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01 Family Medicine > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

AAFP Lecture: Abnormal Uterine Bleeding

1
Q

Define abnormal uterine bleeding

A

Menstrual flow outside of normal volume, duration, regularity or frequency

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2
Q

What are the 5 basic steps of the menstrual cycle?

A
  1. FSH from the pituitary gland induces ovarian follicles to produce estrogen
  2. Estrogen stimulates endometrial proliferation
  3. LH surge prompts ovulation
  4. The resultant corpus luteum produces progesterone which induces a secretory endometrium
  5. In the absence of pregnancy, estrogen and progesterone levels drop and the endometrium lining is shed
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3
Q

What are the two descriptor categories of abnormal uterine bleeding?

A

Heavy menstrual bleeding

Intermenstrual bleeding

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4
Q

What are the etiologies of abnormal uterine bleeding?

A

Polyp

Adenomyosis

Leiomyoma

Malignancy/Hyperplasia

Coagulopathy

Ovulatory dysfunction

Endometrial

Iatrogenic

Not yet classified

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5
Q

Anovulatory v. Ovulatory abnormal uterine bleeding

A

Anovulatory:

  • Irregular or infrequent periods
  • Flow may be light to heavy
  • Estrogen dominant state
  • 14% of women will develop cancer/hyperplasia

Ovulatory:

  • Regular intervals (24-38 days)
  • Excessive volume, passing clots, lasting more than 8 days
  • Less than 1% develop cancer/hyperplasia
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6
Q

Differential for normal anovulatory bleeding?

A

Adolescence (Immature hypothalamic-pituitary-ovarian axis)

Perimenopause (HPO axis changing)

Any other time is abnormal

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7
Q

Differential for Abnormal anovulatory bleeding?

A

Uncontrolled DM

Eating disorder

Thyroid dysfunction

Hyperprolactinemia

Medications (Antiepileptics, antipsychotics)

PCOS

Pregnancy

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8
Q

How to evaluate anovulatory bleeding?

A

Labs:
-Pregnancy test, CBC, TSH, Prolactin

Endometrial Biopsy

Imaging

  • Transvaginal ultrasound
  • Saline infusion sonohysterography
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9
Q

In women with anovulatory bleeding, who needs an endometrial biopsy?

A

Women <45 with one of the following:

  • Chronic anovulation
  • Diabetes
  • Family history of colon cancer
  • Infertility
  • Nulliparity
  • Obesity
  • Tamoxifen use

Women over 45 with suspected anovulatory bleeding

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10
Q

What should be ruled out prior to continuing an anovulatory bleeding work up?

A

Systemic disease

Medication effects

PCOS

Cervical or vaginal pathology

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11
Q

What is the management for women younger than 45 and NO risk factors for endometrial cancer with suspected anovulatory bleeding?

A

Treat with long term medical therapy

If bleeding continues get endometrial biopsy

If biopsy normal get transvaginal ultrasound or Saline infusion sonohysterography

If still unclear get hysteroscopy

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12
Q

What are the long term medical therapy options for treating anovulatory bleeding?

A

Levonorgestrel IUD

Combined OCPs

Oral progestins

Depo-Provera

Oral tranexamic acid or NSAIDS (given when actively bleeding)

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13
Q

If a woman being worked up for anovulatory bleeding has a normal endometrial biopsy, what are the next steps in management?

A

Treat with long term medical therapy

If bleeding continues get transvaginal ultrasound or Saline infusion sonohysterography

If still unclear get hysteroscopy

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14
Q

If a woman being worked up for anovulatory bleeding has hyperplasia without atypia on endometrial biopsy, what are the next steps in management?

A

Treat with medroxyprogesterone, megestrol or levonorgestrel IUD

Repeat endometrial biopsy in 3-6 months

Refer to gynecology if hyperplasia persists

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15
Q

If a women being worked up for anovulatory bleeding has Hyperplasia with atypia or adenocarcinoma on endometrial biopsy, what are the next steps in management?

A

Refer to gynecology for further management

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16
Q

The onset of heavy menses at menarche is often the first sign of what disorder?

A

Von WIllebrand Disease

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17
Q

What is the differential for ovulatory abnormal uterine bleeding?

A

Bleeding Disorders

  • Factor deficiency
  • Leukemia
  • Platelet disorders
  • Von WIllebrand Disease

Hypothyroidism

Advanced liver disease

Fibroids

Polyps

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18
Q

How to evaluate abnormal ovulatory bleeding?

A

Labs:
-Pregnancy test, CBC, TSH, PT/PTT

Imaging: looking for structural cause

  • Transvaginal ultrasound
  • saline infusion sonohysterography

Endometrial biopsy:

  • If <45 with normal labs and imagine and unresponsive to therapy
  • If >45 and risk factors for cancer
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19
Q

What are some risk factors for bleeding disorder in women with abnormal ovulatory bleeding?

A

Family history of a bleeding disorder

Menses longer than 7 days with excessive bleeding, impairing daily activities

History of anemia requiring treatment

History of heavy bleeding after tooth extraction, surgery, vaginal delivery or spontaneous abortion

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20
Q

Treatment for women with abnormal ovulatory bleeding with normal labs, imaging and low risk of endometrial cancer?

A

Long term medical therapy:

Levonorgestrel IUD

Combined OCPs

Oral progestins

Depo-Provera

Oral tranexamic acid or NSAIDS (given when actively bleeding)

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21
Q

Use of transvaginal ultrasound in the setting of abnormal uterine bleeding?

A

Can evaluate myometrium

Low sensitivity and specificity for intracavitary pathology

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22
Q

Use of saline infusion sonohysterography in the setting of abnormal uterine bleeding?

A

Superior to transvaginal ultrasound in detecting intracavitary lesions (polyps, submucosal fibroids)

Can distinguish between focal and uniform thickening of the endometrium

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23
Q

Use of diagnostic hysteroscopy in the setting of abnormal uterine bleeding?

A

Superior to transvaginal ultrasound and saline infusion sonohysterography in detecting intracavitary masses

Increased accuracy of identifying cause of abnormal uterine bleeding compared to dilatation & curettage

Can be done in office

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24
Q

Use of MRI in the setting of abnormal uterine bleeding?

A

May be helpful in guiding treatment of myomas

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25
Explain the endometrial biopsy result: Proliferative
Normal in follicular phase If associated with abnormal uterine bleeding confirms anovulation and effects of unopposed estrogen
26
Explain the endometrial biopsy result: Secretory/menstrual
Confirms ovulation has occurred
27
Explain the endometrial biopsy result: Hyperplasia with atypia
Hyperplasia- advanced effect of unopposed estrogen Atypia- premalignant
28
Explain the endometrial biopsy result: Atrophic
Post menopause Effect of OCPs, Depo-Provera
29
Compare the effectiveness of the medical treatment options for abnormal uterine bleeding
Levonorgestrel IUD -Most effective (71-95% decrease in blood loss) Continuous dose Progestins (87% decrease) OCPs (35-69% decrease) NSAIDs - decrease prostacyclin -> increases platelet aggregation, reduces vasodilation effects - 10-50% decrease - Take when actively bleeding Tranexamic acid - 26-54% decrease - Take when actively bleeding
30
What are the surgical options for abnormal uterine bleeding?
Hysterectomy - Definitive treatment - High patient satisfaction Myomectomy Ablation
31
What must be done prior to endometrial ablation in treating abnormal uterine bleeding?
Rule out preinvasive and invasive endometrial lesions Patient must be done with childbearing and be able to tolerate some menstrual bleeding
32
What is the best alternative to surgery in treating heavy menstrual bleeding?
Levonorgestrel IUD - Better for long term than oral medications - May still have spotting or bleeding - Less risk than hysterectomy
33
Differential for Secondary Amenorrhea?
PCOS Intrauterine synechiae (Asherman syndrome) Functional hypothalamic amenorrhea Hypothyroidism Hyperprolactinemia Primary ovarian insufficiency Progesterone only contraceptives
34
How do you evaluate secondary amenorrhea?
1. Rule out pregnancy 2. Get TSH, prolactin 3. Determine relative estrogen status (Progestin challenge)
35
Describe Progestin challenge testing
5-10mg medroxyprogesterone daily for 10 days Any bleeding within 2-7 days is “positive” -> amenorrhea due to anovulation
36
How is anovulatory amenorrhea diagnosed?
Amenorrheic woman with a positive progestin challenge test | Indicates adequate estrogen production
37
What characteristics are common in women with anovulatory amenorrhea?
PCOS Obesity
38
Why is the risk of endometrial cancer higher in women with anovulatory amenorrhea?
Unopposed estrogen stimulation Inadequate progesterone production
39
What is the treatment of anovulatory amenorrhea?
Progestin 10 mg daily for 7-10 days every month OCPs
40
If no withdrawal bleeding occurs with a progestin challenge or an estrogen and progestin challenge, what is the diagnosis?
Outflow tract obstruction - Asherman syndrome - Mullerian agenesis
41
What is the next step in management if no withdrawal bleeding occurs with a progestin challenge test but does occur with an estrogen and progestin challenge test?
Measure FSH and LH
42
In the work up of amenorrhea, what is the diagnosis if FSH and LH are high?
Primary ovarian insufficiency
43
What is the next step in management for the work up of amenorrhea if FSH and LH are low or normal?
Brain MRI
44
In the work up of amenorrhea, what is the diagnosis if FSH and LH are low or normal and the brain MRI is normal?
Hypothalamic amenorrhea
45
How is hypothalamic amenorrhea diagnosed?
Normal prolactin Low endogenous estrogen (negative progestin challenge) +withdrawal bleeding form estrogen and progestin challenge test Low or normal FSH and LH No pituitary or other lesions seen on MRI
46
What can cause hypothalamic amenorrhea?
Hypogonadotropic Hypogonadism Anorexia, bulimia Stress High intensity exercise Chronic illness
47
What is the effect of hypothalamic amenorrhea on bone density and how is it treated?
Decreased bone density by 10-20% Calcium and weight bearing exercise are not enough to overcome effects OCPs may improve lumbar and total bone mineral but unknown effect on fracture risk Decrease intensity of exercise Increase BMI to >20 to restore menses
48
What can cause ovarian failure?
Primary ovarian insufficiency -Autoimmune, genetic, chemotherapy, mumps Menopause Absence of secondary sex characteristics -Gonadal dysgenesis (Turner syndrome)
49
What are some common comorbidities associated with PCOS?
Metabolic syndrome Obesity Type 2 DM Non alcoholic fatty liver disease Sleep apnea Increased risk of CV disease and mood disorders
50
How is polycystic ovarian syndrome diagnosed?
Rotterdam Criteria, 2 of 3 Hyperandrogenism Ovulatory dysfunction Polycystic ovaries
51
How does hyperandrogenism present in PCOS?
Excessive acne Androgenic alopecia Hirsutism Elevated testosterone or dehydroepiandrosterone
52
How might an androgen secreting tumor present in a female patient?
Virilization- deepening voice, clitoromegaly Rapid onset PCOS symptoms
53
How does ovulatory dysfunction present in PCOS?
Oligomenorrhea (cycles 35-180 days apart) Amenorrhea (absent menses for 6-12 months)
54
How does polycystic ovaries defined in PCOS?
Ovary containing 12 or more follicles measuring 2 to 9 mm in diameter Or Ovary with a volume greater than 10 mL on ultrasound
55
What are some cutaneous findings of PCOS?
Male patterned facial hair Acne Alopecia Acanthosis nigricans Skin tags
56
What is your evaluation for PCOS?
- Pregnancy test - TSH, prolactin - 17-hydroxyprogesterone, testosterone, DHEA - Consider screen for Cushings or acromegaly if clinically indicated - May need to exclude hypothalamic amenorrhea and primary ovarian insufficiency
57
What would elevated 17-hydroxyprogesterone levels indicate?
Adrenal hyperplasia due to 21 hydroxylase deficiency
58
What is the utility of LH, FSH levels in PCOS evaluation?
LH/FSH ratio of 2 or greater may indicate PCOS No exact cutoff, not as reliable
59
What is the utility of transvaginal ultrasound in PCOS evaluation?
Usually unnescessary unless Use to rule out a tumor Or Needed for diagnosis because only one other Rotterdam criteria is met
60
If woman is diagnosed wit PCOS what initial testing does she need?
Measure blood pressure Lipid levels Screen for Type 2 DM Screen for depression Screen for OSA if overweight/obese TSH, prolactin 17-hydroxyprogesterone
61
How can insulin affect ovulation?
Insulin resistance stimulates ovarian androgen production —> anovulation Hyperinsulinemia/hyperandrogenemia alter gonadotropin secretions from pituitary —> changes in LH surge and levels
62
Treatment for oligomenorrhea and amenorrhea in PCOS?
OCPs Monthly Progesterone
63
Treatment for hirsutism in PCOS?
OPCs Spironolactone Finasteride
64
Treatment for insulin resistance in PCOS?
Metformin *may also help regulate menses
65
Treatment for infertility in PCOS
Letrozole Clomiphene
66
What is the effect of weight loss in PCOS?
Improves fertility and metabolic profile
67
Treatment options for perimenopausal bleeding?
Prevents hyperplasia - Progestins 12days/month - Hormone replacement therapy- cyclic dosing Contraception, controls/reduces cycles - OCPs - Levonorgestrel IUD
68
What is the role of FSH levels in identifying menopause transition?
Do not order FSH levels in women in their 40s to identify menopause transition as cause of abnormal uterine bleeding
69
What pattern of bleeding can be normal when starting hormone therapy in postmenopausal women?
Irregular bleeding after initiation Improves within 6-12 months
70
What is considered abnormal postmenopausal bleeding for women on cyclic hormone therapy?
Prolonged or heavy bleeding near the end of the progestin phase Breakthrough bleeding any other time
71
What is considered abnormal postmenopausal bleeding for women on continuous hormone therapy?
Bleeding longer than 6 months Bleeding after amenorrhea has been established
72
What is considered abnormal postmenopausal bleeding for women on NO hormone therapy?
Any bleeding
73
In women on hormone therapy for less than 1 year, How long can postmenopausal bleeding be observed?
Observe for one year before diagnosing as abnormal
74
What is the initial study for postmenopausal bleeding: High risk for endometrial cancer v. Low risk women
High risk: EMB Low risk: TVUS
75
What is the next step in work up for postmenopausal bleeding if EMB is unclear or bleeding continues after initial work up is normal?
Saline infusion sonography
76
What are the first two tests every woman should get for work up abnormal uterine bleeding?
Pregnancy test CBC- for anemia
77
What is the most effective treatment for heavy menstrual bleeding?
Hysterectomy *Levonorgestrel IUD is the most effective medical therapy

01 Family Medicine (16 decks)

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