Abnormal Menstrual Bleeding Flashcards
1
Q
How long is a normal cycle? Flow? Amount?
A
21-35 days (up to 45)
Flow up to 7 days (average 3-5)
80ml/period (1tsp = 5ml)
2
Q
What is menorrhagia?
A
Hypermenorrhea
3
Q
What is metrorrhagia?
A
Intramenstrual bleeding, BTB
4
Q
What is menometrorrhagia
A
Heavy intramenstrual bleeding
5
Q
What is polymenorrhea?
A
Menses < q21d
6
Q
What is contact bleeding
A
Poscoital (post-sex) or post contact bleeding
7
Q
What can initiate abnormal bleeding (6)?
A
- infectious STI
- neoplasms (fibroids, polyps) (fibroids are the most common cause)
- endocrine/hormonal (PCOS, thyroid, obesity, menopause) (about 45% of patients with hypothyroidism have menorrhagia)
- malignancies (endometrial/cervical)
- trauma
- pregnancy (implantation/miscarriage/ectopic)
8
Q
What are causes of menorrhagia (7)?
A
- pregnancy (must rule-out)
- infection (STI screen)
- intrauterine device
- uterine fibroids
- endometrial/cervical polyps
- hypothyroidism (TSH, fT4)
- neoplasms (pap, U/S, EMB)
dysfunctional uterine bleeding (DUB) (if all other causes have been ruled out)
9
Q
What are the symptoms of menorrhagia?
A
- > 80-90ml/period: only 2/5 women who complain of excessive bleeding actually exceed this amount
- Menstrual bleeding >7 days
- unusually heavy bleeding (soaking through pad or tampon every hour)
- requiring change of protection at night
- menstrual flow interfering with lifestyle
- fatigue, dizziness, and/or SOB (symptoms of anemia: occurs in 2/3 of women)
10
Q
How do you work up menorrhagia?
A
- urine pregnancy
- STI screen
- endocrine work-up (PRL, TSH/fT4, FSH, E, P)
- coagulation work-up (PT/PTT)
- PAP
- U/S (pelvic & transvaginal)
- EMB/hysteroscopy & biopsy
11
Q
What are cervical disorders that can contribute to heavy bleeding (4)?
A
- cervicitis (acute or chronic) (chronic has thick yellow discharge with no bacteriological etiology) (requires biopsy to rule out cancer) (acute is often STI related [NG, CT, Trich])
- cervical trauma
- cervical polyps
- cervical cancer
Dx requires pap and/or biopsy
12
Q
What are uterine disorders that can contribute to heavy bleeding (5)? What is the most common cause?
A
- polyps
- fibroids (most common cause)
- adenomyosis (endometrial glands grow into the uterine wall, creating a spongelike effect; sometimes associated with heavy, painful periods and uterine enlargement)
- endometrial hyperplasia
- endometrial cancer
Dx require pelvic U/S, hysteroscopy, EMB (endometrial biopsy)
13
Q
What is a hysteroscopy?
A
Fibroscopic endoscope passed through the cervix to visualize endometrial cavity
14
Q
What are indications for a EMB? (3)
A
- any abnormal bleeding
- postmenopausal bleeding
- fertility issues
15
Q
What is DUB treatment? (8)
A
- Diet and exercise (stabilize estrogen)
- Botanicals: Chaste Tree Berry, Flax seeds
- NSAIDS (anti-inflammatory via prostaglandin inhibition and cause uterine vasoconstriction) (Ibuprofen 400 QID, naproxen 375 BID)
- Progesterone (limit & stabilize endometrial growth) (Transdermal cream: Progest or Progonol) (OCP [P alone (“mini-pill”) or combo with E]) (Mirena IUD (secretes progesterone))
- GnRH agonists (Lupron) “medical menopause” (decrease estrogen levels; expensive & prolonged use = osteoporosis)
- Dilation and Curettage (D&C) or Hysteroscopy & biopsy (procedure in which the cervix is dilated & the endometrium is removed) (H & B may be better at finding occult cancer when combined with EMB)
- endometrial ablation (procedure in which the endometrium is destroyed; 20% have hysterectomy)
- hysterectomy (when medical management fails)
16
Q
What are different endometrial ablations? (3)
A
Treat abnormal uterine bleeding and reduce or prevent future bleeding
- Electrocautery: Approximately 90% of women experience relief of their symptoms within the first few months, with many having scant or absent menstrual periods after the procedure.
- Balloon endometrial ablation: A triangular balloon is placed into the uterus and filled with fluid and heated for several minutes destroying the uterine lining. Results are comparable to electrosurgical methods.
- Freezing of the uterine lining
There is no evidence that one method produces superior success rates
17
Q
What are other names of uterine fibroids?
A
- leiomyomata
- leiomyoma
- fibromyoma
- myoma
18
Q
Uterine fibroids are
- Most common _____ in women
- Typically benign (___% cancerous)
- Overgrowth of ________ & _________ in the wall of the uterus
- Most common indication for __________ = ____ % of _____________
A
- Most common solid tumor in women
- Typically benign (<1% cancerous)
- Overgrowth of muscle & connective tissue in the wall of the uterus
- Most common indication for major surgery in women = 30% of hysterectomies.
19
Q
How does the risk for uterine fibroids increase with age? Race? Genetics? Hormones? Lifestyle?
A
Age = 35-45 (asymptomatic beforehand) Race = African American women 3x more likely Genetic predisposition Hormone = estrogen dominance Lifestyle = nulliparous (no children)
20
Q
What would you expect with the bimanual exam of uterine fibroids related to firmness? Shape? Tenderness?
A
- firm but am vary from soft to rock hard
- irregularly enlarged
- smoothly rounded protrusions
- usually non-tender
*need to rule out pregnancy as a cause of the enlargement.
21
Q
Uterine fibroids are the most common cause of ______
A
Abnormal uterine bleeding
22
Q
What are symptoms of uterine fibroids?
A
- most common cause of abnormal uterine bleeding
- enlarged uterus
- pressure
- bloating
- heaviness
- constipation
- vague feeling of discomfort
- pain with vaginal intercourse
- urinary abnormalities (frequency, urgency, acute or chronic urinary retention, ureteral compression, hydronephrosis)
- pelvic pain-cramping
- backache, esp during menses
- abdominal enlargement
- infertility recurrent SAB
- pain is NOT a typical symptom.
23
Q
What is the chance of a uterine fibroid being a leiomyosarcoma?
A
<1%
24
Q
What are the chances of a uterine fibroid causing infertility? How can it cause infertility?
A
2-10%
- intermittent anovulation
- interfere with implantation
- compression of isthmus
- abnormal uterine blood flow
- interfere with sperm transport
- recurrent SAB
25
What is the imaging choice for uterine fibroid? Why?
Ultrasound
- low cost, safe, versatile, early diagnosis, avoid surgery
May not be definitive
26
What are indication for an abdominal ultrasound?
- better evaluate size, location, complexity
- ovarian mass
- pelvic cancer
- uterine fibroids
- endometrium
- ectopic pregnancy
27
What are management options for uterine fibroids?
- watch and wait
- manage symptoms
— lifestyle modifications
— nutrition/ botanicals
— drugs - Lipton, progestins
— surgery
28
What are the nutritional changes you could suggest a patient with uterine fibroids?
- organic, hormone-free foods
- fiber-ground flax seeds to bind extra estrogen, also green tea
- decrease dietary fat
- eliminate alcohol
- eliminate sugar
- increase soy
29
What is the go-to treatment for uterine fibroids?
There is no single management plan that works for every women
- treatment plans are individual for patient’s specific situation or needs depending on;
— severity of symptoms
— fertility preservation
— size and location
30
What are surgical indications for uterine fibroids?
Dictated by patient tolerance level/effect on quality of life
- bleeding causes severe anemia
- unmanageable bleeding
- severe dysmenorrhea
- pelvic pain
- urinary tract compression (patient tolerant even and kidney function compromised)
- infertility
- *rapid growth*
- affects adnexal evaluation
31
What are surgical options for uterine fibroids?
- remove uterus (not Fallopian tubes etc) = hysterectomy
- preserve uterus
— myomectomy (25% repeat surgery due to recurrence of myoma)
— embolization (preserves uterus) (done by a radiologist, obstruction of arterial flow to create necrotic tissue, cause cramping)
32
What is adenomyosis?
The presence of endometrial glands and stroma within the myometrium
- endometrial gland invasion of myometrium
33
Adenomyosis is common in what women
Porous (have had children) = women between 35-50
34
What are signs/symptoms of adenomyosis?
- diffusely enlarged (asymmetrical) and sometimes tender uterus
- dysmenorrhea
- PMS
- exaggerated cyclic symptoms
35
What is the treatment for adenomyosis?
OC’s
Progestins
Hysterectomy
36
What is endometrial hyperplasia? Is it dangerous?
- overgrowth of endometrial cells in the endometrium
| - benign condition however if left untreated high risk of endometrial cancer
37
What are symptoms of endometrial hyperplasia?
- abnormal bleeding
| - post menopausal bleeding
38
How do you diagnose endometrial hyperplasia?
EMB
| Pelvic ultrasound
39
How do you treat endometrial hyperplasia?
Progesterone, dietary changes, exercise, possible D&C (dilation and curettage), ablation, hysterectomy
40
what are risk factors for endometrial carcinoma?
- age = 50-70
- hyperplasia
- unopposed estrogen
- obesity
- family history (breast, colorectal)
- PCOS/anovulation
- nulliparity
- extended use of tamoxifen
- diabetic
- hypertension
41
What are the largest relative risk factors for endometrial cancer?
- Atypical hyperplasia (29)
- unopposed estrogen (9.5)
- obesity (3-10)
- late menopause (4)
- diabetes (2.8)
- never pregnant (2)
42
What are protective factors of endometrial cancer?
- birth control pills
- pregnancies
- early menopause
43
What are signs and symptoms of endometrial cancer?
- *postmenopausal bleeding*
- postmenopausal pap with endometrial cells
- premenopausal intermenstrual bleeding
44
What is the 5 year survival of a patient with endometrial cancer at each stage?
- stage I = 76%
- stage II = 60%
- stage III = 30%
- stage IV = 10%
45
When a patient reports a history of a hysterectomy, what 4 things should you ask?
- age (average age in 40s)
- reason for hysterectomy (cancer? Stage?)
- ovaries removed? (Bilateral oophorectomy)
- use of ERT (estrogen replacement therapy) (no progesterone needed because no uterus)
