Abnormal/Dysfunctional Uterine Bleeding Flashcards
menstrual cycle depend on a delicate balance between _______ ______ (which secretes ___ and ___), __________ (which secretes ______), and ovaries (which secretes _____ and ________)
pituitary gland (FSH and LH); hypothalamus (GnRH); estrogen and progesterone
how does the hypothalamus secrete GnRH?
in a pulsatile fashion
FSH is secreted in the first _____ of the month. what does it stimulate the ovaries to do?
half; stimulates the ovary to produce estrogen
LSH is secreted in the _______ half of the month. it stimulates the production of what?
second; progesterone
estrogen influences maturation of the ____ and growth of the ___________
ova; endometrium
progesterone strengthens the __________ and help nourish the _________ ____
endometrium; fertilized ova
what phase begins with menstruation?
follicular/proliferative
which phase differs when menses is irregular?
follicular/proliferative
which phase contains the LH surge and ovulation?
ovulatory phase
once the LH surge occurs, how long until ovulation?
30-36 hrs
what is the third phase of the menstrual cycle? how long does it last? what happens to the endometrium and what hormone dominates?
luteal/secretory phase; lasts 14 days; secretory changes in endometrium; progesterone dominates
what pituitary hormone dominates in follicular phase?
FSH
_______ increases to critical level during follicular phase and peaks ____ hrs before ovulation
estradiol; 24
bleeding during the secretory phase is due to?
progesterone withdrawal
ovulatory ovulation kits detect what hormone?
LH
which hormone causes the LH surge?
estrogen at end of follicular phase
midcycle hormonal surge due to ___/___ stimulation of ovaries (which release ______) and then stimulates positive feedback
LH/FSH; estrogen
the hypothalamic/pituitary regulation cycle terminates when?
feedback inhibition by estradiol and progesterone (inhibins are also released by ovaries)
what happens to LH/FSH when estrogen decreases with age?
cells try to compensate and LH/FSH increases (FSH HIGHER)
FSH supports development of _______ and associated with secretion of estrogen, which does what to the endometrium?
follicle; which causes endometrial proliferation
big surge of LH at midcycle does what three things?
rupture of follicle, ovulation, and stimulation of corpus luteum
corpus luteum would stick around to support embryo if what hormone was present?
HCG
degeneration of CL results in drop of ____________, causing degeneration and sloughing off of ___________
progesterone; thick endometrium (menstruation)
what can you give a pt to reset their menstrual cycle?
provera (progesterone combo) for a week
menstrual cycle length
28 plus or minus 7 days
average duration of bleeding
4 plus or minus two days
volume of blood lost during cycle
about 30 ml
what is a limiting factor for menstrual aged women who are anemic?
iron
regular menses usually follows menarche by how many years?
1-5 years
dysmenorrhea decreases with what two things?
pregnancy or OCP use
prevalence of dysmenorrhea? what percent is severe?
60-90%, 15% severe
dysmenorrhea usually starts in __________
adolescence (once ovulatory cycles are established)
primary dysmenorrhea is ___________, from ____ __________
idiopathic, from early adolescence
primary dysmenorrhea is induced by what?
hormone induced increase in prostaglandin precursors (converted to prostaglandins during menstruation)
prostaglandins promote _____ contraction that interrupts blood flow to ________ and results in ____ _________. what symptom does this lead to?
SMC; myometrium; tissue hypoxia; lower abdominal pain
what is secondary dysmenorrhea?
a person who had normal menses early on but later in life something changed
what are some causes of secondary dysmenorrhea? (5)
endometriosis, adenomyosis, fibroids, PID, and cervical stenosis (flow cant come out and uterine becomes inflamed)
tx for dysmenorrhea (5)
heat, NSAIDS- start at higher doses just before onset, OCP, vitamin supplements (B and E), exercise/yoga
what do you consider a pt has if theres no response to NSAIDS or OCP for dysmenorrhea tx?
secondary dysmenorrhea
big characteristic of PMS symptoms
there is a symptom free interval (no disturbance of mood at mid cycle)
PMS symptoms usually cease when?
usually at menstrual onset
PMS is a diagnosis of what?
EXCLUSION- thoroughly examine the pt and take a good hx (rule out major depression, anxiety, hypothyroid, DM)
explain serotonin being a potential cause of PMS?
changes in normal cyclic hormones trigger abnormal serotonin response (SSRIs work well for tx)
if a pt has bloating/edema symptoms for PMS, think of what tx?
diuretics- specifically spironolactone (inhibit RAAS activation)
PMS is diagnosed when symptoms occur in what phase of the menstrual cycle?
LUTEAL (symptom-free during follicular)
what is menstrual magnification?
worsening of other medical conditions in late luteal or menstrual phases (when PMS is occurring)
How to tx PMS? (sequence of events)
combo of tx needed
1) . behavioral modifications- education to pt and family, diet, exercise, relaxation
2) . drugs: OCP, diuretics/antiandrogens (spironolactone/yasmine), NSAIDs, Xanax, Vitamins (B6, E, Ca, Mg)
3) . if SEVERE- intermittent SSRIs at beginning of premenstrual symptoms (stop once symptoms resolve)
what is PMDD?
premenstrual dysphoric disorder, more severe form of PMS where pt has disabling mood symptoms (affecting daily life)
tx of PMDD
SSRI or SNRI (1st line), continuous use
what is dysfunctional uterine bleeding?
excessive/abnormal uterine bleeding with no demonstrative cause (cannot be attributed to other pelvic anatomic/structural causes)
what is polymenorrhea?
bleeding occurring at intervals less than every 21 days
what is oligomenorrhea?
infrequent bleeding (intervals greater than every 35 days)
what is menorrhagia?
more than 7 days or excessive (>80ml) uterine bleeding at regular intervals
what is intermenstrual bleeding?
vaginal bleeding of variable amounts between regular menses
what is metrorrhagia?
uterine bleeding occurring at irregular BUT frequent intervals with variable amounts/duration
what is menometrorrhagia?
prolonged uterine bleeding occurring at irregular intervals
what is one clotting/blood disorder in teenagers that can cause abnormal uterine bleeding?
von willebrand’s dz
whats one structural cause of abnormal uterine bleeding?
endometrial hyperplasia (not enough progesterone to support lining)
4 structural causes of AUB (PALM)
Polyp
Adenomyosis (inner lining of uterus, endometrium, breaks through muscle wall, myometrium)
Leiomyoma (fibroids)
Malignancy & hyperplasia
5 Nonstructural causes of AUB (COEIN)
coagulopathy ovulatory dysfunction endometrial iatrogenic not yet classified
If the ovulatory cycle is occuring at regular intervals what does this tell you?
tell you patient is ovulating appropriately
what is mittelschmerz? is it normal?
its pain upon ovulation (middle of cycle pain); normal part of ovulatory cycle
during an ovulatory cycle, there will be ______ basal body temp
biphasic
consequences of persistent anovulation (6)
1) . infertility
2) . menstrual bleeding probs
3) . PCOS signs
4) . inc risk of endometrial CA
5) . maybe inc risk of breast CA
6) . inc risk of cardiac dz
general workup guidelines (according to hadley) for abnormal uterine bleeding?
STEP wise fashion
1). H and P along with basic labs- CBC and B-HCG
2). Pap smear
3). Ultrasound
then proceed with other appropriate tests
In order to diagnose DUB (dysfunctional uterine bleeding), what do you have to do?
rule out other structural or anatomical causes of abnormal bleeding
DUB is most often attributed to what? heavy bleeding seen in DUB is usually do to what?
problems with the hypothalamus-pit-ovarian hormonal axis (leads to anovulation); heavy bleeding due to the anovulation (overgrowth of endometrium and little progesterone to stabilize growth)
DUB accounts for 50% of all cases of _________ _____________
excessive menstruation
what is a differential of DUB hadley mentioned?
exogenous obesity- obesity increases estrogen levels (causes abnormal bleeding)
how to diagnose DUB?
1). Need two tests to be NORMAL
-transvaginal US (looking for thickness of endometrium)
AND endometrial biopsy (looking at stage of endometrium plus maybe abnormal histology)
IF NORMAL, AUB is likely to be due to DUB (dx of exclusion)
HPO Axis Dysfunction: women over 35 should have __________ before starting hormone therapy. _____ can be used to restart regular periods. If actively bleeding, ______ can be given for 3-6 months
endometrial biopsy; Provera; OCPs
if a pt has hyperprolactinemia thats causing an anovulatory disorder, what do you treat it with?
dopamine agonists (bromocriptine or dostinex) control lactotrophs
surgical management options of AUB (4)
hysteroscopic ablation, resection, uterine artery embolization, hysterectomy
3 medical management options of structural lesions
Provera, GnRH agonist (LUPRON) for endometriosis/fibroids, and iron therapy for anemia
PCOS can cause __________ bleeding, dx by what sign on an US, and treated with what drugs?
anovulatory; dx by “string of pearls” on US; letrazole (induces ovulation), OCPs, metformin
two main categories of AUB?
structural and anovulatory dysfunction (DUB/PCOS)
two most common causes of AUB?
PCOS and leiomyomas
what is usually seen in a pt with AUB around 12-18 yrs old
coagulation defect (usually primary phase)
treatment options of AUB
cyclic progestins provera VS combined OCPs VS surgery
URGENT tx of AUB
monophasic combined OCP (contains 35 micrograms estradiol OR provera 20 mg); TID for seven days
if AUB patient has low H/H and needs emergent cessation of bleeding, how do you treat?
IV estrogen and blood transfusion if necessary
