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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)

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2
Q

What is menorrhagia?

A

Hypermenorrhea

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3
Q

What is metrorrhagia?

A

Intramenstrual bleeding, BTB

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4
Q

What is menometrorrhagia

A

Heavy intramenstrual bleeding

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5
Q

What is polymenorrhea?

A

Menses < q21d

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6
Q

What is contact bleeding

A

Poscoital (post-sex) or post contact bleeding

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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)
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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)

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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)
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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
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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

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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)

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13
Q

What is a hysteroscopy?

A

Fibroscopic endoscope passed through the cervix to visualize endometrial cavity

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14
Q

What are indications for a EMB? (3)

A
  • any abnormal bleeding
  • postmenopausal bleeding
  • fertility issues
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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)
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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

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17
Q

What are other names of uterine fibroids?

A
  • leiomyomata
  • leiomyoma
  • fibromyoma
  • myoma
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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.
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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
Q

What is the imaging choice for uterine fibroid? Why?

A

Ultrasound
- low cost, safe, versatile, early diagnosis, avoid surgery

May not be definitive

26
Q

What are indication for an abdominal ultrasound?

A
  • better evaluate size, location, complexity
  • ovarian mass
  • pelvic cancer
  • uterine fibroids
  • endometrium
  • ectopic pregnancy
27
Q

What are management options for uterine fibroids?

A
  • watch and wait
  • manage symptoms
    — lifestyle modifications
    — nutrition/ botanicals
    — drugs - Lipton, progestins
    — surgery
28
Q

What are the nutritional changes you could suggest a patient with uterine fibroids?

A
  • 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
Q

What is the go-to treatment for uterine fibroids?

A

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
Q

What are surgical indications for uterine fibroids?

A

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
Q

What are surgical options for uterine fibroids?

A
  • 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
Q

What is adenomyosis?

A

The presence of endometrial glands and stroma within the myometrium
- endometrial gland invasion of myometrium

33
Q

Adenomyosis is common in what women

A

Porous (have had children) = women between 35-50

34
Q

What are signs/symptoms of adenomyosis?

A
  • diffusely enlarged (asymmetrical) and sometimes tender uterus
  • dysmenorrhea
  • PMS
  • exaggerated cyclic symptoms
35
Q

What is the treatment for adenomyosis?

A

OC’s
Progestins
Hysterectomy

36
Q

What is endometrial hyperplasia? Is it dangerous?

A
  • overgrowth of endometrial cells in the endometrium

- benign condition however if left untreated high risk of endometrial cancer

37
Q

What are symptoms of endometrial hyperplasia?

A
  • abnormal bleeding

- post menopausal bleeding

38
Q

How do you diagnose endometrial hyperplasia?

A

EMB

Pelvic ultrasound

39
Q

How do you treat endometrial hyperplasia?

A

Progesterone, dietary changes, exercise, possible D&C (dilation and curettage), ablation, hysterectomy

40
Q

what are risk factors for endometrial carcinoma?

A
  • age = 50-70
  • hyperplasia
  • unopposed estrogen
  • obesity
  • family history (breast, colorectal)
  • PCOS/anovulation
  • nulliparity
  • extended use of tamoxifen
  • diabetic
  • hypertension
41
Q

What are the largest relative risk factors for endometrial cancer?

A
  • Atypical hyperplasia (29)
  • unopposed estrogen (9.5)
  • obesity (3-10)
  • late menopause (4)
  • diabetes (2.8)
  • never pregnant (2)
42
Q

What are protective factors of endometrial cancer?

A
  • birth control pills
  • pregnancies
  • early menopause
43
Q

What are signs and symptoms of endometrial cancer?

A
  • postmenopausal bleeding
  • postmenopausal pap with endometrial cells
  • premenopausal intermenstrual bleeding
44
Q

What is the 5 year survival of a patient with endometrial cancer at each stage?

A
  • stage I = 76%
  • stage II = 60%
  • stage III = 30%
  • stage IV = 10%
45
Q

When a patient reports a history of a hysterectomy, what 4 things should you ask?

A
  • 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)

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