Abnormal Bleeding

Question 1

What is Menorrhagia?

Answer 1

Heavy but regular uterine bleeding

Question 2

What is Metrorrhagia?

Answer 2

•Bleeding between menses

Question 3

What is Menometrorrhagia?

Answer 3

Heavy, irregular bleeding

Question 4

How would you advise an adolescent who has just begun menstruating and is worried about how irregular her cycles are or the presence of spotty bleeding?

Answer 4

Reassure her that everything is fine, she will not need an exam typically, and that her body is adjusting to puberty. In these pts. the body is making plenty of estrogen but not enough progesterone yet so if the situation requires treatment, oral contraceptives or course of cyclic progesterone. (all in attempt in reproduce normal cycle)

Question 5

How would a 45-45 yo woman with ireegular menses be managed?

Answer 5

Again, like adolescent girls, these women are entering an anovulatory phase where the absence of the corpus luteum will prevent adeuqate porduction of progesterone causing the endometrium to slough more frequently/irregularly. Thus, if the diagnosis of anovulatory bleeding is made, the pt should be reassured or started on solo progesterin (or a low dose oral contraceptive).

Also need to consider risk of neoplasm is obese, HTN, diabetic, etc.

Question 6

Answer 6

D.

Note that if theres enough estrogen to start menses, there will not typically be any additional growth

Question 7

What is Polycystic ovary syndrome (PCOS)?

Answer 7

is a set of symptoms due to elevated androgens (male hormones) in women

Ultrasound: pearls on a string

Question 8

What are the symptoms of PCOS?

Answer 8

Signs and symptoms of PCOS include irregular or no menstrual periods, heavy periods, hirsutism, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin.

Question 9

What are some associated conditions with PCOS?

Answer 9

Associated conditions include type 2 diabetes (insulin resistance), obesity, obstructive sleep apnea, heart disease, mood disorders, and endometrial cancer.

Question 10

How does PCOS develop?

Answer 10

Obesity results in increased adipocyte tissue which contains aromatase to convert androstenedione to estrone. Estrone then stimulates release of LH, which stimulates the ovaries to produce more androsteneidione (which can then travel to fat cells are stimulate the cycle to occur over and over).

All of the excess andostenedione is converted to testosterone which causes the signs and symptoms of PCOS

Question 11

What is this and why does it occur in PCOS?

Answer 11

This is called acanthosis nigracans, which is caused in PCOS by the accumulation of insulin due to insulin resistance. More common in AA females

Question 12

How would PCO be treated?

Answer 12

Typically depends on what parts of the syndrome pts. are most unhappy with but ALL will be consouled to lose weight

Question 13

What if a pt. with PCOS mainly wants to regularize periods?

Answer 13

• Combined OCs also decreases androgens (improves acne)
• Provides for regular, predictable menses
• Prevents pregnancy

Question 14

What if a pt. with PCOS mainly wants to decrease unwanted hair?

Answer 14

• OCs will help: some with anti-androgen type progestins. Will prevent hair from coming back, wont get rid of current hair
• Dipilatories

Question 15

What if a pt. with PCOS wants help getting pregnant?

Answer 15

• Ovulatory agents
• Metformin

Question 16

What are some other causes of irregular bleeding during reproductive years?

Answer 16

• Pregnancy: all work-up in a reproductive aged woman should include a pregnancy test
• Anorexia: more common in young women; caused by hypogonadotrophic hypogonadism
• Premature ovarian insufficiency- the ovaries quit working early; menopause earlier than age 40; fam hx is a risk factor- radiation and chemo also
• Hypothyroidism
• Hyperprolactinemia

Question 17

What would FSH and LH levels be like if a girl was not menstruating because she was anorexic?

Answer 17

Very low (hypogonadotropic hypogonadism)

Question 18

Other causes of irregular bleeding during reporductive years?

Answer 18

• Cervical cancer
• Endometrial cancer
• Cervicitis
• Endometrial polyp

Question 19

Only if the diagnosis is hormonal

Question 20

What happens to the levels of estrogen and progesterone around menopause?

Answer 20

Ovulation does not occur normally so estrogen levels are normal but progesterone levels are very low. So tx in this time typically including progesterone. At menopause, estrogen levels then drop drastically

Question 21

Question 22

Submucosal usually causes bleeding

Question 23

Management of uterine leiomyomata depends on symptoms, age, desire for future fertility. How would an aymptomatic uterine leiomyomata be tx?

Answer 23

•May be asymptomatic: discovered on exam: No TX if not causing any problems

Question 24

Management of uterine leiomyomata depends on symptoms, age, desire for future fertility. How would a uterine leiomyomata causing menorrhagia and/or anemia be tx?

Answer 24

•NSAIDs to prevent bleeding by stopping prostaglandin production which promotes contraction of the endometrium (stops cramps and contractions) and vessel production (take up to 800mg 3x a day) or

hormonal agents to stop her from ovulating,

iron if anemic

Question 25

Management of uterine leiomyomata depends on symptoms, age, desire for future fertility. How would a uterine leiomyomata causing pressure symptoms or infertility but pt. wants to preserve fertility be tx?

Answer 25

myomectomy

Question 26

Hysterectomy: for severe bleeding (needing transfusion), pain, failed medical management, child-bearing complete (usually try hormonal therapy first or an IUD)

Question 27

When should cancer be suspected as the cause of bleeding?

Answer 27

• History: Menometrorrhagia or any bleeding postmenopausal
• Age: >45 years of age (unless has history of anovulatory cycles, then sooner because estrogen levels will be high)

Question 28

How should suspected uterine cancer be addressed?

Answer 28

• Pap smear
• Endometrial biopsy
• Simple hyperplasia: Treat with Progestins
• Complex with atypia : Hysterectomy

•Ultrasound- May look abnormal, but requires pathologic diagnosis by way of sampling