Abnormal Uterine Bleeding Flashcards
typical blood loss vs heavy blood loss for period
Abnormal Volume: excessive blood loss that interferes with quality of life.
Typical blood loss is 30-40ml vaginal blood loss/cycle. Heavy is >80mL vaginal blood loss. 30% of people with bleeding <80mL think they have heavy bleeding.
Do you need to change your pad/tampon at night?
Do you change your tampon/pad every 1-2 hours?
Have you been told you are anemic?
What are the size of your clots?
*structural causes of AUB results in bleeding that is more likely to be ___/___, and non-structural causes are more likely to result in ___/ __ __- → PALMCOEIN
*structural causes of AUB results in bleeding that is more likely to be regular/cyclical, and non-structural causes are more likely to result in irregular/ non cyclical → PALMCOEIN
PALM-COEIN classification of AUB
Structural = PALM= polyp, adenomyosis, leimyoma, malignancy
non-structural = COEIN = coagulopathy, ovulatory dysfunction, endometrial, iatrogenic
Endometrium growths, occupying large portions of uterine growths
Bleeding after straining or activity. May bleed without reason and cause a prolonged period
polyps
Endometrial glands in the stroma are present in the uterine musculature, causing hypertrophy and globular enlargement of the uterus.
Common cause of heavy and long periods/dysmenorrhea.
adenomyosis
what ethnicity is more affected by meiomyomas aka fibroids?
african descent
Fibroids→ very common. Treatment is not necessary unless there are symptoms.
More common in AFrican women.
Benign growths of the muscle of the uterus. Many do not have symptoms; pressure symptoms based on mass effects, pressure on bladder/rectum/during intercourse.
Can bleed because of increased SA of endometrial cavity. Can also affect the contractility ability of the uterus, making it harder to stop bleeding. Very rarely cause pain unless they degenerate and grow so big that they grow out their blood supply which causes ischemia and thus pain.
leiomyoma
Should suspect ___ for long term dysmenorrhea
malignancy/hyperplasia
Any women over 40 with a change in bleeding patterns should have a work up.
Risk factors (FLIP): Age, nulliparity, HNPCC (hereditary nonpolyposis colon cancer), obesity, PCOS, diabetes, tamoxifen
why may ovulatory dysfunction cause abnormal uterine bleeding?
Estrogen and progesterone may not be made cyclically, which is why they are not ovulating. If there is anovulation, there is a concern for unopposed estrogen (no progesterone to cause a period)
There are a bunch of little follicles that are producing estrogen, but none of them are being selected. There is no dominant follicle to become the corpus luteum and produce progesterone.
Causes continuous growth of the endometrial lining and uterus gets bulky.
Unopposed estrogen can cause cancer.
An immature HPO axis can be seen frequently in teens; stress, weight loss, etc all can contribute.
Must ask about endocrine causes (prolactinomas that may prevent ovulation, thyroid, perimenopause)
note– other causes of abnormal uterine bleeding
- Determine the tests to investigate AUB and the rationale for each test
CBC, Ferritin,
consider : bHCG, TSH, prolactin, FSH/E2, androgens (PCOS), coagulation testing, swabs (STI, cervicitis, esp if they have post coital spotting or intermenstrual bleeding)
FSH/E2 not helpful unless they have hot flashes and you think they may be having premature menopause
Imaging:
Transvaginal US: go for pelvic organs, but if the radiologist suspects a structural abnormality, we can do a saline infusion sonohysterography to distend the uterus, allowing for better visualization.
MRI; not as good
CT; not as good
Endometrial Sampling: to rule out hyperplasia or cancer of the endometrium
- Indications: age >40, failure of medical treatment, significant intermenstrual bleeding, infrequent menses, risk factors for endometrial cancer.
Endometrial Biopsy
- Pros: minimally invasive, generally well tolerated, detects 90% endometrial cancers
- Cons: blind test, might miss a focal lesion
Dilation and Curettage: metal rod to dilate cervix, then use curette to get a biopsy of the endometrium. Still a blind procedure (all by feel)
endometrial biopsy are a mainstay of testing for abnormal uterine bleeding and suspciion of endometrial disorders and cancers. what are the pros and cons?
Endometrial Biopsy
Pros: minimally invasive, generally well tolerated, detects 90% endometrial cancers
Cons: blind test, might miss a focal lesion
nonhormal management for AUB
NSAIDS: COX2 and COX1 expression in the uterus is higher, NSAIDS reduce prostaglandin levels wihch are elevated in women with excessive menstrual bleeding.
Tranexamic acis/cyklokapron
how do combined hormonal contraceptives help with the management of PCOS/anovulatory patient and bleeding
CHC will regulate an anovulatory patient (thus irregularr bleeding).
CHC will decrease flow. Estrogen in the CHC is less than estrogen produced normally. By stopping ovulation or decreasing flow, bleeding is reduced. Bleeding is only done when the CHC is removed at the end of the month
Progesterone only is not removed at the end of the month, and the goal is amenorrhea. You will not bleed at the end of the month.
how do GnRh agonists cause reversible menopause?
GnRH agonist injection: increases FSH and LH initially, but desensitization occurs to decrease FSH and LH over time, reducing estrogen production → causes reversible menopause.
hormonal management options for PCOS, ovulatory and anovulatory bleeding
CHC will regulate an anovulatory patient.
CHC will decrease flow. Estrogen in the CHC is less than estrogen produced normally. By stopping ovulation or decreasing flow, bleeding is reduced. Bleeding is only done when the CHC is removed at the end of the month
Progesterone only is not removed at the end of the month, and the goal is amenorrhea. You will not bleed at the end of the month.
GnRH agonist injection: increases FSH and LH initially, but desensitization occurs to decrease FSH and LH over time, reducing estrogen production → causes reversible menopause.
Selective progesterone receptor modulator (SPERM) → affects endometrium to decrease fibroid size. Off the market
Danazol: feedback to FSh and LH production to produce anti-estrogen effects and endometrial atrophy. Virilization can occur.
syurgical options for abnormal uterine bleeding
Depends on cause and patient factors. Need to consider fertility plans of patients. Structural causes or treatment failure/preference are most often the causes behind surgery
D and C→ mostly for dx, acute tx.
Myomectomy: submucosal fibroid resection.
Polypectomy
Endometrial ablation: heat to denature the endometrium.
Hysterectomy.
PCOS management
weight loss
combined hormonal contraception
progesterone only (no bleeding at all– progestin will maintian the uterine lining and it won’t shed)
mirena IUD
TXA or NSAIDS
KEy coagulopathies that can cause non-structural abnormal uterine bleeding
Von Willebrands: suspected in life long bleeding issues (lots of nosebleeds, dental appts etc). Should be ruled out in adolescent with crazy heavy periods
Immune-Mediated Thrombocytopenia: platelets under 20
Leukemia: thrombocytopenia prevents bleeding reduction
Liver failure: decrease in coagulation factors
Renal failure
rotterdam criteria for PCOS
What key medication can help shrink fibroids
GnRH agonists
