Episode 53 - Abnormal Uterine Bleeding - a podcast by Rio Bravo Family Medicine Residency Program

Colorectal cancer screening update, COVID-19 vaccine update, and abnormal uterine bleeding basics.

Today is May 24, 2021.

Colorectal cancer screening update 
Written by Hector Arreaza, MD. 
Participation: Ikenna Nwosu, MD, and Daniela Viamontes, MD.

Today is May 24, 2021.

On august 29, 2020, we were in the midst of a pandemic and we woke up with the sad news about the death of Chadwick Aaron Boseman (also known as Black Panther). An interesting fact: The tweet in which his family announced his death on Twitter became the most-liked tweet in history. But why are we talking about Chadwick’s death? Because he died of colon cancer. I do not know if this recommendation came because of Chadwick, but it’s a good way to open this episode: remembering Black Panther.

We heard the rumors, but now it’s official. On May 18, 2021, the USPSTF released their final recommendation statement about colorectal cancer screening. The age to start screening has been changed from 50 to 45 years old. This is a grade B recommendation. Grade B means that this recommendation has moderate to substantial net benefit, so offer this service to your patients. 

Screening adults between 76 and 85 years old who have been previously screened has a small net benefit (grade C recommendation). So, select patients may be screened for colorectal cancer in this age group (76-85), especially those who have never been screened.

Do you remember this recommendation from medical school for high risk patients? Start screening at age 40 or 10 years before a patient’s direct-relative was diagnosed with colon cancer. This was a recommendation given by the US Multi-Society Task Force (which includes the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy). This same organization already recommended in 2017 to start screening at age 45 in African American patients, and the American Cancer Society recommended screening all patients at age 45 in 2018. The ACS does not have a guideline to screen high risk patients for colon cancer. Most organizations agreed on not screening after age 85.

Strategies for screening:

High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year

Dani: Stool DNA-FIT every 1 to 3 years (Cologuard®)  

CT colonography every 5 years 

Flexible sigmoidoscopy every 5 years OR Flexible sigmoidoscopy every 10 years + annual FIT 

Colonoscopy screening every 10 years

Discuss different options with your patients, choose your favorite and do it!
 

 

Introduction: Update on COVID 19 vaccines  

By Hector Arreaza, MD, and Lillian Petersen, RN.

 

COVID-19 vaccines now can be co-administered with other vaccines according to the ACIP. COVID-19 vaccines and other vaccines may now be administered without regard to timing. They can be given on the same day or within the 14 days previously recommended between vaccines. 

 

It is not known if reactogenicity of COVID-19 vaccine is increased with co-administration with other reactogenic vaccines (such as vaccines with live attenuated viruses). 

 

How do you decide if you want to co-administer a vaccine? 

1. Consider whether the patient is behind or at risk of becoming behind on recommended vaccines.

2. Consider their risk of vaccine-preventable disease.

3. Consider the reactogenicity profile of the vaccines. If multiple vaccines are administered at a single visit, administer each injection in a different injection site, at least one inch apart or in different limbs. 

Current or previous SARS-CoV-2 infection: 

Everyone should be offered COVID-19 vaccination regardless of their history of COVID-19 infection. Viral testing or serologic test is not recommended for the purposes of vaccine decision-making. People with current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and they have met criteria to discontinue isolation. This applies to patients who got the disease before receiving any vaccine or after receiving the first dose. 

 

A minimum interval between infection and vaccination has not been established, but evidence suggests that the risk of reinfection is low in the months after initial infection but may increase with time due to waning immunity.

 

People with a history of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A):

It is unclear if people with a history of MIS-C or MIS-A are at risk of recurrence of the same dysregulated immune response following reinfection with SARS-CoV-2 or in response to vaccination. People with a history of MIS-C or MIS-A may choose to be vaccinated but they should consider delaying vaccination until they have recovered from their illness and for 90 days after the date of diagnosis. Find more information at the CDC.gov website.

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Abnormal Uterine Bleeding. 
By Sherika Adams, MS3, P. Eresha Perera, MS3, and Hector Arreaza, MD. 

 

Definition. 

AUB is a symptom, not a diagnosis. It is equivalent to say: “This patient’s periods are abnormal.” Anything that falls out of what is considered “normal periods” is classified as abnormal uterine bleeding.

These 4 elements are assessed when determining if a patient has AUB: Regularity, frequency, duration, and volume. 

 

What is considered normal? Frequency = Every 24-38 days, regularity +/- 2-20 days over 12 months, duration = 4.5 to 8 days, volume = 5-80 mL. 10-30% of women of reproductive age may have AUB.

 

According to the American College of Obstetricians and Gynecologists (ACOG), abnormal uterine bleeding is characterized by bleeding or spotting following sexual intercourse or menopause, between menstrual cycles, menstrual cycles lasting more than 38 days or shorter than 24 days, heavy bleeding during menstruation, and “irregular” menstrual cycles that have 7-9 days of variation.

Terms no longer used: menorrhagia, metrorrhagia, and dysfunctional uterine bleeding (DUB). 

Not all symptoms reported as “vaginal bleeding” are coming from the vagina. For example, bleeding from anus, urethra, bladder, and perineum should be ruled out before establishing the diagnosis of AUB.

 

Classification of Abnormal Uterine Bleeding (AUB). 

Abnormal uterine bleeding (AUB) in nonpregnant premenopausal women can be classified by the acronym PALM-COEIN, which was established by the International Federation of Gynecology and Obstetrics (FIGO) in 2011. 

 

PALM-COEIN: 

Palm: Structural etiologies, Coein: Non-structural etiologies
 

P is for polyps: Polyps are epithelial tumors in the endometrium or cervix and can be identified by hysterosonography or hysteroscopic imaging.
 

A is for adenomyosis: Adenomyosis is endometrial stroma and glands in the myometrium and can be identified by histopathology, and now MRI and transvaginal ultrasound.
 

L is for leiomyomas: Leiomyomas also known as uterine fibroids are benign smooth muscle tumors that are diagnosed by pelvic examination and pelvic imaging such as ultrasound with contrast or MRI.
 

M is for malignancy and hyperplasia: Malignancy and hyperplasia are often abnormal epithelial tissue that is benign or cancerous that can be seen with transcervical endometrial sampling.
 

C is for coagulopathy: Coagulopathy is bleeding disorders such as Von Willebrand disease is identified by laboratory testing.
 

O is ovulatory dysfunctions: Ovulatory dysfunction occurs when there is a variation of more than seven days of the menstrual cycle in the past 12 months and ovulation is dysfunctional. In a woman without ovulation, there is no corpus luteum, and there is no progesterone, so estrogen goes unopposed, causing a buildup of endometrium and irregular bleeding.  
 

E is endometrial causes: Endometrial causes can occur when there is normal ovulation, no other identifiable cause of AUB, and there is heavy menstrual bleeding, which includes intermenstrual bleeding. Primary disorders of endometrial hemostasis are likely due to vasoconstriction disorders, inflammation, or infection. Endometrial dysfunction is poorly understood; there are no reliable diagnostic methods, and it should be considered only after other causes are excluded.
 

I is for iatrogenic cause: Iatrogenic causes include gonadal steroids (estrogen, androgens), anticoagulants, intrauterine devices, antipsychotics, antidepressants, and anti-hypertensives.
 

N is for not otherwise classified: Example of an etiology under not otherwise classified might be AV malformations.

 

This classification does not include pregnancy.

 

Postmenopausal bleeding: Abnormal uterine bleeding can also occur in post-menopausal women and is an indication of potentially lethal endometrial cancer. Post-menopausal women should be worked up for cancer when they present with bleeding. However, most common cause of bleeding in this population is atrophy of the vaginal mucosa or endometrium. If younger than 45 patients but history of unopposed estrogen exposure (PCOS, obesity, estrogen therapy) should also undergo endometrial biopsy to rule out possibility of endometrial cancer. 

 

Management of AUB. 

Management of the AUB can be initiated only after the etiology of the bleeding has been established. Firs of all, rule out pregnancy related bleeding by performing a pregnancy test. Also, rule out other sources of bleeding.

 

The first question to answer would be: Does this patient need an emergent treatment for her AUB or can she be treated as outpatient? Determine that by checking the history, vitals, orthostatic vitals, physical exam, and labs. 

 

If patient requires admission, the options for treatment include: uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. In case of severe bleeding without hemodynamic instability, patients can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid.

For chronic AUB, once etiology has been established, the goal is to treat the underlying condition. The goal of treatment is to control the bleeding since AUB can persists until menopause. 

 

Initial outpatient treatment is usually pharmacological. For those not wanting to conceive soon, consider IUD placement. “Among medical therapies, the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is most effective for decreasing heavy menstrual bleeding (71% to 95% reduction in blood loss) and performs similarly to hysterectomy when quality-adjusted life years are considered.”[8]

 

Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, NSAIDs (nonsteroidal anti-inflammatory drugs), and depot medroxyprogesterone.

 

Surgical treatment is often considered for patients on long term medical therapy with no response, or for severe cases of bleeding with recurrent need for emergent treatment.

 

Some surgical options are endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Some structural lesions can be resected via hysteroscopy (polyps).

 

Myomectomy and uterine artery embolization are options for patients with severe AUB who want to preserve fertility. Uterine leiomyomas or adenomyosis can be medically managed with OCPs but can also be treated with surgery as well, depending on the physician-patient discussion of options.

 

Hysterectomy is the definitive treatment of severe AUB.

 

Remember, PALM COEIN stands for: Polyps, Adenomyosis, Leiomyomas, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic cause, Not otherwise classified.

 

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Conclusion.
Written by Hector Arreaza, MD

Now we conclude our episode number 53 “Abnormal Uterine Bleeding”. Eresha and Sherika did a great job explaining the Palm-Coein classification, and gave us a good overview of the management of AUB. Remember to start screening for colorectal cancer at age 45 now, what strategy for screening will you use? And for those patients who were hesitant about getting the COVID-19 vaccine with other vaccines, well, the ACIP said we can co-administer it with other vaccines. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Daniela Viamontes, Ikenna Nwosu, Lillian Petersen, Sherika Adams, and P. Eresha Perera. Audio edition: Suraj Amrutia. See you next week! 

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References:

Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States, Centers for Disease Control and Prevention, https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html#Coadministration, accessed on May 20, 2021. 

 

Colorectal Cancer: Screening, Final Recommendation Statement, U.S. Preventive Services Task Force, May 18, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening.

 

Abnormal Uterine Bleeding FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/abnormal-uterine-bleeding, accessed on May 17, 2021. 

 

Fraser, Ian, et al. Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN etiology classification, Up to Date, last updated: Dec 16, 2019. https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-reproductive-age-women-terminology-and-palm-coein-etiology-classification?search=palm%20coein&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

 

Goodman Annekathryn, et al, Postmenopausal uterine bleeding, Up to Date, last updated: Feb 02, 2021. https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=abnormal%20uterine%20bleeding%20postmenopausal&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Kaunitz, Andre M, Abnormal uterine bleeding: Management in premenopausal patients, Up to Date, last updated: Aug 25, 2020. https://www.uptodate.com/contents/abnormal-uterine-bleeding-management-in-premenopausal-patients?search=abnormal%20uterine%20bleeding%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99(7):435-443. PMID: 30932448. https://pubmed.ncbi.nlm.nih.gov/30932448/

 

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