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Essentials - Gynecology > 3. Abnormal Vaginal Bleeding > Flashcards

3. Abnormal Vaginal Bleeding Flashcards

1
Q

Define: Menorrhagia (1)

A

prolonged (> 7 d) or excessive (> 80 mL) bleeding occurring at regular intervals

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2
Q

Define: Metrorrhagia (1)

A

bleeding occurring at irregular intervals

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3
Q

Define: Menometrorrhagia (1)

A

excessive bleeding during normal menstrual period and at other irregular interval

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4
Q

Define: Polymenorrhea (1)

A

bleeding occurring at intervals < 21 d

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5
Q

Define: Intermenstrual (IMB) (1)

A

bleeding between regular cycles

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6
Q

Define: Postcoital Vaginal Bleeding (1)

A

bleeding after vaginal intercourse

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7
Q

Define: Postmenopausal Vaginal Bleeding (1)

A

anybleeding following menopause

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8
Q

Define: DVB (1)

A

abnormal bleeding not due to organic disease (Dx of exclusion)

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9
Q

Name: Change in Ovarian Function during life (3)

A
  • Premenopause (menarche—43 yr)
  • Perimenopause (~43–49 yr)
  • Menopause (~51 yr)
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10
Q

Define: Premenopause (2)

A
  • menarche—43 yr
  • normal menstrual cycle
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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
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12
Q

Define: Menopause (2)

A
  • ~51 yr
  • depleted ovarian reserve → chronic anovulatory cycles → E and P deficiency (no corpus leuteum)
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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
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14
Q

Monthly blood loss > 80 mL may result in what?

A

in Fe2+ -deficiency anemia and may affect quality of life.

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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
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16
Q

Name categories of DDx of abnormal vagina bleeding (6)

A
  • (R/O pregnancy)
  • Ovulatory
    • Intermenstrual
    • Menorrhagia
  • Anovulatory
    • Age related
    • Endocrine/metabolic
    • Other
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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
Q

Describe focused Hx: Abnormal vaginal bleeding (25)

A
  • 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
Q

Describe Physical Exam: Abnormal vaginal bleeding (6)

A
  • 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
Q

Name Indications for U/S for Abdormal Vaginal Bleeding (3)

A
  • Women with uterine enlargement identified through pelvic exam
  • Any pregnant women with abnormal vaginal bleeding (see CanMED Box)
  • Persistent abnormal vaginal bleeding
28
Q

Name: Indications for Endometrial Biopsy/Cytological Studies (5)

A
  • 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
Q

Name Indications for Specialty Care Referral for Abdormal Vaginal Bleeding (5)

A
  • 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
Q

Pelvic exam is contraindicated at > 20 wk of pregnancy with bleeding until what?

A

U/S has excluded placenta previa.

31
Q

Describe the general management of abnormal vaginal bleeding (3)

A
  • 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
Q

Describe Medical management of abnormal vaginal bleeding: ANOVULATORY (2)

A
  • 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
Q

In the management of anovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Low-dose OCP combined (2)

A
  • Cycle regulation
  • Prevents endometrial hyperplasia
34
Q

In the management of anovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Cyclic progesterone (2)

A
  • Cycle regulation
  • Prevents endometrial hyperplasia
35
Q

Describe Medical management of abnormal vaginal bleeding: OVULATORY (3)

A
  • NSAIDs—start day 1 of menses
  • Antibrinolytics (tranexamic acid) 1 g q6h during heavy days
  • Levonorgestrel (Mirena) IUD
36
Q

In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: NSAIDs (1)

A

Endometrial PG → ↓ menstrual flow

37
Q

In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Antifibrinolytic (1)

A

↓ Menstrual bleeding

38
Q

In the management of ovulatory management of abnormal vaginal bleeding, describe the mechanism of action of this tx: Levonorgestrel (Mirena) IUD (1)

A

Reversible blockade of plasminogen → ↓ menstrual loss

39
Q

Name indications of Surgical Management of Abnormal Vaginal Bleeding (3)

A
  • Bleeding refractory to medical Rx
  • Patients who are not candidates for hormonal Rx
  • Persistent abnormal bleeding in women who have completed childbearing
40
Q

Name Surgical Options of abnormal vaginal bleeding (When Malignancy Has Been Ruled Out) (4)

A
  • 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
Q

If sexual abuse is suspected as cause of abnormal vaginal bleeding, what to do? (4)

A
  • 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.

Essentials - Gynecology (14 decks)

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