15. In the reproductive age group Flashcards
What is the focus of the approach to abnormal uterine bleeding (AUB) in the reproductive age group?
The focus is on an approach to the problem rather than the management of specific disorders.
When discussing AUB, which sources of bleeding must first be excluded?
Rectal, bladder, lower genital tract, and cervical pathology must be excluded.
Does this approach to AUB include bleeding related to pregnancy?
No, bleeding related to pregnancy is not reviewed in this approach.
How should a woman presenting with bleeding be initially described before determining the source?
She should be described as having abnormal vaginal bleeding until a gynecological examination confirms the source.
What are the four key features to assess when describing a menstrual bleeding pattern?
- Regularity of onset
- Frequency of onset
- Duration of flow
- Heaviness/volume of flow
What is the normal frequency of menstrual cycles?
24–38 days
How is a menstrual cycle classified if it occurs more frequently than every 24 days?
Frequent (<24 days).
How is a menstrual cycle classified if it occurs less frequently than every 38 days?
Infrequent (>38 days).
What is considered a regular menstrual cycle based on cycle-to-cycle variation over 12 months?
A variation of 2–20 days.
What cycle-to-cycle variation is classified as irregular?
A variation of >20 days.
What is the normal duration of menstrual flow?
4.5–8 days.
How is menstrual flow classified if it lasts more than 8 days?
Prolonged
How is menstrual flow classified if it lasts less than 4.5 days?
Shortened
What is the normal range for monthly blood loss?
5–80 mL.
How is menstrual bleeding classified if blood loss is >80 mL per month?
Heavy
How is menstrual bleeding classified if blood loss is <5 mL per month?
Light.
How is heavy menstrual bleeding (HMB) defined according to the UK NICE guidelines?
Excessive menstrual blood loss that interferes with a woman’s physical, emotional, social, and material quality of life, occurring alone or with other symptoms.
What is intermenstrual bleeding?
Bleeding that occurs between normally timed cycles, in either a regular or irregular pattern.
What is the definition of acute uterine bleeding?
An episode of bleeding in a non-pregnant woman of reproductive age that requires immediate intervention to prevent further blood loss.
What is the definition of chronic abnormal uterine bleeding?
Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency, and has been present for the majority of the last 6 months.
Why should the term dysfunctional uterine bleeding (DUB) no longer be used?
The term is obsolete and has been replaced by more specific classifications of abnormal uterine bleeding.
What does the PALM-COEIN classification system describe?
It categorizes the causes of abnormal uterine bleeding into structural (PALM) and non-structural (COEIN) causes.
What does the P in PALM stand for?
Polyp – a benign overgrowth of endometrial or cervical tissue.
What does the A in PALM stand for?
Adenomyosis – endometrial tissue growing into the myometrium.
What does the L in PALM stand for?
Leiomyoma (fibroids) – classified into submucosal and other types.
What does the M in PALM stand for?
Malignancy & hyperplasia – abnormal endometrial growth, which can be precancerous or cancerous.
What does the C in COEIN stand for?
Coagulopathy – bleeding disorders that affect clotting, such as von Willebrand disease.
What does the O in COEIN stand for?
Ovulatory dysfunction – irregular or absent ovulation leading to unpredictable bleeding patterns.
What does the E in COEIN stand for?
Endometrial causes – local endometrial dysfunction leading to abnormal bleeding.
What does the I in COEIN stand for?
Iatrogenic – bleeding caused by medications or medical interventions (e.g., hormonal therapy, anticoagulants, IUDs).
What does the N in COEIN stand for?
Not yet classified – emerging or unknown causes of abnormal uterine bleeding.
What is the primary goal of history-taking in AUB?
To determine ovulatory status and possible underlying causes
How does ovulatory bleeding typically present?
Predictable, cyclic menstruation (suggests normal ovulation).
How does anovulatory bleeding typically present?
Irregular, unpredictable cycles (suggests ovulatory dysfunction).
How sensitive is a structured history for detecting coagulation disorders?
90% sensitive.
What is a positive screening result for a coagulopathy?
Any of the following:
- Heavy menstrual bleeding since menarche
- One of the following:
- Postpartum hemorrhage
- Surgical-related bleeding
- Bleeding after dental work
- Two or more of the following:
- Bruising 1–2 times per month
- Epistaxis 1–2 times per month
- Frequent gum bleeding
- Family history of bleeding disorders
How is AUB due to anticoagulants classified?
AUB-C1
What are the key objectives of the physical exam in AUB?
- Detect problems not obvious from history
- Identify anaemia and other consequences of blood loss
- Exclude cervical and lower genital tract pathology
- Confirm that bleeding is of uterine origin
- Identify pelvic masses that may contribute to symptoms
What basic laboratory test should be done in all AUB patients?
Full blood count (FBC) to assess for anaemia.
When should endocrinopathy be evaluated?
If anovulation is suspected.
When should testing for inherited coagulopathy be done?
If screening for coagulopathy is positive.
When should an endometrial sample be taken?
- All women >45 years
- Younger women at high risk for endometrial cancer
What imaging tests may be useful in AUB?
Transvaginal and/or transabdominal ultrasound
Sonohysterography and hysteroscopy
When should a PAP smear be performed?
As per screening guidelines to exclude cervical pathology.
Management
As per screening guidelines to exclude cervical pathology.
