking of progestin when we are trying to treat endometriosis, operation or abnormal bleeding, which of these is the strongest at the level of the uterus to block endometrial proliferation. All right. one. Maybe 2. I appreciate your asking. Right because people don't know this too. Okay. Two. Okay. Alright. Some people here. Okay so I'll just answer. Someone asked if it's two or three weeks of estradiol. It's three weeks of estradiol for the for the estrogen progesterone test. So you guys are right. Soma dropsy progesterone acetate is pro vera. Pro vera is the strongest um of the progestin. Okay. Um uh progesterone is prom atrium. It's actually rather we to be honest um In terms of in terms of of treating bleeding. I don't give prom a tree um for bleeding. I really give it for menopausal hormone therapy. North in drone acetate. So that's your adjustment. It's actually really good. But it's not quite as strong. Um and then north in drone um .35. Um Is not is not my recommendation. Okay so if you're giving somebody medication um you can do if you want to give them non hormonal you can actually give them trans ischemic 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 T. X. A. It's great. You take it only during your bleeding cycle um Three times a day. Usually for five days it is safe to use with birth control pills. The pharmacist will tell you know they'll be an alert yada yada. It's actually safe. This was part of my um my uh recent like re certification of my O. B. G. Y. N. License. They made us read through all the data. Um And the kind of recommendations to say that really when people are on birth control they're still having heavy bleeding it's fine to throw in TX A. Um The other progestin. So mad roxie progesterone acetate. So that's your pro vera you can start at 10 mg but you can go all the way up to 40 B. I. D. 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 north in drone. I usually you know you can give it that's your suggestion or thundering acetate. It's 2.5 to 7.5. Um You can use microns progesterone but I don't like it and then you know an I. U. D. Is great and depot is great. Please don't use North in drone Progesterone only pill for abnormal uterine bleeding. Um I see this a lot for the progesterone. The only pill is just pure North in drone. It's in this baby dose it is for birth control is not good for abnormal bleeding. It makes people bleed, it doesn't stop ovulation. Um So when we talk about progesterone you I usually think a 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. A Justin North in drone acetate is not the same but you can see that the North indian 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 metabolizes gonna be much stronger than the North in drone. A Justin is not approved as a contraceptive though. So I always tell people I'm gonna give you a Justin, it's North in drone acetate. It is it has never been studied as a birth control method. It probably works but it's not approved as such. Um Alright okay 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 okay. Um Okay 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 projections but you can also use them as a method of contraception. So O. C. P. S. Are great to use. Um I actually will often times do it taper. Um And so there's no really right way to do this but if someone's having really heavy bleeding you want to just head it off at the past give them one pill T. I. D. For three I just say three pills for three days, two pills for two days and then every day. Um There is data that shows you can use up to you know three pills a day for seven days. Again people are gonna feel kind of lousy. Obviously if somebody is at risk of a blood clot, you're not gonna want to do this. But in general I like the OCP tapers. I think they work well for acute bleeding in the operating room will actually give people ivy 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 ivy 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 But the most important is making sure that the structural causes not just incidental so if if the fibroids in the wall of the uterus or they happen to have like really mild added no I don't I can't really surgically remove addendum aosis without removing the whole uterus and that will certainly cure their abnormal bleeding. But really this is about whether or not I think the fibroids causing their bleeding. Um and so I have to just know exactly where it is. I will do endometrial ablation for patients. Um typically what I do. So you can do a thermal like where you put in hot water, thermal ablation ball Kateri, there's a freezing one. But the one I actually do the most of his radio frequency 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 because its failure rate starts to increase after about five 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 P. O. I. 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 as 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 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 super 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 appendectomy. So it's a totally separate procedure. Super cervical is just where we leave the cervix. Um And then um so that's a super cervical hysterectomy. Um I talked 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. Alright. For route of surgery, you guys who work with me know that my preferred route is vaginal. A lot of surgeons don't do this, they're only doing laproscopic 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 Alright 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 decrease in progesterone level. Sometimes they might mean you could it could be a polyp, you can always get an ultrasound. I'm not worried About a malignancy doing that. Um it's usually gonna be kind of in between and not premenstrual, 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 really just chalk up to depending on what it is. It's really just a decreasing and progesterone. Um sally asked is it standard to do a self injector me when someone has a hissed 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 recommend taking out the tubes. There's no use for the tubes of 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. 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. Alright. Lastly, alright, so let's just go back over everything. Um Remember a UBI is the preferred terminology abnormal uterine bleeding. It can be broken down into structural versus medical causes. Usually imaging or procedure is needed to rule out structural causes. Right? So if we think it's a polyp fibroid adenoma lignin c we're gonna need to do something to prove that. Um If it's we think it's an oval A. Torrey cause we want to do labs in 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've got to work with them on that. And this is why I love T. X. A. Um you know, and and also just kind of figure 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 gynecologists, I really give people all of their options and I really let them make 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 how much time we have for questions, but I'm happy to answer any that are remaining.