3. Abnormal Vaginal Bleeding Flashcards
1
Q
Define: Menorrhagia (1)
A
prolonged (> 7 d) or excessive (> 80 mL) bleeding occurring at regular intervals
2
Q
Define: Metrorrhagia (1)
A
bleeding occurring at irregular intervals
3
Q
Define: Menometrorrhagia (1)
A
excessive bleeding during normal menstrual period and at other irregular interval
4
Q
Define: Polymenorrhea (1)
A
bleeding occurring at intervals < 21 d
5
Q
Define: Intermenstrual (IMB) (1)
A
bleeding between regular cycles
6
Q
Define: Postcoital Vaginal Bleeding (1)
A
bleeding after vaginal intercourse
7
Q
Define: Postmenopausal Vaginal Bleeding (1)
A
anybleeding following menopause
8
Q
Define: DVB (1)
A
abnormal bleeding not due to organic disease (Dx of exclusion)
9
Q
Name: Change in Ovarian Function during life (3)
A
- Premenopause (menarche—43 yr)
- Perimenopause (~43–49 yr)
- Menopause (~51 yr)
10
Q
Define: Premenopause (2)
A
- menarche—43 yr
- normal menstrual cycle
11
Q
Define: Perimenopause (3)
A
- ~43–49 yr
- ↓ # ovarian follicle pool →↓ inhibin →↑ FSH secretion → fewer FSH receptors in a decreased cohort of follicles → poor dominant follicle development → anovulatory cycles
- Irregular menstrual cycles due to anovulatory cycles
12
Q
Define: Menopause (2)
A
- ~51 yr
- depleted ovarian reserve → chronic anovulatory cycles → E and P deficiency (no corpus leuteum)
13
Q
Describe: Normal Menstrual Characteristics
- Menstruation length
- Blood loss
- Cycle length
A
- Menstruation length: 7 d or less
- Blood loss: 20 to 80 mL/cycle
- Cycle length: 21 to 35 d
14
Q
Monthly blood loss > 80 mL may result in what?
A
in Fe2+ -deficiency anemia and may affect quality of life.
15
Q
Name: DDx of anormal vagina bleeding PREMENARCHAL (4)
A
- Precocious puberty
- Trauma, sexual abuse, foreign body
- Vulvovaginal inflammation/infection/dermatoses
- Other: ovarian tumor, urethral prolapse
16
Q
Name categories of DDx of abnormal vagina bleeding (6)
A
- (R/O pregnancy)
- Ovulatory
- Intermenstrual
- Menorrhagia
- Anovulatory
- Age related
- Endocrine/metabolic
- Other
17
Q
Name premenopausal ovulatory-intermenstrual DDx of abnormal vagina bleeding (4)
A
- Infection: cervicitis, endometritis, vaginitis, STIs
- Benign growths: cervical/endometrial polyp, broids, ectropion
- Malignant tumors: uterine, cervical, vaginal, vulvar, ovarian
- Vulvovaginal etiologies: infection, dermatoses (e.g., Lichen sclerosis), systemic illnesses (e.g., Crohn’s)
18
Q
Name premenopausal ovulatory-menorrhagia DDx of abnormal vagina bleeding (3)
A
- Neoplasms: endometrial, CA, uterine sarcoma, broids, adenomyosis
- Coagulopathies (congenital or acquired)
- Other: endometritis, hypothyroidism
19
Q
Name premenopausal anovulatory-age related DDx of abnormal vagina bleeding (2)
A
- Immature HPO axis
- Perimenopausal anovulatory cycles
20
Q
Name premenopausal anovulatory-Endocrine/metabolic DDx of abnormal vagina bleeding (3)
A
- Thyroid: hyper/hypo
- Chronic disease
- Neoplasms (hormone producing)
21
Q
Name anovulatory-other DDx of abnormal vagina bleeding (5)
A
- PCOS
- Weight loss
- Exercise
- Stress
- Structural disease
22
Q
Name postmenopausal DDx of abnormal vagina bleeding (7)
A
- Endometrial CA until proven otherwise
- Genital tract disease
- Malignant disease: uterine, cervical, vaginal, vulvar, ovarian, metastatic
- Benign disease: atrophic vaginitis, cervical/endometrial polyps, infection
- Vulvovaginal etiologies as above
- Drugs
- Hormone replacement
- Anticoagulants
- Chemotherapy
23
Q
Describe Approach to Dx of abnormal vaginal bleeding in nonpregnant women. (Figure)
A
24
Q
Describe history: Abnormal vaginal bleeding (4)
A
- The most clinically important aspects in the evaluation of patients presenting with abnormal vaginal bleeding are determination of their:
- Hemodynamic status: vitals (BP, HR), signs/Sx (dizziness, pallor, weakness, mal- aise, dyspnea on exertion, etc.), investigations (CBC, coagulation profile)
- Pregnancy status: b-hCG testing
- Hx is helpful, but Dx depends on hormonal, cytologic, and/or radiographic investigations
25
Describe focused Hx: Abnormal vaginal bleeding (25)
* Menstrual Hx:
* LMP
* cycle regularity
* pattern
* duration
* clots
* intermenstrual bleeding
* postcoital bleeding
* quantity (frequency of pad/tampon changes, flooding)
* Associated Sx:
* Anemia symptoms
* Pelvic pressure
* abdo pain or bloating
* early satiety
* constitutional symptoms
* New onset dyspareunia
* vaginal discharge
* fever
* Sexual and pregnancy Hx
* Parity
* previous C/S Hx of PID/STIs
* Pap tests
* Medical Hx
* Coagulopathies
* Chronic disease (IBD, renal, liver, etc.)
* Endocrinopathies
* Drug Hx: Contraceptives, anticoagulants, HRT
* Weight: Δ, diet/exercise Hx
* FHx: Breast, endometrial, ovarian or GI cancers Blood dyscrasias
26
Describe Physical Exam: Abnormal vaginal bleeding (6)
* Vital signs, weight, height, general appearance
* Thyroid
* Abdo exam
* External genitalia
* Speculum exam: swabs for infections and cervical cytology
* Bimanual exam: adnexal mass, uterine size, tenderness
27
Name Indications for U/S for Abdormal Vaginal Bleeding (3)
* Women with uterine enlargement identified through pelvic exam
* Any pregnant women with abnormal vaginal bleeding (see CanMED Box)
* Persistent abnormal vaginal bleeding
28
Name: Indications for Endometrial Biopsy/Cytological Studies (5)
* Women \> 40 yr with abnormal vaginal bleeding or **any** postmenopausal bleeding
* Women at high risk of endometrial CA (nulliparity and Hx of infertility, obesity (BMI \> 30), PCOS or Hx of oligomenorrhea, FHx endometrial/colon CA, Hx of tamoxifen use)
* Persistent abnormal vaginal bleeding despite a 3-mo course of medical Rx
* Postmenopausal women (including those without bleeding, but with endometrial thickness \> 11 mm on TVS)
* F/U of previously diagnosed endometrial hyperplasia or abnormal Pap smear with atypical cells favoring endometrial origin
29
Name Indications for Specialty Care Referral for Abdormal Vaginal Bleeding (5)
* Persistent abnormal vaginal bleeding
* Endometrial pathology—hyperplasia with or without atypia, CA
* Uterine pathology—fibroids, polyps
* Endocrine disorders—PCOS, hyper/hypothyroidism, hyper-PRL, hypothalamic
* Coagulopathies—1° disease, 2° to liver disease, or CRF
30
Pelvic exam is contraindicated at \> 20 wk of pregnancy with bleeding until what?
U/S has excluded placenta previa.
31
Describe the **general** management of abnormal vaginal bleeding (3)
* Tailored to etiology
* Must take into consideration the patient’s age, desire to preserve fertility, coexisting medical conditions, and patient preference
* Heavy vaginal bleeding leading to severe anemia and/or hemodynamic instability requires emergency care and specialist referral
32
Describe Medical management of abnormal vaginal bleeding: ANOVULATORY (2)
* Low-dose OCP combined
* Cyclic progesterone (to induce withdrawal bleed at least every 90 d):
* Medroxyprogesterone acetate (Provera) 5–10 mg qd × 5–10 d
* Norethindrone acetate (Aygestin) 2.5–10 mg qd × 5–10 d
33
In the management of anovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Low-dose OCP combined (2)
* Cycle regulation
* Prevents endometrial hyperplasia
34
In the management of anovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Cyclic progesterone (2)
* Cycle regulation
* Prevents endometrial hyperplasia
35
Describe Medical management of abnormal vaginal bleeding: OVULATORY (3)
* NSAIDs—start day 1 of menses
* Antibrinolytics (tranexamic acid) 1 g q6h during heavy days
* Levonorgestrel (Mirena) IUD
36
In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: NSAIDs (1)
Endometrial PG → ↓ menstrual flow
37
In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Antifibrinolytic (1)
↓ Menstrual bleeding
38
In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Levonorgestrel (Mirena) IUD (1)
Reversible blockade of plasminogen → ↓ menstrual loss
39
Name indications of Surgical Management of Abnormal Vaginal Bleeding (3)
* Bleeding refractory to medical Rx
* Patients who are not candidates for hormonal Rx
* Persistent abnormal bleeding in women who have completed childbearing
40
Name Surgical Options of abnormal vaginal bleeding (When Malignancy Has Been Ruled Out) (4)
* Operative hysteroscopy––removal of intrauterine structural abnormalities
* Endometrial resection or global endometrial ablation
* Myomectomy or uterine artery embolization––Rx of leiomyomas
* Hysterectomy––patient declines medical or conservative surgical management, Rx of atypical hyperplasia
41
If sexual abuse is suspected as cause of abnormal vaginal bleeding, what to do? (4)
* Reporting is at the discretion of the victim unless victim is a child.
* MD must report abuse of children.
* Before collection of samples forevidence, victims should give informed consent.
* Samples should be stored securely even if the patient decides against reporting the abuse.
