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6. Women's Health > 1- Abnormal Uterine Bleeding > Flashcards

1- Abnormal Uterine Bleeding Flashcards

1
Q

When is bleeding considered abnormal? (5)

A
  • 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
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2
Q

What is the definition for abn menstrual bleeding?

A

Abn quantity, duration, schedule; cycle < 24 days or > 38 days, bleeding > 8 days, blood loss > 80mL, intermenstrual bleeding

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3
Q

What is AUB/ HMB?

What is AUB/ IMB?

A

AUB/ HMB- heavy menstrual bleeding

AUB/ IMB- intermenstrual bleeding

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4
Q

What are the most common etiologies of AUB?

A

Anovulation, structural uterine pathology, bleeding disorders, uterine neoplasia

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5
Q

What is the current etiology classification system for AUB?

A

PALM-COEIN

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6
Q

What does the PALM in PALM-COEIN stand for? (classification for etiologies of AUB)

A

Structural causes

P- polyp

A- adenomyosis

L- leiomyoma (uterine fibroid)

M- malignancy and endometrial hyperplasia

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7
Q

What does the COEIN in PALM-COEIN stand for? (classification for etiologies of AUB)

A

Nonstructural causes

C- coagulopathy

O- ovulatory dysfunction

E- endometrial

I- iatrogenic

N- not otherwise classified

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8
Q

What is included in the initial eval of AUB besides determining the pattern, severity, and etiology?

A

Confirm uterus is the source and exclude pregnancy

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9
Q

What is the most common cause of AUB in 13-18 yo?

A

Anovulation (immature HPO axis)

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10
Q

What is the most common cause of AUB in 19-39 yo?

A

Pregnancy, then structural lesions (leiomyoma, polyp)

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11
Q

What is the most common cause of AUB in 40 yo to menopause?

A

Anovulatory bleeding

(also consider endometrial hyperplasia and carcinomas)

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12
Q

What is the most common etiology of anovulatory AUB in nonpregnant reproductive-aged women?

A

Unpredictable bleeding (related to hypothalamic abns or PCOS)

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13
Q

What is the most common etiology of ovulatory AUB in nonpregnant reproductive-aged women?

A

Menorrhagia (a/w structural lesions), coagulation disorder, or intermenstrual bleeding (due to cervical pathology- dysplasia/ infection)

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14
Q

Abn bleeding how long prior to menopause is common?

A

5-10 year prior

(anovulation due to declining numbers of ovarian follicles)

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15
Q

Although perimenopausal bleeding can be common, what is considered abn and how is this evaluated?

A

Frequent, heavy, prolonged

Eval w/ endometrial bx (EMB) to exclude endometrial hyperplasia or CA

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16
Q

Is postmenopausal bleeding normal or abn?

A

ABN (concerning for endometrial carcinoma)- assess w/ pelvic US and/or EMB

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17
Q

What should be evaluated on PE of pt with AUB? (3)

A

Signs of bleeding disorder, enlarged thyroid, evidence of hyperandrogenism

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18
Q

What should be evaluated on pelvic exam of pt with AUB?

A

Source of bleeding, IUD strings (if applicable), uterine size/ contour

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19
Q

What is the first diagnostic study that should be performed on a pt with AUB?

A

Pregnancy test

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20
Q

If you suspect anovulatory bleeding as the cause of AUB, what diagnostic tests should be ordered?

A

CBC

(consider TSH, prolactin, androgen levels)

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21
Q

If you suspect ovulatory bleeding due to menorrhagia as the cause of AUB, what diagnostic tests should be ordered?

A

CBC, pelvic US, consider EMB

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22
Q

Pt presents with AUB and you suspect the cause to be intermenstrual ovulatory bleeding. What diagnostic tests should be ordered?

A

Pap smear + cervical cultures

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23
Q

Who should undergo EMB sampling if > 45 yo?

A

> 45 yo w/ AUB and postmenopausal women with ANY uterine bleeding

24
Q

Who should undergo EMB sampling if < 45 yo?

A

< 45 yo with AUB +

  • RFs for unopposed estrogen exposure
  • Persistent bleeding
  • Failed med management of AUB
25
Q

What is inpatient management for acute AUB?

A

Admit if heavy bleeding w/ signs/ sxs or hemodynamic instability

Treat w/ IV estrogen or possible D+C (dilation and curettage)

26
Q

What is part of outpatient management of acute AUB?

A

Hormonal treatments, tranexamic acid IV or oral (alternative to hormonal tx)

27
Q

What hormonal treatments are included in the management of acute AUB?

A

COCs (monophasic pill w/ 35mcg ethinyl estradiol- 3 pills qd x 7 days)

Provera- oral

High dose oral estrogen w/ antiemetic

28
Q

What is included in the medical management for chronic AUB?

A

Hormone therapy (Mirena IUD), tranexamic acid, NSAIDS

29
Q

What is included in the surgical management for chronic AUB?

A

Endometrial ablation, hysterectomy (extreme cases), endometrial artery embolization or myomectomy for leiomyomas

30
Q

What is the major cause of AUB on both ends of the reproductive spectrum?

A

Anovulation

(immature HPO axis for 13-18 yo and perimenopause for 40 yo- menopause)

31
Q

Anovulatory AUB is usually unpredictable bleeding while ovulatory AUB is usually what?

A

Regular cycle length and + sxs a/w ovulation

32
Q

What is defined as painful menstruation in the absence of disease, occurs during ovulatory cycles, and typically affects ages 17-22?

A

Primary dysmenorrhea

33
Q

What is defined as painful menstruation due to organic pelvic disease and is more common as a woman ages?

A

Secondary dysmenorrhea

(most common in 30-40 yo)

34
Q

What is the pathogenesis of primary dysmenorrhea?

A

Prostaglandins released from endometrium during cell lysis (when ovum not fertilized) → uterine contractions and ischemia → pain

35
Q

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?

A

Primary dysmenorrhea

(other possible sxs: N/V/D, HA, LBP, fatigue)

36
Q

Is pelvic exam usually N or abn with primary dysmenorrhea?

A

Normal

37
Q

How is primary dysmenorrhea diagnosed?

A

Clinical diagnosis

(consider HCG, pap smear/ cultures)

38
Q

Aside from self care (heat, massage, exercise, nutrition supplements, smoking cessation), what is used in the treatment of primary dysmenorrhea?

A

NSAIDS (first line therapy)

Hormonal contraceptives (reduce menstrual flow and inhibit ovulation)

39
Q

What should be considered in the treatment of primary dysmenorrhea if resistant?

A

Laparoscopy and/or possible GnRH analogue

40
Q

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
A

Follow up and/or referral

41
Q

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?

A

Secondary dysmenorrhea

42
Q

Secondary dysmenorrhea is usually a/w what?

A

Other sxs (dyspareunia, infertility, AUB)

43
Q

The following are common causes of what?

Endometriosis, adenomyosis, adhesions, PID, leiomyomas

A

Secondary dysmenorrhea

44
Q

What is included in the management of secondary dysmenorrhea?

A

Treat underlying cause

Hormone therapy (COCs), pelvic surgery if complicated (refer)

(pelvic surgeries: dx laparoscopy, hysterectomy, oophrecomy, myomectomy)

45
Q

How is pre-menstrual syndrome (PMS) defined?

A

Physical + behavioral changes that occur in a regular, cyclic relationship to luteal phase that interfere with some aspect of pts life

46
Q

What is defined as PMS with more severe emotional sxs?

A

PMDD (premenstrual dysphoric disorder)

(premenstural sxs → PMS → PMDD)

47
Q

Although etiology of PMS is possibly due to N hormone fluctuations triggering an abn serotonin response, it is ultimately what?

A

Unlcear

48
Q

What is decreased in the progesterone-dominant luteal phase? (possibly attributing to PMS)

A

Serotonin

49
Q

Abd bloating, fatigue, swelling, breast tenderness, and HAs are a/w what?

A

Menstrual cycle associated disorders (PMS)

(physical sxs)

50
Q

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?

A

Menstrual cycle associated disorders (PMS)

(affective/ behavioral sxs)

51
Q

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?

A
  • 1-4 sxs that are physical, behavioral, or affective/ psychological OR
  • ≥ 5 sxs that are physical or behavioral
52
Q

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
A

1+ AND 1+ (must have 5/11 sxs overall)

53
Q

According to DSM-5 criteria for PMDD, sxs must be what?

A
  • 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
54
Q

What is the most notable difference between PMS/ PMDD and MDD?

A

Monthly cyclicity

55
Q

Management for PMS or PMDD is based on what?

A

Sxs

56
Q

The following are used as non-pharmacologic txs for what?

  • Decrease salt, caffeine, alcohol
  • Aerobic exercise
  • Supplements
  • Stress reduction
  • Cognitive therapy
A

PMS/ PMDD with mild sxs

57
Q

Pharmacologic treatment of PMS/ PMDD might include what?

A

SSRIs (first line therapy for PMDD, continuous or luteal phase therapy)

(also oral contraceptives, NSAIDS, spironolactone, GnRH agonists)

6. Women's Health (13 decks)

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