1- Abnormal Uterine Bleeding Flashcards
When is bleeding considered abnormal? (5)
- Bleeding/ spotting between periods or after sex
- Heavy bleeding during period
- Menstrual cycles > 38 days or < 24 days
- “Irregular” periods (cycle length varies > 7-9 days)
- After menopause
What is the definition for abn menstrual bleeding?
Abn quantity, duration, schedule; cycle < 24 days or > 38 days, bleeding > 8 days, blood loss > 80mL, intermenstrual bleeding
What is AUB/ HMB?
What is AUB/ IMB?
AUB/ HMB- heavy menstrual bleeding
AUB/ IMB- intermenstrual bleeding
What are the most common etiologies of AUB?
Anovulation, structural uterine pathology, bleeding disorders, uterine neoplasia
What is the current etiology classification system for AUB?
PALM-COEIN
What does the PALM in PALM-COEIN stand for? (classification for etiologies of AUB)
Structural causes
P- polyp
A- adenomyosis
L- leiomyoma (uterine fibroid)
M- malignancy and endometrial hyperplasia
What does the COEIN in PALM-COEIN stand for? (classification for etiologies of AUB)
Nonstructural causes
C- coagulopathy
O- ovulatory dysfunction
E- endometrial
I- iatrogenic
N- not otherwise classified
What is included in the initial eval of AUB besides determining the pattern, severity, and etiology?
Confirm uterus is the source and exclude pregnancy
What is the most common cause of AUB in 13-18 yo?
Anovulation (immature HPO axis)
What is the most common cause of AUB in 19-39 yo?
Pregnancy, then structural lesions (leiomyoma, polyp)
What is the most common cause of AUB in 40 yo to menopause?
Anovulatory bleeding
(also consider endometrial hyperplasia and carcinomas)
What is the most common etiology of anovulatory AUB in nonpregnant reproductive-aged women?
Unpredictable bleeding (related to hypothalamic abns or PCOS)
What is the most common etiology of ovulatory AUB in nonpregnant reproductive-aged women?
Menorrhagia (a/w structural lesions), coagulation disorder, or intermenstrual bleeding (due to cervical pathology- dysplasia/ infection)
Abn bleeding how long prior to menopause is common?
5-10 year prior
(anovulation due to declining numbers of ovarian follicles)
Although perimenopausal bleeding can be common, what is considered abn and how is this evaluated?
Frequent, heavy, prolonged
Eval w/ endometrial bx (EMB) to exclude endometrial hyperplasia or CA
Is postmenopausal bleeding normal or abn?
ABN (concerning for endometrial carcinoma)- assess w/ pelvic US and/or EMB
What should be evaluated on PE of pt with AUB? (3)
Signs of bleeding disorder, enlarged thyroid, evidence of hyperandrogenism
What should be evaluated on pelvic exam of pt with AUB?
Source of bleeding, IUD strings (if applicable), uterine size/ contour
What is the first diagnostic study that should be performed on a pt with AUB?
Pregnancy test
If you suspect anovulatory bleeding as the cause of AUB, what diagnostic tests should be ordered?
CBC
(consider TSH, prolactin, androgen levels)
If you suspect ovulatory bleeding due to menorrhagia as the cause of AUB, what diagnostic tests should be ordered?
CBC, pelvic US, consider EMB
Pt presents with AUB and you suspect the cause to be intermenstrual ovulatory bleeding. What diagnostic tests should be ordered?
Pap smear + cervical cultures
Who should undergo EMB sampling if > 45 yo?
> 45 yo w/ AUB and postmenopausal women with ANY uterine bleeding
Who should undergo EMB sampling if < 45 yo?
< 45 yo with AUB +
- RFs for unopposed estrogen exposure
- Persistent bleeding
- Failed med management of AUB
What is inpatient management for acute AUB?
Admit if heavy bleeding w/ signs/ sxs or hemodynamic instability
Treat w/ IV estrogen or possible D+C (dilation and curettage)
What is part of outpatient management of acute AUB?
Hormonal treatments, tranexamic acid IV or oral (alternative to hormonal tx)
What hormonal treatments are included in the management of acute AUB?
COCs (monophasic pill w/ 35mcg ethinyl estradiol- 3 pills qd x 7 days)
Provera- oral
High dose oral estrogen w/ antiemetic
What is included in the medical management for chronic AUB?
Hormone therapy (Mirena IUD), tranexamic acid, NSAIDS
What is included in the surgical management for chronic AUB?
Endometrial ablation, hysterectomy (extreme cases), endometrial artery embolization or myomectomy for leiomyomas
What is the major cause of AUB on both ends of the reproductive spectrum?
Anovulation
(immature HPO axis for 13-18 yo and perimenopause for 40 yo- menopause)
Anovulatory AUB is usually unpredictable bleeding while ovulatory AUB is usually what?
Regular cycle length and + sxs a/w ovulation
What is defined as painful menstruation in the absence of disease, occurs during ovulatory cycles, and typically affects ages 17-22?
Primary dysmenorrhea
What is defined as painful menstruation due to organic pelvic disease and is more common as a woman ages?
Secondary dysmenorrhea
(most common in 30-40 yo)
What is the pathogenesis of primary dysmenorrhea?
Prostaglandins released from endometrium during cell lysis (when ovum not fertilized) → uterine contractions and ischemia → pain
Pt c/o of cramp-like and intermittent pain beginning a few hours before or just after onset of menstruation that lasts 12-72 hours. Pain is most intense in lower abd (+/- radiation). What are you concerned for?
Primary dysmenorrhea
(other possible sxs: N/V/D, HA, LBP, fatigue)
Is pelvic exam usually N or abn with primary dysmenorrhea?
Normal
How is primary dysmenorrhea diagnosed?
Clinical diagnosis
(consider HCG, pap smear/ cultures)
Aside from self care (heat, massage, exercise, nutrition supplements, smoking cessation), what is used in the treatment of primary dysmenorrhea?
NSAIDS (first line therapy)
Hormonal contraceptives (reduce menstrual flow and inhibit ovulation)
What should be considered in the treatment of primary dysmenorrhea if resistant?
Laparoscopy and/or possible GnRH analogue
In any of the following cases of primary dysmenorrhea, what is indicated?
- Pain worsening w/ each menses
- Pain lasts longer than first 2 days of menses
- Meds no longer controlling pain
- Menstrual bleeding becomes increasingly heavy
- Pain + fever
- Abn discharge or bleeding
- Pain occurs at times unrelated to menses
Follow up and/or referral
Pt presents with pain less related to 1st day of menses, not limited to menses but worsens around this time. What are you concerned for?
Secondary dysmenorrhea
Secondary dysmenorrhea is usually a/w what?
Other sxs (dyspareunia, infertility, AUB)
The following are common causes of what?
Endometriosis, adenomyosis, adhesions, PID, leiomyomas
Secondary dysmenorrhea
What is included in the management of secondary dysmenorrhea?
Treat underlying cause
Hormone therapy (COCs), pelvic surgery if complicated (refer)
(pelvic surgeries: dx laparoscopy, hysterectomy, oophrecomy, myomectomy)
How is pre-menstrual syndrome (PMS) defined?
Physical + behavioral changes that occur in a regular, cyclic relationship to luteal phase that interfere with some aspect of pts life
What is defined as PMS with more severe emotional sxs?
PMDD (premenstrual dysphoric disorder)
(premenstural sxs → PMS → PMDD)
Although etiology of PMS is possibly due to N hormone fluctuations triggering an abn serotonin response, it is ultimately what?
Unlcear
What is decreased in the progesterone-dominant luteal phase? (possibly attributing to PMS)
Serotonin
Abd bloating, fatigue, swelling, breast tenderness, and HAs are a/w what?
Menstrual cycle associated disorders (PMS)
(physical sxs)
Labile mood/ irritability, sad/ depressed mood, anxiety/ tension, sensitivity to rejection, diminished interest in activities, and increased appetite/ food cravings are a/w with what?
Menstrual cycle associated disorders (PMS)
(affective/ behavioral sxs)
According to the diagnostic criteria for PMS, how many sxs must be physical, behavioral, or affective/ psychological in nature OR how many sxs must be physical/ behavioral?
- 1-4 sxs that are physical, behavioral, or affective/ psychological OR
- ≥ 5 sxs that are physical or behavioral
How many of set 1 criteria PLUS how many of set 2 criteria must be present for a DSM-5 dx of PMDD?
Set 1
- Mood swings, sudden sadness, increased sensitivity to rejection
- Sense of hopelessness, depressed mood, self-critical thoughts
- Anger, irritability
- Tension, anxiety, feeling on edge
Set 2
- Difficulty concentrating
- Change in appetite, food cravings
- Diminished interest in usual activities
- Easy fatigability, decreased energy
- Feeling overwhelmed, out of control
- Sleeping too much or not enough
- Breast tenderness, bloating, weight gain, joint/ muscle aches
1+ AND 1+ (must have 5/11 sxs overall)
According to DSM-5 criteria for PMDD, sxs must be what?
- Present in most menstrual cycles over previous year
- Present during wek prior to menses/ resolving w/ onset
- A/w significant distress/ interference w/ usual activities
What is the most notable difference between PMS/ PMDD and MDD?
Monthly cyclicity
Management for PMS or PMDD is based on what?
Sxs
The following are used as non-pharmacologic txs for what?
- Decrease salt, caffeine, alcohol
- Aerobic exercise
- Supplements
- Stress reduction
- Cognitive therapy
PMS/ PMDD with mild sxs
Pharmacologic treatment of PMS/ PMDD might include what?
SSRIs (first line therapy for PMDD, continuous or luteal phase therapy)
(also oral contraceptives, NSAIDS, spironolactone, GnRH agonists)
