21- Abnormal Uterine Bleeding

Question 1

What is dysfunctional uterine bleeding?

Answer 1

Abnormal uterine bleeding in the absence of uterine pathology or medical illness
Associated with anovulation
Diagnosis of exclusion

Question 2

What are the five phases of menstrual cycle?

Answer 2

Menstrual endometrium- thin dense tissue, stable non functioning
Proliferative
Secretory
Implantation( stratum spongiosum, compactum and unchanged basalis)
Exfoliative or endometrial breakdown

Question 3

What are the diagnosis of irregular bleeding?

Answer 3

Most cases of anovulatory bleeding are the result of estrogen withdrawal or estrogen breakthrough bleeding
High sustained levels of estrogen and heavy bleeding are associated with polycystic ovaries

Question 4

What are the menstrual characteristics of anovulatory bleeding?

Answer 4

Patient with marked irregular periods
Occasionally misses months
Variation of menstrual flow can occur

Question 5

What are the characteristics of progesterone breakthrough bleeding ?

Answer 5

Seen in patients who are on birth control
Not pathologically significant
Continuous progesterone exposure causes a functional atrophy of the endometrial lining
Treated by adding estrogen to progesterone only methods

Question 6

What test to run in uterine bleeding?

Answer 6

CBC
HCG- rule out pregnancy 
Thyroid function test
Abnormalities of the uterus
Sampling of the endometrial cavity

Question 7

What are the therapies available?

Answer 7

Progesterone therapy- restore synchrony to the endometrial lining
Estrogen- rapid growth of the endometrium
Low dose oral contraceptives- in young anovulatory women with prolonged unopposed estrogen
Antiprostaglandins

Question 8

What is the treatment for ovulating women with menorrhagia?

Answer 8

NSAIDs
Progestin daily for 7 days before menses
Oral contraceptives

Question 9

When is dilation and curettage done?

Answer 9

Used as a second line diagnosis and management in younger patients who have failed medical therapy
Highly cautious on adolescent
First line therapy for patients who are in the second half of reproductive life and who are bleeding very heavily

Question 10

What is endometrial ablation?

Answer 10

Surgical procedure designed to destroy the endometrium to the basalis layer
Destruction of the functional endometrium leads to amenorrhea

Question 11

When is hysterectomy done?

Answer 11

More reserved for patients with anatomic lesions( fibroids) or malignancy or severe premalignant changes