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What I Wish I’d Known in Residency: The Menstrual Cycle and AUB

What I Wish I’d Known in Residency: The Menstrual Cycle and AUB. Kathryn C. Calhoun, MD UNC-Chapel Hill Reproductive Endocrinology & Infertility. Me on the last day of my residency!!!.

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What I Wish I’d Known in Residency: The Menstrual Cycle and AUB

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  1. What I Wish I’d Known in Residency:The Menstrual Cycle and AUB Kathryn C. Calhoun, MD UNC-Chapel Hill Reproductive Endocrinology & Infertility

  2. Me on the last day of my residency!!! (I am smiling even though I still don’t fully understand the menstrual cycle because I am so excited to be done with my indentured servitude!)

  3. Objectives • Understand the normal menstrual cycle • Characteristics and endocrine regulation • Understand abnormal uterine bleeding (AUB) • Functional uterine bleeding (menorrhagia, metrorrhagia, post-coital bleeding) • Dysfunctional Uterine Bleeding (DUB) • Evaluation and work-up of above

  4. The Menstrual Cycle • Normal intervals: 24-35 days • Normal duration: 4-7 days • Normal EBL: 50ml • Who measured that?! • “Are you soaking more than one super pad/tampon per hour for multiple hours?”

  5. The Menstrual Cycle • Too much bleeding = Menorrhagia • Bleeding between periods = Metrorrhagia • Both = Menometrorrhagia • Bleeding too little = Oligo or Amenorrhea • A talk for another time.

  6. The Normal Menstrual Cyclesee also paper handout

  7. The Gyn Consult:Abnormal Uterine Bleeding The Scream – Edvard Munch

  8. The Gyn Consult • Don’t be a jerk. • You are a specialist and most physicians who decided against Gynecology did so on purpose.

  9. Abnormal Uterine Bleeding (AUB) • Rule out pregnancy.

  10. Abnormal Uterine Bleeding (AUB) • Confirm that bleeding is uterine • vaginal, urethral, cervical, anorectal

  11. Abnormal Uterine Bleeding (AUB) • Take a thorough history. • Determine if bleeding patterns are functional or dysfunctional (more on this later)

  12. Abnormal Uterine Bleeding (AUB) • History: • Age: Teen (immature HPO axis, bleeding d/o); age 20-40 (mature HPO axis – AUB usually anovulatory); 40+ (think: menopause) • Nature of bleeding: timing, amount, relationship to activity, presence of moliminal symptoms • PMH • Medications • FH

  13. Abnormal Uterine Bleeding Ovulatory (Functional) Anovulatory (Dysfunctional)

  14. Functional Uterine Bleeding Menorrhagia +/- Metrorrhagia Abnormal bleeding superimposed on ovulatory cycles STRUCTURAL: Fibroid Polyp Laceration Adenomyosis Endometriosis AVM Eval: Imaging Treatment: Surgery Medicine CANCER: Vulvar Vaginal Cervical Uterine Eval: Pap, EmBx Treatment: GynOnc HEMATOLOGIC: Coagulopathy Platelet d/o Liver Spleen Kidney Eval: Labs Treatment: Refer, medical suppression MEDICATIONS: Anticoagulants Birth Control Eval and Treatment: Change meds INFECTIONS: Vaginitis Cervicitis Endometritis Eval: SSE, cultures Treatment: Abx

  15. Dysfunctional Uterine Bleeding (DUB) Unpredictable Bleeding Patterns Rule out HypergonadotrophicHypogonadism (Ovarian failure) Rule out HypogonadotrophicHypogonadism ENDOCRINE: Thyroid Prolactin Acromegaly Cushing’s Eval: Exam, labs, imaging Treatment: Medicine, Surgery PCOS: Oligo/anovulation Elevated androgens PCO Eval: FSH/E2/?LH 17 OHP Imaging Treatment: Cyclic Prog Ov induction NC CAH: Oligo/anovulation Elevated androgens Early hirsutism? Chronic Anov: Stress Illness

  16. A Case

  17. A Case: AUB • 26yo female presents to ED with heavy VB • Soaking pads every 30 minutes for 2 days • Menarche age 13 • predictable bleeds with normal flow • OCPs intermittently with IMB/spotting • Changed to Depo 2009 …. What do you want to do?

  18. A Case: AUB • VS: BP WNL, tachy 110s • Pregnancy test negative • CBC reveals anemia • PMH/PSH nc • Meds: Depo • No FH coagulopathy, menorrhagia

  19. A Case: AUB • SSE: NEFG, normal vagina and cervix • TVUS: thin uterine lining (2mm), no obvious fibroids, ovaries quiet … what do you want to do?

  20. A Case: AUB • Admitted for IV Estrogen + pRBCs • Stable and sent home

  21. A Case: AUB • Re-presents with bleeding  D+C and Mirena • Stabilized and sent home

  22. A Case: AUB • Re-presents with bleeding  D+C and IUD removal • Thin lining with “progesterone effect” on biopsy • Stabilized and sent home on Premarin

  23. A Case: AUB • Returns to the office • Has tapered off Premarin with small bleed • Wants contraception. …. What do you want to do?

  24. A Case: AUB • TVUS reveals thin ES • Patient desires contraception

  25. Here’s what I did • Hormone holiday • Menstrual diary • Premarin Rx just in case • RTC 3 months

  26. Here’s what I did • After 3 months, has had predictable bleeds with normal flow characteristics • Considering barrier vs. Paragard IUD for contraception

  27. Why I did what I did • Progesterone attenuation of the lining appeared to be the culprit • In a combined OCP, “progesterone always wins” - Marc Fritz • Paragard may seem counter-intuitive but when she is not on progesterone, her periods are normal

  28. Questions?

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