4: Uterine Bleeding Flashcards
When should an MRI be ordered?
If ovarian or endometrial cancer is suspected.
This med is a good second-line agent in women who want to avoid hormonal therapy. It is also useful in von Willebrand’s disease.
Tranexamic acid (Lysteda)
_____ is diagnosed when low estrogen production is identified while the serum FSH is high.
Ovarian failure is diagnosed when low estrogen production is identified while the serum FSH is high.
Transvaginal ultrasounds of the pelvis are one of the 1st-line diagnostic tools. When should you perform them on premenopausal women?
Between days 4-6 of cycle
Women who have regular, ovulatory menstrual cycles often experience premenstrual symptoms such as bloating, fatigue, constipation, and mood changes. What is the collective name for these symptoms?
Molimina
What might this indicate? Decreased iron levels.
Iron-deficiency anemia secondary to bleeding
Which labs would you order to r/o cervical or uterine pathological causes of AUB?
- General labs
- Colposcopy with biopsy
- Endometrial biopsy
- Hysteroscopy
Which ablation system can be performed in an office setting with conscious sedation?
NovaSure system (radiofrequency electricity)
Clitoral hypertrophy is a sign of excess of which hormone?
Androgen
Obstruction of menses that leads to blood in the uterus.
Hematometra
Assessing for the presence of galactorrhea and performing a visual field evaluation are particularly important when women present with headaches or galactorrhea, both of which are suggestive of _____ disease.
Assessing for the presence of galactorrhea and performing a visual field evaluation are particularly important when women present with headaches or galactorrhea, both of which are suggestive of pituitary disease.
_____ therapy stimulates rapid endometrial proliferation and resolves the bleeding from a denuded endometrium.
Estrogen therapy stimulates rapid endometrial proliferation and resolves the bleeding from a denuded endometrium.
What might this indicate? Platelets less than 150,000.
Clotting abnormalities.
What is a contraindication for tranexamic acid (Lysteda)?
History or at risk for thrombosis
T/F D and C is the quickest surgical way to stop bleeding and is a long-term treatment for heavy menstrual bleeding.
False. It is a temporary measure and is not considered long-term.
Level I evidence consistently demonstrates that the treatment of choice for abnormal uterine bleeding is what?
Combined contraceptives
Which labs would you order to r/o endocrine causes of AUB?
- General labs
- Prolactin
- FSH
- LH
Name 4 surgical options for management of heavy bleeding.
- D and C
- Endometrial ablation
- Uterine artery embolization
- Hysterectomy
How should acute bleeding (potential to be hemodynamically unstable) be treated?
Estrogen therapy. Once under control, add a progestin.
What might this indicate? Progesterone levels <10 ng/mL
Anovulatory
Progestogens can be used to treat chronic heavy bleeding that is due to _____.
Progestogens can be used to treat chronic heavy bleeding that is due to anovulation.
The withdrawal of progesterone also causes the production of _____, which in turn stimulates the production of PGF2 alpha.
The withdrawal of progesterone also causes the production of arachidonic acid, which in turn stimulates the production of PGF2 alpha.
T/F Transvaginal ultrasonography is more reliable for evaluation of the endometrial cavity of women with AUB than saline infusion sonohysterography.
False. Saline infusion sonohysterography is more effective.
Estrogen therapy should not continue past how many days? After completion, how long should progestin therapy be?
- Estrogen: 25 days
- Progestin: 10 days
A random serum estradiol level that is greater than _____ pg/mL indicates functioning ovaries.
A random serum estradiol level that is greater than 40 pg/mL indicates functioning ovaries.
Progestogen therapy for chronic anovulation.
- Medroxyprogesterone acetate (Provera) 10 mg × 10 days
- Norethindrone 5 mg 2×/day × 10 days
- Oral micronized progesterone (Prometrium) 200 mg/day × 10 days
- Depo medroxyprogesterone acetate (Depo-Provera) 150 mg IM every 12 weeks
- Levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena, Skyla)
T/F Heavy menstrual bleeding raises all cause healthcare costs for those women.
True
Which labs would you order to r/o infectious causes of AUB?
- General labs
- Gonorrhea
- Chlamydia
- Wet mount
- Consider need for WBC
When should outflow tract abnormalities due to abnormal development of Mullerian duct be considered?
Primary amenorrhea if the cervix is not visible or if the vagina is not patent.
What are management goals for treating AUB?
- Normalize the bleeding
- Correct any anemia
- Prevent cancer
- Restore quality of life
The typical picture of a woman diagnosed with _____ amenorrhea is the adolescent who is underweight, overexercises, and is experiencing a great deal of stress.
The typical picture of a woman diagnosed with functional hypothalmic amenorrhea is the adolescent who is underweight, overexercises, and is experiencing a great deal of stress.
What is the most common cause of amenorrhea?
Ovarian function abnormalities
T/F Hysteroscopy is highly accurate in diagnosing endometrial cancer because it allows for direct visualization of the endometrial cavity and permits the clinician to take directed biopsies.
True
What might this indicate? Prolactin levels >100 ng/mL
Pituitary adenoma
T/F Endometrial ablation is an alternative to hysterectomy for women who want to preserve fertility.
False. Both alter fertility.
Name 2 contraindications to NSAID use for AUB.
- Ulcers
- Bronchospastic lung disease
This allergy is a contraindication to Prometrium (oral micronized progesterone).
Peanut (peanut oil is used in the manufacturing process)
_____ are useful for ovulatory–idiopathic HMB. The heavier the bleeding, the better the effectiveness.
NSAIDs are useful for ovulatory–idiopathic HMB. The heavier the bleeding, the better the effectiveness.
Which labs would you order to r/o hormone-producing tumor causes of AUB?
- General labs
- MRI
- CT scan
- Cortisol levels
Long-term use of hormonal contraceptives can lead to amenorrhea caused by what?
Endometrial atrophy
What might this indicate? Hemoglobin <10.
Anemia
Which labs would you order to r/o renal disease as the cause of AUB?
Renal function tests
If the woman has no contraindications to their use, _____ are a particularly effective therapy for HMB caused by fibroids.
If the woman has no contraindications to their use, intrauterine devices containing levonorgestrel are a particularly effective therapy for HMB caused by fibroids.
T/F Progestogens are not as effective as estrogen in stopping acute bleeding, but are effective for long-term treatment once the acute bleeding episode has been resolved.
True. Additionally, progestogens may be the management regimen of choice if the woman has contraindications to taking estrogen.
What might this indicate? TSH levels <0.8 or >4
- Hypothyroidism
- Hyperthyroidism
Obstruction of menses that leads to blood in the peritoneum.
Hematoperitoneum
Which labs would you order to r/o amenorrhea causes of AUB?
- General labs
- FSH
- LH
- Prolactin
- TSH
- T3
- T4
Any uterine bleeding that is irregular in amount, duration, or timing.
Abnormal uterine bleeding (AUB)
Women with fibroids are candidates for the LNG-IUS if the fibroid does not distort the uterine cavity and the uterus is less than _____ in size.
Women with fibroids are candidates for the LNG-IUS if the fibroid does not distort the uterine cavity and the uterus is less than 12 weeks’ gestation in size.
T/F If a woman presents with amenorrhea with no history of infection or trauma and her pelvic examination and bimanual examination are normal, then an abnormality of the outflow tract is not likely.
True
Which labs would you order to r/o adrenal causes of AUB?
- General labs
- Adrenal studies
- Testosterone levels
- Adjunct: CT scan of abdomen
- Cortisol levels
Which herb may increase the risk of bleeding?
Bromelain
T/F Chinese herbal medicine has no side effects and may be useful in treatment of heavy menstrual bleeding.
True
Although the pathology of dysmenorrhea is not entirely understood, it is believed that dysmenorrhea associated with ovulatory bleeding results from the effects of _____ that cause vasoconstriction and contraction of smooth muscle.
Although the pathology of dysmenorrhea is not entirely understood, it is believed that dysmenorrhea associated with ovulatory bleeding results from the effects of PGF2 alpha that cause vasoconstriction and contraction of smooth muscle.
Which labs would you order to r/o coagulation disorder causes of AUB?
- PTT/PT
- Assessment of platelet function
You have a patient who reports taking purslane seeds as a treatment for heavy menstrual bleeding. You recognize your patient is probably from which country?
Iran
What might this indicate? PT/PTT with increased bleeding time.
- von Willebrand’s disease (vWD)
- Leukemia
- Prothrombin deficiency
What is the treatment of choice for hyperprolactinemia?
Dopamine agonist
Which labs would you order to r/o liver disease as the cause of AUB?
LFTs
T/F Saline infusion sonohysterography (SIS) may offer an even more complete evaluation of the endometrium, but cannot be undertaken if the woman has an IUD in place.
True
A _____ test that produces withdrawal bleeding is indicative of functioning ovaries, because bleeding will occur only if a sufficient amount of circulating estrogen is present.
A progesterone challenge test that produces withdrawal bleeding is indicative of functioning ovaries, because bleeding will occur only if a sufficient amount of circulating estrogen is present.
T/F Do not use progestogen therapy if the woman thinks she might be pregnant, even if her pregnancy test is negative.
True
Endometrial thickness of greater than _____ on TVS in a postmenopausal woman warrants follow-up.
Endometrial thickness of greater than 5 mm on TVS in a postmenopausal woman warrants follow-up.
Obstruction of menses that leads to blood in the vagina.
Hematocolpos
Anovulation can lead to which cancer?
Endometrial
Name the 3 components of the outflow tract.
- Uterus
- Cervix
- Vagina
What is the current biomedical standard for measuring blood loss during menstruation?
Alkaline hematin method, which is quite expensive and can be inconvenient for women. It requires a woman to collect all menstrual products (pads, tampons) used during a menses and bring them to a lab, where these materials are then tested to determine how much blood they contain, enabling a calculation of the amount of blood lost during the menses. The products are treated with sodium hydroxide for 48 hours to convert the menstrual blood hemoglobin to alkaline hematin and then the optical density of the alkaline hematin is measured spectrophotometrically. Next, venous blood is drawn from the woman and the optical density of the alkaline hematin in that peripheral blood is measured. The ratio of the hemoglobin concentration in the total menstrual discharge to the peripheral blood is considered the volume of menstrual blood loss.
Though these drugs are expensive and have many side effects, they can be helpful in stemming bleeding while waiting for surgery. Short-term use only.
Gonadotropin-releasing hormone agonists (GnRHas) such as leuprolide acetate (Lupron), nafarelin acetate (Synarel), and goserelin acetate (Zoladex)
Normal menses results from a functional _____ and a precise sequence of hormonal events that lead to ovulation.
Normal menses results from a functional hypothalamic–pituitary–ovarian axis (HPOA) and a precise sequence of hormonal events that lead to ovulation.
Which labs would you order to r/o von Willdibrand’s disease as the cause of AUB?
Ristocetin cofactor assay
Which surgical intervention for heavy menstrual bleeding also addresses fibroids?
Uterine artery embolization
What might this indicate? FSH levels >30 (or 40)
- Amenorrhea d/t menopause
- Premature ovarian failure
For a woman who is hemodynamically stable, a monophasic COC administered twice daily should also result in the reduction of bleeding within _____ hours.
For a woman who is hemodynamically stable, a monophasic COC administered twice daily should also result in the reduction of bleeding within 24 hours. Taper to 1x/day after 5-7 days.
Molimina are caused by what?
Progesterone surge in the luteal phase.
Which labs would you order to r/o structural abnormality causes of AUB?
- General labs
- US
What might this indicate? hCG levels lower than expected or lack of significant increase in 48 hours.
- Ectopic pregnancy
- Impending spontaneous abortion
