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GY10 Gynecology
Disorders of Menstruation
Toronto Notes 2019
Table 5. AUB – Etiologies, Investigations, and Management
Etiology
Polyps (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L) Submucosal (AUB-Lsm) Other (AUB-Lo)
Malignancy and Hyperplasia (AUB-M)
Coagulopathy (AUB-C) Ovulatory dysfunction (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not yet classified (AUB-N)
Treatment
Investigations
Management
Polypectomy (triage based on symptoms,polyp size, histopathology and patient age)
See Adenomyosis, GY13
See Fibroids (Leiomyomata), GY13
Dependent on diagnosis
Dependent on diagnosis (hormonal modulation (e.g. OCP), Mirena IUD, endometrial ablation)
See Infertility, GY23
Tranexamic acid
Hormonal modulation (e.g. OCP) Mirena IUD
Endometrial ablation
Remove offending agent ––
STRUCTURAL
Transvaginal sonography
Saline Infusion sonohysterography
Transvaginal sonography MRI
Transvaginal sonography
Saline infusion sonohysterography Diagnostic hysteroscopy
Transvaginal sonography
Endometrial biopsy - consider biopsy in women >40 yr with AUB to exclude endometrial cancer
NON-STRUCTURAL
CBC, coagulation profile (especially in adolescents), vWF, Ristocetin cofactor, factor VIII
Bloodwork: β-hCG, ferritin, prolactin, FSH, LH, serum androgens (free testosterone, DHEA), progesterone, 17-hydroxy progesterone, TSH, fT4
pelvic ultrasound
Endometrial biopsy
Transvaginal sonography (rule out forgotten IUD) Review OCP/HRT use
Review meds (especially neuroleptic use)
––
• resuscitatepatientifhemodynamicallyunstable • treatunderlyingdisorders
■ if anatomic lesions and systemic disease have been ruled out, consider AUB • medical
■ mild AUB
◆ NSAIDs
◆ anti-fibrinolytic (e.g. Cyklokapron®) at time of menses
◆ combined OCP
◆ progestins (Provera®) on first 10-14 d of each month or every 3 mo if AUB-O ◆ Mirena® IUD
◆ danazol
◆ correct anemia - iron
■ acute, severe AUB
– replace fluid losses, consider admission
a) estrogen (Premarin®) 25 mg IV q4h x 24 h with Gravol® 50 mg IV/PO q4h or anti-fibrinolytic (e.g. Cyklokapron®) 10 mg/kg IV q8h (rarely used)
b) tapering OCP regimen, 35μg pill TID x7d then taper to 1 pill/d for 3w with Gravol® 50 mg IV/PO q4h – ortaperto1tabtidx2d→bidx2d→OD(morecommonlyused)
◆ after (a) or (b), maintain patient on monophasic OCP for next several months or consider alternative medical treatment
• surgical
■ endometrial ablation
◆ if finished childbearing
◆ repeat procedure may be required if symptom reoccur, especially if <40 yr ■ hysterectomy: definitive treatment