Abnormal Uterine Bleeding

Question 1

Origin of leiomyoma

Answer 1

Mullerian duct

Question 2

Most common presenting symptom of leiomyoma

Answer 2

Recurrent miscarriages and infertility

Question 3

Causes of AUB

Answer 3

PALM COEIN
• polyps
• adenomyosis
• leiomyoma
• malignancy
• coagulopathy
• Ovarian d/o
• endometrial
• iatrogenic: anticoagulants
• not otherwise specified

Question 4

Leiomyoma dx (2)

Answer 4

Clinical dx: pv cervix displaced upwards and u/s homogenously enlarged uterus/ solid mass ( regular borders )

Question 5

Def adenomyosis

Answer 5

Endometrium grow into myometrium

Question 6

Rx Small, asymptomatic leiomyoma

Answer 6

expectant management and follow up every 3 months

3 -7% untreated regress over 6 months - 3 years

Advocated for symptomatic and/or perimenopausal women

Question 7

Picture 2: identify condition and label

Answer 7

Myomatous uterus (leiomyoma). See picture 3

Question 8

Normal volume of blood a woman loses during menstruation

Answer 8

80 ml

Question 9

Normal menstrual cycle length

Answer 9

26-38 days

Question 10

Acute pharmacological management of excessive bleeding

Answer 10

Tranexamic acid (antifibrinolytic)

Question 11

FIGO classification of uterine fibroids (9)

Answer 11

0 pedunculated intracaVitary
1 submucosal < 50% intramural
2 submucosal 50% or more
3 contact with endometrium 100% intramural
4 intramural
5 subserosal 50% or more intramural
6 subserosal < 50% intramural
7 subserosal pedunculated
8 other eg cervical, parasitic

Question 12

Treatment options uterus leiomyomata? (10)

Answer 12

• Expectant
• Medical
  → tranexamic acid
  → coc and progestins
  → LNG IUD
  → gnrh agonist + oestrogen therapy
• radiological
  → uterine artery embolisation
  → high intensity focused ultrasound (hifu) aka MR guided focused ultrasound (MRgFUS)
  → us guided radio frequency ablation

Surgical
→ myomeCtomy: hysteroscopic/laparoscopic
→ hysterectomy: vaginal /laparosopic / abdominal

Question 13

Management symptomatic uterine fibroids in patients that wish to maintain fertility (6)

Answer 13

Medical

• Tranexamic acid 1 g hrly 3-4 days: control excessive menstrual bleeding
• oral contraceptive: control bleeding
• LNG IUD: control bleeding best but can only be inserted if non- distorted uterus (submucosal fibroids) and small fibroids (higher risk expulsion)
• gnrha zoladex: shrink by 40 - 50%in first 3 months and reduce blood loss. prescribed 3-6 months with add-back oestrogen therapy (vasomotor symptoms + bone loss) within 1-3 months. Recur when stop so best pre-op,
• selective progesterone receptor modulators SPRMs ulipristal: antiproliferative + proapoptotic

Surgical

• myomectomy: increased blood loss, operative time. 15% recurrence, 10% will need hysterectomy in 5-10 years
  → hysteroscopic: type 0 (intracaVitary),1 (intramural) and some 2 (submucosal).
  → laparoscopic: >3 fibroids <15 cm

Question 14

Management symptomatic uterine fibroids in patients that do not wish to maintain fertility (4)

Answer 14

Surgical

• can give pre-op gnrha or SPRM to shrink
• hysterectomy: most effective
  → vaginal: only if uterus not too enlarged > 12 weeks, no extrauterine disease eg adnexal masses, no pelvic endometriosis or severe pelvic adhesions.
  → laparoscopic: intramural + submucosal myOma
  → abdominal

Radiological conservative

• uterine artery embolisation: less complications but increased risk future reintervention. Complications = vaginal discharge, fever, postembolisation syndrome
• Mr guided focused ultrasound (mrgfus) / high intensity focused ultrasound (hifu): max 5 fibroids no larger than 10 cm. Disadvantages = high exclusion rate, prolonged time, treatment 1 fibroid at a time.
• ultrasound guided radiofrequency ablation (rfa)

Question 15

Which types of leiomyoma can impact fertility

Answer 15

• Submucosal (type o-2)
• intramural if > 5 cm (4)

Question 16

Name 8 risk factors leiomyoma

Answer 16

• Nulliparity
• early menarche
• increased frequency menses
• history dysmenarrhoea
• family history fibroids
• African
• obesity
• age

Question 17

Stage the leiomyomas on picture 24

Answer 17

See picture 25

Question 18

Approach to AUB in prepubertal girls? (10)

Answer 18

Secondary sex characteristics and <8 = precocious puberty

No secondary sex characteristics

• acute onset
  → vulvovaginal mass
  > urethral prolapse
  > straddle injury with haematoma
  > neoplasm
  → no mass
  > other injury
  > sexual abuse
  > infectious vulvovaginitis
• Chronic onset
  → foreign body
  → dermatoses eg lichen sclerosis , atopic dermatitis/eczema
  → irritant vulvovaginitis

Question 19

How investigate for polyps?

Answer 19

• Saline instillation sonography best
• hysteroscopy = gold standard, and can treat simultaneously with polypectomy

Question 20

Treatment polyps?

Answer 20

Hysteroscopic polypectomy

Question 21

Risk factors adenomyosis? (5)

Answer 21

• Prolonged oestrogen exposure
• local trauma
• infection
• age 40 - 50
• high parity

Question 22

Examination finding adenomyosis?

Answer 22

Bulky, tender uterus

Question 23

Diagnosis adenomyosis (4)

Answer 23

TV us:

• asymmetrical myometrial thickening
• increased vascularity in lesions
• hyperechoic islands (light)
• specific functional zone irregularities/ disruptions

Question 24

Treatment adenomyosis (7)

Answer 24

Medical: (for. Heavy and painful menstruation symptoms )

→ tranexamic acid
→ coc and progestins
→ LNG IUD
→ gnrh agonist + oestrogen therapy

If fail: surgical

• hysterectomy = definitive
• hysteroscopic resection and uterine artery embolisation: if localised foci and desire fertility (may cause scarring )

Other: radiological

• mrgfus for isolated lesions

Question 25

Investigations for suspected coagulopathy causing AUB?

Answer 25

• FBC
• pt
• bleeding time
• Vwf

Question 26

Name examples of primary endometrial disorders as cause of AUB

Answer 26

Secondary to inflammation/infection endometrium
(Endometritis)
Diagnosis of exclusion

Question 27

Name examples of iatrogenic cause of AUB (4)

Answer 27

Pharmacological

• hormonal: oestrogen, progestogens, androgens
• non-hormonal that effect dopamine metabolism: phenothiazines, TCA
• anticoagulants

Intrauterine systems

Question 28

Name examples of not otherwise classified cause of AUB

Answer 28

Arteriovenous malformations

Question 29

Investigations for post menopausal AUB? (2)

Answer 29

• All need endometrial sampling ( hysteroscopy gold standard, but pipelle will suffice)
  -TV us: endometrial thickness > 5 mm is abnormal in menopause

Question 30

Management acute abnormal bleeding?

Answer 30

• assess and Resuscitate
• antifibrinolytic: tranexamic acid (cyclocapron) iv 1g 8 hourly to increase clot formation
• progestogen: if due to prolonged oestrogen exposure (anovulation) to convert proliferative endometrium to secretory. Medroxy progesterone acetate oral 10-30 mg daily for 7-10 days
• high dose oestrogen followed by progestogen: only of cause due to endometrial atrophy. Oestrogen cause rapid growth of endometrium, stimulate vasospasm of uterine arteries, promote platelet aggregation + stability in coagulation cascade. Give antiemetics

Question 31

Dose tranexamic acid (cyclocapron) for acute bleeding?

Answer 31

iv 1g 8 hourly
(Antifibrinolytic)

Question 32

Definitive long term pharmacological treatment of abnormal bleeding? (8)

Answer 32

Non hormonal

• antifibrinolytics: tranexamic and 500 mg-1g 3x per day for 5-7 days.
• NSAIDs: reduce prostaglandin synthesis

Hormonal

• coc for non-structural causes
• progestogens
• LNG IUD
• gnrh analogues as last resort

Surgical

• hysterectomy first line
• endometrial ablation (destroy basal layer)