102. Vaginal Bleeding Flashcards
In any woman with vaginal bleeding, rule out what ?
pregnancy
Differenciate menstruation regularity (3)
- Normal variation is 2-20 days
- Irregular (>20 day bleed-free intervals within 90 days)
- Absent/amenorrhea (No bleed in 90 days)
Describe menstruation frequency (3)
- Normal 24-38 days
- Infrequent (>38d)
- Frequent (<24d)
Describe normal/prolonged/shortened menstruations
- Normal 3-8 days)
- Prolonged (>8d)
- Shortened (<3d)
Name outside reproductive age
- Post-menopausal
- Precocious (<9y)
Name DDX : Vaginal bleeding (6)
- Pregnancy (Ectopic)
- Trauma
- Infection
- Systemic (Hypothyroid, Hyperprolactinemia, Cushing’s, PCOS, Adrenal, Hypothalamic suppression - stress)
- Iatrogenic / Medication (anticoagulants, hyperprolactinemia - antipsychotics, antidepressants)
- AUB
Name categories of AUB
- PALM (structural)
- COEIN (nonstructural)
Name STRUCTURAL causes of AUB (4)
PALM
- Polyp
- Adénomyose
- Léiomyome (Submucosal, Other)
- Malignancy/hyperplasia
Name NON-STRUCTURAL causes of AUB (5)
COEIN
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Describe history of vaginal bleeding (7)
- Anemia (presyncope, SOBOE)
- Sexual and reproductive history (pregnancy, STI, vaginal discharge, cervical screening)
- Systemic (hypothyroidism, hyperprolactinemia, coagulation disorder, PCOS, adrenal/hypothalamic)
- Pelvic pain/pressure
- Impact on QOL
- Fam Hx (coagulation, PCOS, endometrial/colon CA)
- Comorbid (hormone tumours, thromboembolic disease, CVD) could impact treatment options
Describe physical exam of vaginal bleeding (7)
Potential sites of bleeding
* Vulva, vagina, cervix, urethra, anus, perineum
Pelvic examination, speculum
* Mass, laceration, friable area
* Cervical polyp
* Uterine enlargement (pregnancy, leiomyoma, adenomyosis, uterine malignancy)
General exam for systemic illness, thyroid, hyperandrogenism, acanthosis nigricans, galactorrhea
Name investigations for menstrual bleeding (10)
- CBC (Hb)
- B-hCG (Serum positive 9d post-conception, Urine positive 28d after LMP)
- TSH, Prolactin
- Blood type and screen
- Coags, vWF, Fibrinogen (history of menorrhagia)
- Iron studies
- Gono/Chlam (cervicitis)
- Cervical cancer screening (as per guidelines)
- Endometrial sampling if …
- Imaging if exam findings of structural lesion, symptoms persist
When to do endometrial sampling? (4)
- > 40yo. Note: If postmenopausal on HRT <12mo can observe for one year before diagnosing AUB
- Risk factor (Obesity, PCOS, nulliparity, diabetes, Hereditary nonpolyposis colorectal cancer (Lynch Syndrome 40-60% endometrial CA)
- Failed management / persistent AUB
- Consider if Infrequent AUB >3y (suggests anovulatory)
Name possible imaging for AUB (2)
- Pelvic ultrasound (eg. ovulatory heavy bleeding)
- Saline sonography for submucosal fibroids
Describe ACUTE management of non-pregnant vaginal bleeding (5)
- Conjugated equine estrogen 25mg IV q4-6h x24h. Consider antiemetic due to side effects of nausea/vomiting
- Combined OCP TID x7d
- Medroxyprogesterone acetate 20mg TID x7d
- Tranexamic acid 1g PO/IV TID x5d
- Procedure (D&C, endometrial ablation, uterine artery embolization, hysterectomy)
