Abnormal Uterine Bleeding Flashcards
Origin of leiomyoma
Mullerian duct
Most common presenting symptom of leiomyoma
Recurrent miscarriages and infertility
Causes of AUB
PALM COEIN • polyps • adenomyosis • leiomyoma • malignancy • coagulopathy • Ovarian d/o • endometrial • iatrogenic: anticoagulants • not otherwise specified
Leiomyoma dx (2)
Clinical dx: pv cervix displaced upwards and u/s homogenously enlarged uterus/ solid mass ( regular borders )
Def adenomyosis
Endometrium grow into myometrium
Rx Small, asymptomatic leiomyoma
expectant management and follow up every 3 months
3 -7% untreated regress over 6 months - 3 years
Advocated for symptomatic and/or perimenopausal women
Picture 2: identify condition and label
Myomatous uterus (leiomyoma). See picture 3
Normal volume of blood a woman loses during menstruation
80 ml
Normal menstrual cycle length
26-38 days
Acute pharmacological management of excessive bleeding
Tranexamic acid (antifibrinolytic)
FIGO classification of uterine fibroids (9)
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
Treatment options uterus leiomyomata? (10)
- 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
Management symptomatic uterine fibroids in patients that wish to maintain fertility (6)
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
Management symptomatic uterine fibroids in patients that do not wish to maintain fertility (4)
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)
Which types of leiomyoma can impact fertility
- Submucosal (type o-2)
- intramural if > 5 cm (4)
Name 8 risk factors leiomyoma
- Nulliparity
- early menarche
- increased frequency menses
- history dysmenarrhoea
- family history fibroids
- African
- obesity
- age
Stage the leiomyomas on picture 24
See picture 25
Approach to AUB in prepubertal girls? (10)
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
How investigate for polyps?
- Saline instillation sonography best
- hysteroscopy = gold standard, and can treat simultaneously with polypectomy
Treatment polyps?
Hysteroscopic polypectomy
Risk factors adenomyosis? (5)
- Prolonged oestrogen exposure
- local trauma
- infection
- age 40 - 50
- high parity
Examination finding adenomyosis?
Bulky, tender uterus
Diagnosis adenomyosis (4)
TV us:
- asymmetrical myometrial thickening
- increased vascularity in lesions
- hyperechoic islands (light)
- specific functional zone irregularities/ disruptions
Treatment adenomyosis (7)
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
