Abnormal Uterine Bleeding Flashcards
What is the normal range of menstrual cycle length?
21-35 days
What is the average length of menses?
3-5 days; normal variation 2-7 days
What is the average age of menarche in the U.S.?
12.4 years
In regards to the menstrual cycle physiology, when does the hypothalamus release gonadotropin releasing hormone (GnRH)?
Begins secreting several days before onset of menstraution in a pulsatile manner
What is polymenorrhagia?
< 21 days between cycles
What is oligomenorrhea?
> 35 days between cycles
What is dysmenorrhea?
Pain with menses
In primary amenorrhea, if normal secondary to sexual characteristics what are the common causes?
- Imperfect hymen
- Transverse vaginal septum
- Cervical or Mullerian agenesis: absence of vagina and/or uterus
If there is breast development but no pubic or axillary hair leading to primary amenorrhea, what is the likely cause?
Androgen insensitivity
In primary amenorrhea, if there is incomplete development of secondary sexual characteristics what are the likely etiologies?
- Hypothalamus or pituitary tumor
- Hypothyroidism
- Premature ovarian failure
- Hyperprolactinemia
Is physiological delay of puberty common in girls?
No
What is the most common cause of secondary amenorrhea?
Pregnancy
Any bleeding prior to menarche is abnormal, if bleeding is present what is there concern for?
Malignancy
Trauma
Sexual abuse
Urinary tract issues
What is the primary concern if there is any post-menopausal bleeding?
Malignancy until proven otherwise
What is the epidemiology of abnormal uterine bleeding?
- Common condition affecting 1:4 women
- Most common beginning and end of reproductive years
- More prevalent in obese or extremely low BMI
- 90% of cases are due to ovulatory dysfunction (causing anovulation)
Can uterine bleeding be an emergency?
Yes, extreme blood loss
What is the treatment of acute uterine bleeding?
Emergency measures: volume replacement with bleeding cessation
- stabilize hemodynamically (IV fluids, blood products)
- Hormonal control (estrogen replacement)
- Gynecology consult
What is the most common gynecological malignancy?
Endometrial cancer
What is the most common presenting symptom of endometrial cancer?
abnormal uterine bleeding
What are the risk factors for endometrial cancer?
- Obesity
- Nulliparity
- DM
- Infertility/unopposed estrogen/chronic anovulatory cycles
- > 35 years old
- Tamoxifen
What is the treatment for endometrial cancer?
Total hysterectomy and bilateral salpingo-oophorectomy
Why is it so important to obtain medication history and current treatment in abnormal uterine bleeding?
Medications can cause ovulatory problems
*medications that are dopamine based most commonly, soy or ginko supplements, SSRI’s, corticosteroids
Does a corpus luteum form during an anovulatory cycle?
No
What are causes of ovulatory AUB?
PCOS
Endometriosis
*excessive bleeding during regular menstrual cycles
What are the structural causes of abnormal uterine bleeding?
Polyp
Adenomysis
Leiomyoma
Malignancy and hyperplasia
When working up AUB in women of reproductive age all should receive what test?
Urine or blood pregnancy test
What are some potential causes of pregnancy related bleeding?
- Threatened abortion
- Incomplete abortion
- Missed abortion
- Ectopic pregnancy
- Placenta previa
- Trophoblastic disease
If all clinically indicated tests are normal in the work-up of abnormal uterine bleeding what should be the diagnosis?
Ovulatory dysfunction
What imaging modality can detect most sources in abnormal uterine bleeding?
TVUS
What is the most common pelvic tumor in women?
Uterine leiomyoma (Fibroids)
In working-up fibroids, what is the first-line of imaging?
TVUS
What is the most common presentation of uterine leiomyoma (fibroids)?
*Often asymptomatic
- Bleeding (m/c)
- Symptoms depend on number, size and location
What is the only definitive treatment for fibroids?
Hysterectomy
What are the medication treatments for fibroids?
Hormonal therapies (GnRH agonists, OCPs, IUD)
What is the most accurate imaging tool in diagnosing adenomyosis?
MRI
What is the treatment for adenomyosis?
- D&C, GnRH agonist
- Definitive treatment is hysterectomy
What are the signs and symptoms of endometriosis?
- Dysmenorrhea
- Dyspareunia
- Spotting
- Pelvic pain
What is the diagnostic testing for endometriosis?
- TVUS
- Laparoscopy and biopsy of lesions
What is the first-line treatment for endometriosis?
NSAIDs and OCP
What is dysfunctional uterine bleeding (DUB)?
Absence of organic disease or anatomic lesion
*diagnosis of exclusion
What is the most common cause of dysfunctional uterine bleeding?
Ovulation failure shortly after menarche or during perimenopause
What is the treatment for endometrial hyperplasia in postmenopausal women?
D&C with strong consideration for hysterectomy
Ovulatory dysfunction is the leading cause of AUB, so what is the treatment in pre-menopausal women?
*Need to correct hormones
Hormone therapy
- OCP, progestogen, IUD
What is premenstrual syndrome (PMS)?
Wide range of physical or emotional symptoms usually occuring 5-11 days before monthly menstrual cycle
