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Obs & Gynae > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

1
Q

Describe the average menstrual cycle

A

28 +/- 7 days with average flow of 4 days, range of 2 to 7 days.
Average blood loss ~35ml
Maximum blood loss ~80ml (if exceeded results in anaemia)

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2
Q

What is the primary goal in the evaluation of a woman with abnormal uterine bleeding

A

To exclude pregnancy or cancer

And to establish the exact cause of the abnormal bleeding so that appropriate treatment can be offered

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3
Q

How can abnormal menstrual bleeding be identified?

A

Either by the length of cycle or the amount of blood loss.

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4
Q

How are menstrual cycle abnormalities determined? Which phase is affected?

A
  • They are mainly hormone determined.
  • Because in ovulatory cycles, the literal phase is virtually constant - 14 days, changes in cycle length occur because of changes in the follicular phase.
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5
Q

Investigations for HMB

A

Full blood count (FBC) (but serum ferritin should not be performed).
• Coagulation screen only if coagulation HMB since menarche or family history of coagulation defects.
• Hormone testing should not be performed.
• Pelvic ultrasound scan if history suggests structural or histological abnormality such as PCB, IMB, pain/pressure symptoms, or enlarged uterus or vaginal mass is palpable on pelvic examination.
• High vaginal and endocervical swabs.
• Endometrial Biopsy should be considered if risk factors such as age over 45, treatment failure or risk factors for endometrial pathology. Sensitivity of EB increases when performed in addition to using the cut-off of 4 mm endometrial thickness on TVUSS.
• Thyroid function tests should only be carried out when the history is suggestive of a thyroid disorder.

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6
Q

What are the patterns of abnormal menstrual bleeding?

A 
 Oligomenorrhea
 Polymenorrhea
 HMB/Menorrhagia/Hypermenorrhea
  Hypomenorrhea
 IMB/Metrorrhagia 
 Menometrorrhagia
  Amenorrhea
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7
Q

What is Oligomenorrhea?

A

This is when the menstrual cycle is longer than 35 days. This is so because the follicular phase is prolonged.

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8
Q

What are the causes of oligomenorrhea?

A
  1. Familial
  2. Emotional, usually due to stress
  3. Anovulation from any cause
     Hypothalamic
     Pituitary
     Ovarian
     Uterine
     Hyperthyroidism
  4. Drugs e.g. long-acting progestogens such as Depo-Provera
  5. Post-menarche - during the first few years after menarche about 20% of girls have oligomenorrhea
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9
Q

What is polymenorrhea?

A

This refers to cycle lengths that are shorter than 21 days. In effect, the woman has more menstrual in years than expected from the norm.

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10
Q

What are the causes of polymenorrhea?

A

 Imperfect follicular development

 Defective corpus luteum

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11
Q

What is hypomenorrhea?

A

This is diminished flow or shortening of the days of menstrual flow. It is unusually light menstrual flow, sometimes presenting as spotting only.

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12
Q

Causes of hypomenorrhea

A

 anovulation
 hymenal obstruction
 cervical stenosis
 Asherman’s syndrome

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13
Q

What is HMB?

A

This is heavy or prolonged menses occurring at regular intervals. With menses occurs >7 days, blood loss is usually >80ml. It is synonymous with hypermenorrhea.

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14
Q

Organic - Systemic causes of HMB

A

Systemic

 Disorders of coagulation (Von Willebrand)
 Leukemia
 Idiopathic
thrombocytopenia
 Hypersplenism
 Hypothyroidism
 Cirrhosis
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15
Q

Organic - Reproductive Tract causes of HMB

A 
 Fibroids
 Adenomyosis
 Endometrial polyps
 Endometrial
hyperplasia
 Cervical polyps
 PID
 Endometriosis 
 Cervical carcinoma
 IUCD in utero
 Tubercular endometritis

 Granuloma cell tumor of ovary
 Retroverted uterus (due to congestion)

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16
Q

Dysfunctional and Other causes of HMB

A

Drug Therapy - Warfarin
Ovulatory
Anovulatory

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17
Q

What is IMB?

A

This is bleeding occurring between menstrual periods.

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18
Q

Causes of IMB( Metrorrhagia)

A

 bleeding at ovulation
 endometrial polyps
 cervical polyps
 cervical cancer

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19
Q

What is menometrorrhagia?

A

This is heavy or prolonged menses occurring at irregular intervals. The causes are those found in menorrhagia and metrorrhagia.

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20
Q

What is amenorrhea?

A

This is the absence of menses during the reproductive years. It can be physiologic (pregnancy, postpartum) or pathologic. If it is pathologic, it is further classified as primary or secondary.

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21
Q

What is Breakthrough Bleeding?

A

This refers to abrupt, unpredictable bleeding that occurs following non- support of excessive endometrial growth (usually from unopposed oestrogen action).

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22
Q

What is withdrawal bleeding?

A

This refers to bleeding (sometimes predictable) following withdrawal of progesterone support for the oestrogen-primed endometrium. Normal menses is a form of withdrawal bleeding.

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23
Q

Why is age importance when approaching a woman with AUB?

A

Uterine bleeding is uncommon in pre-pubertal girls and post- menopausal women, whereas it is commonly found in adolescents, women in the reproductive age and peri-menopausal women.

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24
Q

What are the causes of AUB in children?

A 
 Vulvovaginitis
 Foreign body
 Trauma including sexual abuse
 Urethral mucosal prolapse
 Precocious puberty
 Genital tract neoplasm
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25
Q

What are the causes of AUB in adolescents?

A 
 Anovulation
 Coagulopathy
 Pregnancy-related causes
 Vaginal/Pelvic Infection
 Exogenous hormones/Drugs
 Coital injury
 Genital tract neoplasms
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26
Q

What are the causes of AUB in the reproductive years?

A 
 Pregnancy-related causes
 Anovulation
 Vaginal/pelvic Infection
 Adenomyosis
 Fibroid uterus
 Coital laceration
 Endocrine (PCOS, thyroid disorders)
 Exogenous hormones
 Coagulopathies
 Genital tract neoplasm
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27
Q

What are the causes of AUB in the perimenopausal period?

A 
 Anovulation
 Uterine fibroids
 Adenomyosis
 Cervical lesions
 Endometrial hyperplasia
 Endometrial polyps
 Coital laceration
 Genital tract neoplasm
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28
Q

Causes of AUB in menopausal women

A 
 Malignancies—cervical, endometrial, ovarian
 Endometrial hyperplasia and polyps
 Atrophic changes
 Coital lacerations
 Exogenous
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29
Q

What is the special classification for the causes of AUB in the non-gravid woman of reproductive age?

A

There are two main categories - PALM-COEI(N): 4 causes related to structural abnormalities and 4 causes that are not related to structural abnormalities.

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30
Q

What does PALM - COIEN stand for?

A 
PALM
Polyps
Adenomyosis
Leiomyomata
Malignacy & Hyperplasia

COIEN

Coagulopathy
Ovulatory dysfunction Endometrial (primary disorders) Iatrogenic
Not yet classified

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31
Q

Describe the approach to evaluating a patient with AUB

A

History
Physical examination
Pelvic examination in theatre ± anaesthesia ± biopsy (tissue sampling) Histologic evaluation
Laboratory evaluation
Imaging studies usually ultrasound, hysteroscopy

32
Q

Questions to ask in the history - HMB ( assoc. & dermographics)

A

Age of patient
Associated symptoms
👌Irregular bleeding, PCB, IMB - Endometrial/Cervical polyp/other cervical abnormality.
👌Excessive bleeding/bruising from other sites, hx of pph, excessive bleeding with dental extractions, excessive postop bleeding, family hx of bleeding problem - Coagulation disorder (in 20% of pts with unexplained HMB)
👌Unusual vaginal discharge- PID
👌Urinary symptoms, abdominal mass/fullness - Pressure from fibroid
👌Weight change, skin changes, fatigue - Thyroid disease

33
Q

Questions to ask in Gynae hx - AUB

A

Duration of bleed
Length of full cycle
Day 1 of LMP
Pattern of bleed (regular/irregular) - heavy anovulatory bleeds assoc. with PCOS, early puberty, perimenopause.
Amount of blood loss ( no of pad changes, does pad get soaked, does she soil herself)
Did HMB start @ menarche (less likely assoc. with pathology)
Previous pelvic infection, gynae procedures, galactorrhea

34
Q

Signs to look for O/E

A

🌟Stigmata of systemic disease esp. endocrine disorders
🌟Signs of anemia (also with hx)
🌟Pelvic and abdominal organ enlargement
🌟Bimanual pelvic exam -uterine and adnexal enlargement &tenderness.
🌟Pelvic exam - speculum exam to locate source of bleeding, look for signs of infection, trauma, polyps & lesions on cervix, palpate pelvic masses, visualize cervix for polyps and carcinoma, swabs for pelvic infection, cervical smear,

35
Q

Investigations for AUB -1

A

 Should be guided by the history and physical examination
 For a female in the reproductive age, urine pregnancy test is done to exclude pregnancy
 For a woman in the peri-menopausal period, cervical and endometrial sampling to exclude
malignant or pre-malignant change is warranted
 Full blood count is necessary to assess for anaemia
 Other tests that may be done if history/examination indicate: PAP smear, biopsy of
suspicious lesions, cervical cultures, thyroid function tests, LFTs, RFTs, prolactin, coagulation
profile, FSH, LH and androgens

36
Q

Investigations for AUB 2

A

 Endometrial biopsy –important in the peri-menopausal period; hysteroscopically-directed
biopsy, if available, can also be done.
 Imaging: trans-abdominal or trans-vaginal ultrasound to define pelvic structures
 Hysteroscopy, if available
 Saline infusion sonography (SIS): useful in defining endometrial polyps
 CT-Scan if preliminary investigations show malignancy and extent of tumour invasion has to
be assessed

37
Q

Treatment for AUB 1(depends on cause)

A

 Pregnancy-related bleeding: EOU for incomplete or septic abortion and laparotomy (if it is ectopic pregnancy)
 Uterine fibroids: conservative treatment or surgical (myomectomy or hysterectomy)
 Polyps: polypectomy
 Infection (endometritis or cervicitis): antibiotics

38
Q

Treatment for AUB 2

A

 Endometrial hyperplasia: depends on whether it is with atypia or not. Without atypia,
progestin can be tried for a period and DD&C repeated. Endometrial ablation techniques can also be used. Hormonal IUD (Intra-uterine systems) can also be tried. When there is atypia, consider hysterectomy if she has completed her family.
 IUCD-associated bleeding → NSAIDs
 If anti-coagulants are the cause, dosages should be adjusted to obtain normal INR.

39
Q

Medical management of HMB 1( if no structural or histological abnormality)

A
  • Levonorgestrel intrauterine system (LNG-IUS, MirenaTM), provided long-term use of at least 12 months is expected. LNG-IUS, MirenaTM . It provides a highly effective alternative to surgical treatment for HMB. Not suitable for women wishing to conceive.
  • Tranexamic acid, an antifibrinolytic that reduces blood loss by 50% and is taken during menstruation, or mefenamic acid, which inhibits prostaglandin synthesis and reduces blood loss by 30%, or COCP, which will induce slightly lighter periods.
40
Q

Medical management for HMB 2

A
  • Norethisterone, taken 15 mg daily in a cyclical pattern from day 6 to day 26 of the menstrual cycle.
  • (GnRH) agonists: these drugs act on the pituitary to stop the production of oestrogen, which results in amenorrhoea. These are only used in the short term due to the resulting hypo-oestrogenic state that predisposes to osteoporosis. They may be used preoperatively to shrink fibroids or cause endometrial suppression to enhance visualization at hysteroscopy. In severe HMB they can allow the patient the opportunity to improve their haemoglobin by providing a respite from bleeding.
41
Q

Considerations when going for surgical management of HMB

A

🌟Restricted to women for whom medical treatments have failed or where there are associated symptoms such as pressure symptoms from fibroids or prolapse.
🌟Women contemplating surgical treatment for HMB must be certain that their family is complete. (For hysterectomy, endometrial ablation).

🌟The risks of a pregnancy after an ablation procedure theoretically include prematurity and morbidly adherent placenta

42
Q

Surgical management for HMB

A

🌟Endometrial ablation
🌟Umbilical artery embolization - For HMB with fibroids
🌟Myomectomy - HMB with large fibroids, pressure symptoms and wishes to conceive @ a realistic age
🌟Transcervical resection of submucosal fibroid, reduce HMB & for women with fertility wishes
🌟Hysterectomy - for women who haven’t responded to treatment above. It may be a first-line treatment in women who have HMB associated with large fibroids with pressure symptoms, or who have a smaller uterus and associated uterine prolapse.

43
Q

Endometrial ablation

A

Ablation is suitable for women with a uterus no bigger than 10 weeks’ size and with fibroids less than 3 cm.
Prevents regeneration of endothelium (if done to sufficient depth).

44
Q

Techniques of endometrial ablation

A

Newer , 2nd generation
🌟Impedance controlled endometrial ablation (NovosureTM).
🌟Thermal uterine balloon therapy.
🌟Microwave ablation (MicrosulisTM)

Traditional

transcervical resection of the endometrium with electrical diathermy or rollerball ablation

45
Q

Notable things in treatment of acute AUB

A

They require admission, stabilization, examination to exclude cervical abnormalities and pelvic masses, medication to arrest bleeding and correct anaemia, investigation and discharge with a long-term plan to avoid further admissions.

46
Q

Management of acute HMB

A
  • Admit.
  • Pelvic examination.
  • FBC, coagulopathy screen - bedside clotting/ clotting profile, biochemistry.
  • Intravenous access and resuscitation or transfusion as required.
  • Tranexamic acid oral or IV.
  • TVUSS.
  • High-dose progestogens to arrest bleeding.
  • Consider suppression with GnRH or ulipristol acetate in the medium term.
  • Longer-term plan when a diagnosis has been made.
47
Q

When is the diagnosis of Dysfunctional uterine bleeding/bleeding of endometrial origin made?

A

When there has been an exclusion of pathological causes of abnormal bleeding

48
Q

When does DUB occur and how is it classified?

A

🌟Occurs mostly at the extremes of the reproductive age (20% of adolescents and 40% of women over 40 years).

🌟DUB is classified into ovulatory and anovulatory types

49
Q

What causes ovulatory DUB?

A

A persistent corpus luteum
Or
A short luteal phase.

50
Q

What causes anovulatory DUB?

A

It is caused by a dysfunction in the HPO axis resulting in a continued estrogenic stimulation of the endometrium. The latter outgrows its blood supply and is then shed in an irregular manner (break-through bleeding).

51
Q

How is anovulatory DUB managed?

A

Management is re-assurance and improving folliculogenesis (and thus regulating ovulation) with ovulating induction agents.

52
Q

What is Post Coital Bleeding?

A

This is bleeding associated with sexual intercourse. It may occur during or after the act. It may be a form of contact bleeding.

53
Q

Causes of Post Coital Bleeding?

A 
 Cervical eversion
 Cervical polyps
 Cervicitis
 Vaginal infections, eg trichomoniasis
 Atrophic vaginitis
 Coital laceration
 Cervical cancer
54
Q

Notes on coital laceration/injury

A

This can follow either consensual or forced sex. Injuries span a continuum of severity ranging from minor abrasions to major vaginal lacerations.

55
Q

Predisposing factors to coital laceration?

A

 virginity
 disproportion between the penis and vagina as in an adult male and a pre-pubertal girl
 prolonged sexual inactivity
 atrophic vagina in postmenopausal women
 acquired gynaetresia

56
Q

Immediate contributing factors to Coital laceration

A

 absence of adequate foreplay
 alcohol and drug use
 rough and violent thrusting of the penis during intercourse
 coital positions that promote deep penetration, such as the dorsal decubitus with hyperflexion
of the thighs, sitting/squatting positions.

57
Q

How is diagnosis of coital laceration made?

A

🤩From the history, although in most cases there is an initial attempt to deny this.
🌟Examination in theatre will often reveal the laceration which may be actively bleeding.

58
Q

Treatment for coital laceration

A

🌟Suturing of lacerations under general anaesthesia.

🌟Blood should be transfused if blood loss is significant and has resulted in anaemia.

59
Q

What should be done in the scenario where the injury resulted from forced sexual intercourse by an unknown male?

A

🌟Evaluation for Hepatitis B & C, gonorrhea, chlamydia and HIV should be done and appropriate prophylaxis given.
🌟Where partner abuse is suspected, it should be appropriately evaluated and addressed.

60
Q

What is post menopausal bleeding?

A

Vaginal bleeding occurring 12 months after cessation of menses (following ovarian follicular depletion).
Or
It is any vaginal bleeding that occurs during the menopause.

61
Q

Note about PMB

A

It is more likely to be caused by pathologic disease and must always be investigated.

62
Q

What are the causes of PMB?

A

🌟Exogenous hormones (HRT) - excluded with careful history
🌟Vulvar lesions - eg dystrophies and tumors must be excluded
🌟Atrophic vaginitis - commonest cause, may be precipitated by trauma (coital/non-coital)
🌟Endometrial atrophy or hyperplasia 🌟Tumors of the genital tract - Ca. vulva/vagina, cervix, endometrium and ovary.

63
Q

Diagnosis of PMB

A

 Examination in theatre, preferably under anaesthesia is required to establish the source of bleeding
 Biopsies must be taken from obvious growths and suspicious areas—vaginal, cervical and endometrium
 Hysteroscopy, if available, should be performed to assist in diagnosis
 Pelvic ultrasound—to help diagnose ovarian tumours and endometrial growth

64
Q

PMB Treatment

A

🌟Aimed at cause

🌟Atrophic vaginitis is managed with topical estrogens.

65
Q

What is Pre-menstrual syndrome?

A

It is the cyclical presence of somatic, psychological and emotional symptoms that worsen as menses approach and are ameliorated by the onset of the menstrual flow.

66
Q

Epidemiology of PMS

A
  • Nearly all women with regular cycles do experience some form of symptomatology in the premenstrual phase but 5% of them are debilitating.
  • More than 150 symptoms have been linked to PMS. Common symptoms include bloating, mastalgia/mastodynia, cyclic weight gain, abdominal cramps, fatigue, headache, depression and irritability.
67
Q

Criteria for PMS

A

 Cyclic and occurs in the 2nd half of the cycle
 Symptoms increase in severity as cycle progresses
 Symptoms are relieved with onset of menses and absent by day 3 of flow
 There must be post-menstrual pain-free period of at least 7 days

68
Q

How is PMS treated?

A

This depends on the severity of symptoms.
 Re-assurance
 Changes in eating habits—limiting use of caffeine, alcohol and chocolate; decreasing sodium
intake
 Stress management and aerobic exercises
 Drugs—NSAIDs, calcium carbonate, vitamins, spironolactone (for cyclic edema) and anxiolytics

69
Q

What is dysmenorrhea and what are the types?

A

🌟This is menstruation associated with pain such as to prevent normal activity and warrant medication.

🌟There are 2 main types: Primary (no organic cause) and Secondary (pathologic cause present).

70
Q

Pathogenesis of 1* Dysmenorrhea

A

Primary dysmenorrhea has been associated with ovulatory cycles. The mechanism has been attributed to prostaglandin activity as well as leukotrienes and vasopressin. Psychologic factors such as attitudes passed from mother to child and emotional anxiety are believed to be co-factors.

71
Q

Clinical Findings in 1* Dysmenorrhea

A

 The pain typically occurs a day to onset of menses or at the onset of flow.
 Nausea and vomiting may occur.
 There is generalized lower abdominal tenderness.

72
Q

How is 1* Dysmenorrhea treated?

A
  1. NSAIDS or other pain-killers
  2. Ovulation may be stopped by giving drugs such as the Combined Pill in intractable cases
  3. Psychological counselling
73
Q

Causes of Secondary Dysmenorrhea

A 
Uterine myomas
Endometriosis 
adenomyosis 
pelvic adhesions
Cervical stenosis and haematometra (rarely).
74
Q

What is 1* Dysmenorrhea + evidence?

A

🌟Painful periods since onset of menarche and is unlikely to be associated with pathology.

🌟There is some evidence to support the assertion that primary dysmenorrhoea improves after childbirth, and it also appears to decline with increasing age.

75
Q

What is 2* Dysmenorrhea?

A

Painful periods that have developed over time and usually have a secondary cause.

76
Q

General approach to treatment of Dysmenorrhea

A

🌟For some patients reassurance that the pain may be normal for her will help.
🌟For others the ability to alter the menstrual cycle to avoid having a period during key events will be helpful.

77
Q

History - Severity of pain in Dysmenorrhea

A

Do you need to take painkillers for this pain? Which tablets help?
• Have you needed to take any time off work/school due to the pain?

Obs & Gynae (6 decks)

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