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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
Q

Explain the endometrial biopsy result:

Proliferative

A

Normal in follicular phase

If associated with abnormal uterine bleeding confirms anovulation and effects of unopposed estrogen

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26
Q

Explain the endometrial biopsy result:

Secretory/menstrual

A

Confirms ovulation has occurred

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27
Q

Explain the endometrial biopsy result:

Hyperplasia with atypia

A

Hyperplasia- advanced effect of unopposed estrogen

Atypia- premalignant

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28
Q

Explain the endometrial biopsy result:

Atrophic

A

Post menopause

Effect of OCPs, Depo-Provera

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29
Q

Compare the effectiveness of the medical treatment options for abnormal uterine bleeding

A

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
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30
Q

What are the surgical options for abnormal uterine bleeding?

A

Hysterectomy

  • Definitive treatment
  • High patient satisfaction

Myomectomy

Ablation

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31
Q

What must be done prior to endometrial ablation in treating abnormal uterine bleeding?

A

Rule out preinvasive and invasive endometrial lesions

Patient must be done with childbearing and be able to tolerate some menstrual bleeding

32
Q

What is the best alternative to surgery in treating heavy menstrual bleeding?

A

Levonorgestrel IUD

  • Better for long term than oral medications
  • May still have spotting or bleeding
  • Less risk than hysterectomy
33
Q

Differential for Secondary Amenorrhea?

A

PCOS

Intrauterine synechiae (Asherman syndrome)

Functional hypothalamic amenorrhea

Hypothyroidism

Hyperprolactinemia

Primary ovarian insufficiency

Progesterone only contraceptives

34
Q

How do you evaluate secondary amenorrhea?

A
  1. Rule out pregnancy
  2. Get TSH, prolactin
  3. Determine relative estrogen status (Progestin challenge)
35
Q

Describe Progestin challenge testing

A

5-10mg medroxyprogesterone daily for 10 days

Any bleeding within 2-7 days is “positive” -> amenorrhea due to anovulation

36
Q

How is anovulatory amenorrhea diagnosed?

A

Amenorrheic woman with a positive progestin challenge test

Indicates adequate estrogen production

37
Q

What characteristics are common in women with anovulatory amenorrhea?

A

PCOS

Obesity

38
Q

Why is the risk of endometrial cancer higher in women with anovulatory amenorrhea?

A

Unopposed estrogen stimulation

Inadequate progesterone production

39
Q

What is the treatment of anovulatory amenorrhea?

A

Progestin 10 mg daily for 7-10 days every month

OCPs

40
Q

If no withdrawal bleeding occurs with a progestin challenge or an estrogen and progestin challenge, what is the diagnosis?

A

Outflow tract obstruction

  • Asherman syndrome
  • Mullerian agenesis
41
Q

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?

A

Measure FSH and LH

42
Q

In the work up of amenorrhea, what is the diagnosis if FSH and LH are high?

A

Primary ovarian insufficiency

43
Q

What is the next step in management for the work up of amenorrhea if FSH and LH are low or normal?

A

Brain MRI

44
Q

In the work up of amenorrhea, what is the diagnosis if FSH and LH are low or normal and the brain MRI is normal?

A

Hypothalamic amenorrhea

45
Q

How is hypothalamic amenorrhea diagnosed?

A

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
Q

What can cause hypothalamic amenorrhea?

A

Hypogonadotropic Hypogonadism

Anorexia, bulimia

Stress

High intensity exercise

Chronic illness

47
Q

What is the effect of hypothalamic amenorrhea on bone density and how is it treated?

A

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
Q

What can cause ovarian failure?

A

Primary ovarian insufficiency
-Autoimmune, genetic, chemotherapy, mumps

Menopause

Absence of secondary sex characteristics
-Gonadal dysgenesis (Turner syndrome)

49
Q

What are some common comorbidities associated with PCOS?

A

Metabolic syndrome

Obesity

Type 2 DM

Non alcoholic fatty liver disease

Sleep apnea

Increased risk of CV disease and mood disorders

50
Q

How is polycystic ovarian syndrome diagnosed?

A

Rotterdam Criteria, 2 of 3

Hyperandrogenism

Ovulatory dysfunction

Polycystic ovaries

51
Q

How does hyperandrogenism present in PCOS?

A

Excessive acne

Androgenic alopecia

Hirsutism

Elevated testosterone or dehydroepiandrosterone

52
Q

How might an androgen secreting tumor present in a female patient?

A

Virilization- deepening voice, clitoromegaly

Rapid onset PCOS symptoms

53
Q

How does ovulatory dysfunction present in PCOS?

A

Oligomenorrhea
(cycles 35-180 days apart)

Amenorrhea (absent menses for 6-12 months)

54
Q

How does polycystic ovaries defined in PCOS?

A

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
Q

What are some cutaneous findings of PCOS?

A

Male patterned facial hair

Acne

Alopecia

Acanthosis nigricans

Skin tags

56
Q

What is your evaluation for PCOS?

A
  • 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
Q

What would elevated 17-hydroxyprogesterone levels indicate?

A

Adrenal hyperplasia due to 21 hydroxylase deficiency

58
Q

What is the utility of LH, FSH levels in PCOS evaluation?

A

LH/FSH ratio of 2 or greater may indicate PCOS

No exact cutoff, not as reliable

59
Q

What is the utility of transvaginal ultrasound in PCOS evaluation?

A

Usually unnescessary unless

Use to rule out a tumor

Or

Needed for diagnosis because only one other Rotterdam criteria is met

60
Q

If woman is diagnosed wit PCOS what initial testing does she need?

A

Measure blood pressure

Lipid levels

Screen for Type 2 DM

Screen for depression

Screen for OSA if overweight/obese

TSH, prolactin

17-hydroxyprogesterone

61
Q

How can insulin affect ovulation?

A

Insulin resistance stimulates ovarian androgen production —> anovulation

Hyperinsulinemia/hyperandrogenemia alter gonadotropin secretions from pituitary —> changes in LH surge and levels

62
Q

Treatment for oligomenorrhea and amenorrhea in PCOS?

A

OCPs

Monthly Progesterone

63
Q

Treatment for hirsutism in PCOS?

A

OPCs

Spironolactone

Finasteride

64
Q

Treatment for insulin resistance in PCOS?

A

Metformin

*may also help regulate menses

65
Q

Treatment for infertility in PCOS

A

Letrozole

Clomiphene

66
Q

What is the effect of weight loss in PCOS?

A

Improves fertility and metabolic profile

67
Q

Treatment options for perimenopausal bleeding?

A

Prevents hyperplasia

  • Progestins 12days/month
  • Hormone replacement therapy- cyclic dosing

Contraception, controls/reduces cycles

  • OCPs
  • Levonorgestrel IUD
68
Q

What is the role of FSH levels in identifying menopause transition?

A

Do not order FSH levels in women in their 40s to identify menopause transition as cause of abnormal uterine bleeding

69
Q

What pattern of bleeding can be normal when starting hormone therapy in postmenopausal women?

A

Irregular bleeding after initiation

Improves within 6-12 months

70
Q

What is considered abnormal postmenopausal bleeding for women on cyclic hormone therapy?

A

Prolonged or heavy bleeding near the end of the progestin phase

Breakthrough bleeding any other time

71
Q

What is considered abnormal postmenopausal bleeding for women on continuous hormone therapy?

A

Bleeding longer than 6 months

Bleeding after amenorrhea has been established

72
Q

What is considered abnormal postmenopausal bleeding for women on NO hormone therapy?

A

Any bleeding

73
Q

In women on hormone therapy for less than 1 year, How long can postmenopausal bleeding be observed?

A

Observe for one year before diagnosing as abnormal

74
Q

What is the initial study for postmenopausal bleeding:

High risk for endometrial cancer v. Low risk women

A

High risk: EMB

Low risk: TVUS

75
Q

What is the next step in work up for postmenopausal bleeding if EMB is unclear or bleeding continues after initial work up is normal?

A

Saline infusion sonography

76
Q

What are the first two tests every woman should get for work up abnormal uterine bleeding?

A

Pregnancy test

CBC- for anemia

77
Q

What is the most effective treatment for heavy menstrual bleeding?

A

Hysterectomy

*Levonorgestrel IUD is the most effective medical therapy

01 Family Medicine (16 decks)

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