ABNORMAL UTERINE BLEEDING

Question 1

General considerations of Abnormal Uterine Bleeding

Answer 1

(1) Normal menstrual bleeding lasts an average of 5 days (range 2-7 days)
(2) Mean blood loss per cycle is 40ml
(3) Menorrhagia- blood loss over 80ml
(4) Metrorrhagia- bleeding between periods
(5) Polymenorrhea- bleeding that occurs more often than every 21 days
(6) Oligomenorrhea- bleeding that occurs less frequently than every 35 days
(7) Abnormal uterine bleeding was previously called or referred to as
“dysfunctional uterine bleeding”
(8) Classified by the descriptive terms denoting the bleeding pattern:
(a) Heavy
(b) Light
(c) Menstrual
(d) Intermenstrual
(9) Etiologies (PALM-COEIN)
(a) Polyp
(b) Adenomyosis
(c) Leiomyoma
(d) Malignancy (and hyperplasia)
(e) Coagulopathy
(f) Ovulatory dysfunction
(g) Endometrial
(h) Iatrogenic
(i) Not yet classified
(10) In adolescents, usually the
result of anovulation (not yet ovulating)
(a) Due to immature hypothalamic-pituitary ovarian axis
(b) Considered normal
(11) Once regular menses is established ovulatory dysfunction (AUB-O) is the most common cause
(12) AUB in women 19-39 is often the result of
(a) Pregnancy
(b) Structural lesions
(c) Anovulatory cycles
(d) Use of hormonal contraceptives
(e) Endometrial hyperplasia

Question 2

Pertinent anatomy of Abnormal Uterine Bleeding

Answer 2

(1) Uterus
(a) Endometrium
(2) Cervix

Question 3

Signs and symptoms of Abnormal Uterine Bleeding

Answer 3

(1) May have painful menstrual cramping
(2) May be asymptomatic except for spotting
(3) Depending on the amount of blood, you could have signs of anemia
(a) Fatigue
(b) Pallor
(c) Lightheadedness or dizziness with exertion
(d) Pica
(e) Weakness
(f) HA

Question 4

The diagnosis of Abnormal Uterine Bleeding depends on

Answer 4

(1) A history of the duration and amount of flow, associated pain, and relationship to the last menstrual period (LMP)
(a) presence of blood clots or the degree of inconvenience caused by the
bleeding serving as useful indicators
(2) A history of pertinent illnesses, such as recent systemic infections, other
significant physical or emotional stressors such as thyroid disease or weight change
(3) A history of medications
(a) Warfarin
(b) Heparin
(c) Exogenous hormones
(4) A history of coagulation disorders in the patient or family members
(5) Complete physical exam to evaluate for
(a) excessive weight and of polycystic ovary syndrome (PCOS)
(b) thyroid disease
(c) insulin resistance
(d) bleeding disorder
(6) Pelvic examination
(a) rule out vulvar, vaginal, and cervical lesions
(b) pregnancy
(c) uterine myomas
(d) adnexal masses
(e) adenomyosis
(f) infection

Question 5

Laboratory findings of Abnormal Uterine Bleeding

Answer 5

(1) Complete blood count
(2) Pregnancy test (HCG)
(3) Thyroid function tests
(4) Coagulation studies
(a) For those with heavy menstrual bleeding
(5) Gonorrhea and chlamydia testing
(a) As indicated
(6) Pap Smear
(7) Endometrial sampling

Question 6

Imaging of Abnormal Uterine Bleeding

Answer 6

(1) Transvaginal ultrasound
(a) Intrauterine or ectopic pregnancy
(b) Adnexal or uterine masses
(c) Endometrial thickness
(2) Sonohysterography or hysteroscopy

Question 7

Treatment of Abnormal Uterine Bleeding

Answer 7

(1) All patients with abnormal uterine bleeding should be referred to OB-GYN
(2) For premenopausal patients treatment depends on etiology of the AUB
(3) AUB secondary to certain causes may require definitive treatment
(a) Submucosal myomas
(b) Infection
(c) Early abortions
(d) Thrombophilias
(e) Pelvic neoplasm
(4) AUB-O
(a) Treated hormonally with progestin
(b) NSAIDS at normal doses can reduce the amount of blood loss

Question 8

Complications of Abnormal Uterine Bleeding

Answer 8

(1) Depends on the underlying cause but can include:
(a) Anemia
(b) Infertility

Question 9

Follow up of Abnormal Uterine Bleeding

Answer 9

As dictated by OB-GYN

Question 10

Special consideration of Abnormal Uterine Bleeding

Answer 10

(1) Postmenopausal bleeding
(a) Vaginal bleeding that occurs 6 months or more following cessation of menstrual
cycle
(b) Postmenopausal bleeding of any amount should be evaluated by OB/GYN
1) Must have a high suspicion for cancer
(c) Transvaginal ultrasound measurement of the endometrium is an important
tool in evaluating the etiology of bleeding
(d) Most common
1) Endometrial atrophy
2) Endometrial proliferation or hypertrophy
3) Endometrial or cervical cancer