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Gynaecology > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

1
Q

Origin of leiomyoma

A

Mullerian duct

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2
Q

Most common presenting symptom of leiomyoma

A

Recurrent miscarriages and infertility

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3
Q

Causes of AUB

A 
PALM COEIN
• polyps
• adenomyosis
• leiomyoma
• malignancy
• coagulopathy
• Ovarian d/o
• endometrial
• iatrogenic: anticoagulants
• not otherwise specified
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4
Q

Leiomyoma dx (2)

A

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

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5
Q

Def adenomyosis

A

Endometrium grow into myometrium

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6
Q

Rx Small, asymptomatic leiomyoma

A

expectant management and follow up every 3 months

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

Advocated for symptomatic and/or perimenopausal women

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7
Q

Picture 2: identify condition and label

A

Myomatous uterus (leiomyoma). See picture 3

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8
Q

Normal volume of blood a woman loses during menstruation

A

80 ml

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9
Q

Normal menstrual cycle length

A

26-38 days

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10
Q

Acute pharmacological management of excessive bleeding

A

Tranexamic acid (antifibrinolytic)

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11
Q

FIGO classification of uterine fibroids (9)

A

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

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12
Q

Treatment options uterus leiomyomata? (10)

A
  • 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

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13
Q

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

A

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
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14
Q

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

A

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)
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15
Q

Which types of leiomyoma can impact fertility

A
  • Submucosal (type o-2)
  • intramural if > 5 cm (4)
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16
Q

Name 8 risk factors leiomyoma

A
  • Nulliparity
  • early menarche
  • increased frequency menses
  • history dysmenarrhoea
  • family history fibroids
  • African
  • obesity
  • age
17
Q

Stage the leiomyomas on picture 24

A

See picture 25

18
Q

Approach to AUB in prepubertal girls? (10)

A

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
19
Q

How investigate for polyps?

A
  • Saline instillation sonography best
  • hysteroscopy = gold standard, and can treat simultaneously with polypectomy
20
Q

Treatment polyps?

A

Hysteroscopic polypectomy

21
Q

Risk factors adenomyosis? (5)

A
  • Prolonged oestrogen exposure
  • local trauma
  • infection
  • age 40 - 50
  • high parity
22
Q

Examination finding adenomyosis?

A

Bulky, tender uterus

23
Q

Diagnosis adenomyosis (4)

A

TV us:

  • asymmetrical myometrial thickening
  • increased vascularity in lesions
  • hyperechoic islands (light)
  • specific functional zone irregularities/ disruptions
24
Q

Treatment adenomyosis (7)

A

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
25
Q

Investigations for suspected coagulopathy causing AUB?

A
  • FBC
  • pt
  • bleeding time
  • Vwf
26
Q

Name examples of primary endometrial disorders as cause of AUB

A

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

27
Q

Name examples of iatrogenic cause of AUB (4)

A

Pharmacological

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

Intrauterine systems

28
Q

Name examples of not otherwise classified cause of AUB

A

Arteriovenous malformations

29
Q

Investigations for post menopausal AUB? (2)

A
  • All need endometrial sampling ( hysteroscopy gold standard, but pipelle will suffice)
    -TV us: endometrial thickness > 5 mm is abnormal in menopause
30
Q

Management acute abnormal bleeding?

A
  • 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
31
Q

Dose tranexamic acid (cyclocapron) for acute bleeding?

A

iv 1g 8 hourly
(Antifibrinolytic)

32
Q

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

A

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)
33
Q

Cause of primary dysmenorrhea

A

Excessive prostaglandin synthesis during breakdown of premenstrual endometrium

Onset 12 months after menarche with peak prevalence late teens/early 20s

34
Q

Name 7 causes of secondary dysmenorrhea

A

Associated with:
- chronic pelvic infection
- fibroids
- endometriosis (most common)
- adenomyosis
- ectopic pregnancy
- Chronic pelvic pain
- interstitial cystitis

Usually older women

35
Q

Define primary amenorrhoea

A

No menstruation by 14 years of age and absent secondary sexual characteristics
Or
No menstruation by 16

36
Q

Define secondary amenorrhoea

A

Amenorrhoea for at least 3 months in women with previous normal menses
Or
6 months if menses abnormal

37
Q

Define secondary amenorrhoea

A

Amenorrhoea for at least 3 months in women with previous normal menses
Or
6 months if menses abnormal

38
Q

2 most common causes of primary amenorrhoea

A
  • chromosomal irregularities that lead to primary ovarian insufficiency eg turner syndrome
  • anatomic abnormalities eg mullerian agenesis
39
Q

4 most common causes of secondary amenorrhoea

A
  • PCOS !
  • hypothalamic amenorrhea (stress/eating disorders, rapid weight loss, gonadotrophin deficiency eg kallmann syndrome, infection eg TB RPR meningitis, TBI/brain tumours )
  • hyperprolactinaemia
  • Primary ovarian insufficiency (congenital gonadal dysgenesis, turner syndrome, acquired autoimmune destruction/ chemotherapy / radiation)

Gynaecology (40 decks)

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