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Not all abnormal uterine bleeding is equal
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NASHVILLE, Tenn. — Making the distinction between the different types of abnormal uterine bleeding is critical to ensure proper treatment, according to a presentation at the American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting.
Health care costs, lost productivity costs and lost work wages associated with abnromal uterine bleeding [AUB] can total more than $12 billion annually, Kristen A. Matteson, MD, MPH, associate professor of obstetrics and gynecology, Women and Infants Hospital and Warren Alpert Medical School of Brown University, told attendees.
“AUB is a super common problem. That is why it is so important that we know how to diagnose and treat these patients,” she said.
Matteson provided the following information to help physicians distinguish between the various types of AUB:
- AUB-A, also known as adenomyosis, occurs when endometrial tissue grows within the myometrium. Matteson said patients with the condition may have pelvic pain or no symptoms at all.
- AUBP, used when endometrial polyps are observed along with the AUB. However, the polyps may be “incidental findings” and may disappear without warning
- AUB-O, used when ovulatory dysfunction takes place along with the bleeding. This type of AUB is identified by what Matteson called “a fragile vascular endometrium with insufficient stromal support.” She added that other distinctive traits include erratic, unpredictable, non-cyclic bleeding with inconsistent volume and that as one area heals, another begins bleeding.
- AUB-E, also known as endometrial dysfunction, occurs when there are “local disturbances” in endometrial function such as excesses or deficiencies of the proteins that influence coagulation.
- AUB-N is used when the AUB cannot be classified into any of the above definitions.
Matteson addressed the importance of making the distinction between the types of AUB.
“A combination of a structured history, imaging and additional lab testing for appropriate patients can help determine the most likely etiology. Knowing the cause of the AUB will help guide management strategies and treatment choice,” she said.
The treatment options for these types of AUB vary, and there is the caveat that some options have greater evidence supporting their use than others.
- AUB-A: NSAIDs, oral contraceptives, danazol, dienogest, levonorgestrel-releasing intrauterine devices, GnRH agonists, selective estrogen receptor modulators, aromatase inhibitors, ulipristal acetates, antiplatelet therapies, uterine artery embolization, high intensity focused ultrasound, endomyometrial ablation or resection and hysterectomy;
- AUB-P: blind polypectomy, hysteroscopic uterine polypectomy, electrosurgical and various mechanical devices;
- AUB-O and AUB-E: oral progestin, levonorgestrel-releasing intrauterine device, combined oral contraceptives, tranexamic acid, NSAIDs and endometrial ablation; and
- AUB-N: treat the condition that is causing the bleeding and/or the AUB-O and AUB-E treatments.
Matteson said it is important to remember that “one size does not fit all” when it comes to treating AUB.
“Some patients will want the predictability of knowing when their bleeding will occur. Some might want the lightest bleed possible. What matters is the needs and expectations of that one individual who is sitting across from you in the office,” she said– by Janel Miller
References:
Matteson KA. “Abnormal uterine bleeding: Wading through the evidence on treatment effectiveness.” Presented at: American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting; May 3-6, 2019; Nashville, Tenn.
Also:
Clark TJ, et al. Best Pract Res Clin Obstet Gynaecol. 2017;doi:10.1016/j.bpobgyn.2016.09.005.
Cohen D and Coco A. J Am Board Fam Med. 2014;doi:10.3122/jabfm.2014.01.130045.
Li J-J, et al. Biomed Res Int. 2018;doi10.1155/2018/6832685.
Disclosures: Matteson reports serving as a scientific advisor for Myovant and receiving honoraria from the American Board of Obstetrics and Gynecology, ACOG and NIH for participating in working groups and meetings. Please see the studies for those authors’ relevant financial disclosures.