3. Abnormal Vaginal Bleeding Flashcards
Define: Menorrhagia (1)
prolonged (> 7 d) or excessive (> 80 mL) bleeding occurring at regular intervals
Define: Metrorrhagia (1)
bleeding occurring at irregular intervals
Define: Menometrorrhagia (1)
excessive bleeding during normal menstrual period and at other irregular interval
Define: Polymenorrhea (1)
bleeding occurring at intervals < 21 d
Define: Intermenstrual (IMB) (1)
bleeding between regular cycles
Define: Postcoital Vaginal Bleeding (1)
bleeding after vaginal intercourse
Define: Postmenopausal Vaginal Bleeding (1)
anybleeding following menopause
Define: DVB (1)
abnormal bleeding not due to organic disease (Dx of exclusion)
Name: Change in Ovarian Function during life (3)
- Premenopause (menarche—43 yr)
- Perimenopause (~43–49 yr)
- Menopause (~51 yr)
Define: Premenopause (2)
- menarche—43 yr
- normal menstrual cycle
Define: Perimenopause (3)
- ~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
Define: Menopause (2)
- ~51 yr
- depleted ovarian reserve → chronic anovulatory cycles → E and P deficiency (no corpus leuteum)
Describe: Normal Menstrual Characteristics
- Menstruation length
- Blood loss
- Cycle length
- Menstruation length: 7 d or less
- Blood loss: 20 to 80 mL/cycle
- Cycle length: 21 to 35 d
Monthly blood loss > 80 mL may result in what?
in Fe2+ -deficiency anemia and may affect quality of life.
Name: DDx of anormal vagina bleeding PREMENARCHAL (4)
- Precocious puberty
- Trauma, sexual abuse, foreign body
- Vulvovaginal inflammation/infection/dermatoses
- Other: ovarian tumor, urethral prolapse
Name categories of DDx of abnormal vagina bleeding (6)
- (R/O pregnancy)
- Ovulatory
- Intermenstrual
- Menorrhagia
- Anovulatory
- Age related
- Endocrine/metabolic
- Other
Name premenopausal ovulatory-intermenstrual DDx of abnormal vagina bleeding (4)
- 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)
Name premenopausal ovulatory-menorrhagia DDx of abnormal vagina bleeding (3)
- Neoplasms: endometrial, CA, uterine sarcoma, broids, adenomyosis
- Coagulopathies (congenital or acquired)
- Other: endometritis, hypothyroidism
Name premenopausal anovulatory-age related DDx of abnormal vagina bleeding (2)
- Immature HPO axis
- Perimenopausal anovulatory cycles
Name premenopausal anovulatory-Endocrine/metabolic DDx of abnormal vagina bleeding (3)
- Thyroid: hyper/hypo
- Chronic disease
- Neoplasms (hormone producing)
Name anovulatory-other DDx of abnormal vagina bleeding (5)
- PCOS
- Weight loss
- Exercise
- Stress
- Structural disease
Name postmenopausal DDx of abnormal vagina bleeding (7)
- 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
Describe Approach to Dx of abnormal vaginal bleeding in nonpregnant women. (Figure)
Describe history: Abnormal vaginal bleeding (4)
- 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
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
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
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
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
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
Pelvic exam is contraindicated at > 20 wk of pregnancy with bleeding until what?
U/S has excluded placenta previa.
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
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
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
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
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
In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: NSAIDs (1)
Endometrial PG → ↓ menstrual flow
In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Antifibrinolytic (1)
↓ Menstrual bleeding
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
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
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
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.
