Can endometrial ablation be used in post menopausal women (57yrs) who have peristent AUB (despite negative biopsy x 2, and normal hysteroscopy)?
Response: I've never done that. Would worry about an underlying non endometrial based malignancy (sarcoma, endometrial stromal sarcoma).
Would likely get an MRI and consider a hysterectomy.
Can Nexplanon be used as progestine ?
Response: It is good for dysmenorrhea but not to treat abnormal bleeding because it itself causes abnormal bleeding.
How long after starting progestin should we expect the bleeding to subside?
Response: 1-2 weeks.
Can you comment on the use of pelvic u/s for evaluating endometrial thickness as a tool on deciding if we should do an endoemtrial bx in women age 40-45 w/ AUB?
Response: Only if its really thick - like more than 22 mm.
When to use TXA Vs progestins for acute AUB?
Response: TXA for acute self limited episodes / P for chronic recurrent problems.
if a menopausal woman with only 1 episode of vaginal bleed (just once on only one day), does such a patient need an U/S and endometrial biopsy, or does watch to see if it recurs again is acceptable?
Response: I think doing nothing is acceptable for a SINGLE self limited episode provided you have examined the patient.
Can you comment again on endometrial bx, if you have lower threshold for perimenopausal AUB in women 40-45? Several different gynes recently refused or said not necessary as long as ultrasound is normal.
Response: As always depends on the patient: BMI, other medical issues, thickness > 22 mm should be biopsied.
What is the dose of drosperinone for abnormal bleeding? Same as contraceptif?
Response: Slynd is 4 mg of DRS alone.
What do you do with breakthrough bleeding with slynd (taking same time daily)?
Response: There is NO fix. Period.
What would be the dose regimen for the progestins?
Response: Provera 20-40 mg x 2-4 weeks to make the bleeding stop.
I thought FSH is useless in perimenopause? Does not predict well.
Response: Correct UNLESS it's over 40.
Any issue for Slynd and BMI, as effective? Ok in perimenopause?
Response: None, safe with any underlying medical issue or BMI.
Is a biopsy automatically indicated for all perimenopausal women >40 years who are experiencing changes in their menstrual bleeding pattern?
Response: Depends on how long and how heavy.
Use your gut feeling
Endometriosis on bimanual, what are you looking for?
Response: Fixed immobile uterus.
Nodularity of the cul de sac.
Once you feel it your never forget it.
Woman in early perimenopause (ie 40-45 yo) with heavier bleeding but still regular what would you propose for treatment?
Response: TXA prn 3-4 days per month / Mirena / Ablation
Also beginning perimenopause symptoms like occasional hotflashes and increase fatigue
Response: In appropriate patient (thin, healthy, non smoker) low dose OC OK.
Can and how to do EM biopsy in women with IUD?
Response: Yes you can it is possible but very rarely helpful.
Which combined pill do you recommend - in terms of estrogen/progestin amount ex. Yaz vs Marvelon?
Response: All are pretty much the same but Marvelon has always been my go-to. Monophasic. Reasonable dose of estrogen.
Perimenopausal, prolonged spotting, normal labs, normal pap, normal US, endometrial biopsy?
Response: Yes
Would you consider a biopsy in a woman with heavy prolonged bleeding that has PCOS (30s, no diabetes or obesity)
Response: Yes, they can be at higher risk for hyperplasia and even cancer if they have bleeding after prolonged periods of amenorrhea.
Do most Gynecologists do office US?
Response: No. I do and can't imagine ever working without it.
Do cervical polyps need to be removed if no bothersome spotting and found incidentally on PAP?
Response: Only if bothersome, they are ALWAYS benign.
After how much time should you step down high does progestins? To what doses?
Response: 20-40 mg x 2-4 weeks, then reevaluate.
Can you use TXA with progestin? No risk dvt?
Response: Yes, safe.
Any role for uterine artery embolization? Any centers in Montreal that do this?
Response: Only for abnormal bleeding associated with uterine fibroids. MUHC, CHUM, Sacre Coeur, HMR, JGH.
Is Slynd (drospirenone) ok as a first line choice over Provera? Advantages?
Response: Is effective for contraception. Provera is NOT.
Is ablation done in office or hospital?
Response: In OR under conscious sedation.
Just to clarify, is the 2-4 weeks of provera only in the context of continuous bleeding? Or also for irregular spotting?
Response: Yes- 2-4 weeks will stop the bleeding. Then reevaluate to see if this is a recurrrent issue. Less effective to treat spotting.
How do you find nextellis compares to other combined ocp?
Response: Well tolerated in general. Good bleeding profile.
To follow-up on the recent question - context was post menopausal bleed that led to biopsy and the blood result that showed elevated CA-125 in mid 200s range.... any thought on PET-Scan to r/o any malignancy?
Response: Refer directly to GYN ONC.
Do you premeditate with analgesics before endometrial biopsy?
Response: I use something called Penthrox. Google it. A game changer.
Patient with anemia/heavy menses, also some insomnia/perimenopausal. Would NETA or Slynd be a good choice for her? Other suggestions?
Response: Depends, it may be a good choice for her bleeding and has some benefits for mood but not sleep.
Approach to breakthrough bleeding on OCP?
Response: ALWAYS the same formula: add supplemental estrogen. 1-2 mg of Estrace per day.
Dose of drosperinone is 4mg how many days for bleeding? 2 weeks?
Response: Uniquely for a progestin only method it is a 24/4 formulation. Still highly effective for birth control even though there are 4 placebo pills per month.
Which ocp is E4 15 mg /DRSP 3mg? (commercial name)
Response: Nextstellis
Is a biopsy automatically indicated for all perimenopausal women >40 years who are experiencing changes in their menstrual bleeding pattern?
Response: No, case by case.
During perimenopause, how do we know irregular bleeding warrants biopsy or not.
Response: Biopsy if prolonged-more than 3 weeks.
Can nexplanon be used for aub?
Response: Yes and no. It is itself associated with abnormal spotting in 30% of patients.
Should all women 40+ with increased/new heavy menstrual bleeding have endometrial biopsy? There is a lot that have this as a perimenopausal change.
Response: US first; if endometrium under 16 mm, wouldn't rush to biopsy.
What is Neta exactly, to be used after provera x 2-4 wks?
Response: Norlutate or Norethindrone acetate; Comes in a 5 mg pill.
Do you start the “emergency med eg Transanexmic acid or provers, and the birth control pill at the same time?
Response: Carefully and for only a few days if started with OC.
I used to frequently remove polyps when seen on speculum exam and send to pathology. I’ve heard that some gynes like to see these patients before removal. Should I be sending all cervical polyps to gyne?
Response: No need to; ALWAYS benign.
What is the degree of risk of thrombosis of combining of tranexamic acid and combined oral contraceptives? Any pts in which to avoid this (other than ones in which combined OC not appropriate to begin with)?
Response: Only case reports, no large studies.
Is it safe to use transexamic acid every month long term for menorrhagia?
Response: Yes
Can you talk more about endometrial ablation (availability, wait-time, when you use it vs medical or surgical Tx)?
Response: Done under conscious sedation.
5-10 minute procedure.
When patients can't tolerate hormones or refuse them.
Just to confirm - do you consider Drospirenone (Slynd) first line for AUB alongside NETA or MPA? Preference one over another?
Response: In women who need contraception, Slynd better option.
If no CI to estrogen, do you favor OCP or Progestin?
Response: OC, generally always better cycle control with OC.
Can the kyleena IUS or the implanted contraceptive device be used for heavy uterine bleeding? Can the implanted devise be used for endometrial protection in the context of PCOS?
Response: Klyeena can; no data for Nexplanon - has been shown to be effective for dysmenorrhea but not as a Rx for AUB.
Who is an ideally patient for ablation vs medical treatment?
Response: Normal US.
Intolerant to hormones.
No prior C section.
How does adenomyosis cause AUB
Response: Generally causes HMB not AUB. But a very common co existing problem.
In adolescent with irregular uterine bleeding on LOLO , Nextstellis. Is it true that higher concentration estrogene are better choice in this population?
Response: Risk of VTE negligible and always better cycle control with 30 mg + but you have to balance that with concerns about weight gain etc.
Why the 24/4 regimen is the newer pill? What are the problems with continuous OC or progestin?
Response: 24/4 applies to Slynd.
24/2/2 for Nextstellis.
Less pill free days less likely to ovulate and get pregnant and better cycle control.
To clarify, in a premenopausal patient age 40 or more with negative ultrasound, there should be a biopsy done?
Response: If she is obese, diabetic or the bleeding is prolonged or completely chaotic.
What are options for your patients who are trying to get pregnant to have heavy menstrual bleeding?
Response: TXA would be the only option because the others are all contraceptives.
Endometrial ablation can be done in the office?
Response: No, requires conscious sedation.
Abnormal uterine bleeding is a common clinical problem that affects women of reproductive age from menarche to menopause. A basic understanding of the causes, pathophysiology and investigation can help guide treatment. Initial treatment is generally medical and can be initiated with confidence once serious pathology, which is rare in the age group, has been excluded.
1. An introduction to the PALM-COEIN mnemonic for the various causes of abnormal uterine bleeding.
2. The role of transvaginal ultrasound, blood tests and endometrial sampling in making a clear diagnosis.
3. Effective medical treatment with tranexamic acid, oral contraceptives, oral and intrauterine progestins and knowing when referral to a gynecologist is advisable.