Abnormal Uterine Bleeding

Question 1

What is menstruation?

Answer 1

-Phase of ovulatory cycle
-Failure of embryo, oestrogen fails, progesterone withdrawals as trigger for menstruation (upper 2/3 endometrium shed in inflammatory reaction)
-Brain, ovary, uterus axis

Question 2

Describe typical menstruation

Answer 2

-Duration: 4.5-8 days
-Frequency: 24-38 day cycle
-Regularity: less than 9 days variation
-Volume: 5-80ml (manageable)

Question 3

Describe atypical menstruation

Answer 3

-Duration: prolonged (>8 days)
-Frequency: too frequent (<every 24 days)/ too infrequent (>every 38 days)
-Regularity: irregular (>10 variation)
-Volume: heavy (unmanageable: 90-450ml)

Question 4

What menstrual blood loss is acceptable?

Answer 4

Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms

Question 5

How common are menstrual bleeding problems?

Answer 5

1 in 3
=Most likely underestimated

Question 6

Medical treatments for abnormal uterine bleeding

Answer 6

-Non hormonal
=Tranexamic acid
=NSAIDs (mefenamic acid)
-Hormonal
=COCP
=Progestogens: IUS, Cyclical progestogens, POP, Injectable progestogens, Implants
=GnRH analogues
=Selective Progesterone Receptor Modulators

Question 7

Surgical management of AUB

Answer 7

-Endometrial ablation
-Hysterectomy +/- bilateral salpingo-oophorectomy

=EFFECTIVE CONTRACEPTION

Question 8

Personalised medicine

Answer 8

-User requirements, safety, preference
-Maximise effectiveness and minimise side effects

Question 9

FIGO classification of menstrual disorders

Answer 9

-Polyp
-Adenomyosis
-Leiomyoma (fibroids)
-Malignancy and hyperplasia

-Coagulopathy
-Ovulatory dysfunction
-Endometrial
-Iatrogenic
-Not otherwise classified

Question 10

Structural causes of AUM (PALM)

Answer 10

-Polyp= intermenstrual bleeding, benign, chlamydia in young women vs malignancy
-Adenomyosis= heavy, painful bleeding (lining embedded in muscle)
-Leiomyoma= HMB (Submucosal- like a tap)
-Malignancy (endometrial/ cervical/ vaginal)= IMB, PCB (post coital in cervical), PMB (post menopausal in endometrial)

Question 11

Specific treatments for Leiomyoma

Answer 11

-Uterine artery embolisation
-Myomectomy

Question 12

Non-structural causes of AUB (COEIN)

Answer 12

-Coagulopathy= AUB since menarche (von Willebrand)
-Ovulatory dysfunction= irregular/ infrequent menstruation
-Endometrial= regular HMB
-Iatrogenic= drug history (warfarin/ apixaban)
-Not otherwise classified= deep dyspareunia/ dyschezia
=Isthmocoele, endometriosis, AV malformation

Question 13

Definition of post menopausal bleeding

Answer 13

Vaginal bleeding occurring after 12 months of amenorrhoea, in a woman of age when menopause can be expected.

Should be treated as malignant until proven otherwise. Patients with postmenopausal bleeding (PMB) have a10–15% chance of having endometrial carcinoma

Question 14

Aetiology of PMB

Answer 14

-Vaginal Atrophy @ 90%
-Endometrial or cervical polyps
-On occasions Trauma can occur with pessaries used to treat vaginal prolapse.
-Use of Unopposed HRT/HRT
-Tamoxifen
-Endometrial hyperplasia especially atypical hyperplasia- histological diagnosis.
-Endometrial carcinoma

Question 15

Rare causes of PMB

Answer 15

-Ovarian carcinoma
-Cervical carcinoma
-Vaginal carcinoma
-Vulvar carcinoma
-Uterine sarcoma

Question 16

History taking for PMB

Answer 16

-LMP in women over 45 years of age
-Parity
-Smear history- Negative/abnormal smears
-Sexual history, STI, contraception, age of menarche, menopause, HRT, cycle, PV discharge, fertility
-PMB episodes , how much (small amounts could be due to atrophy): sanitary pad needed?
-Related to bowels/ sexual intercourse/ pain
-Breakthrough bleeding on HRT
-Type of HRT Sequential or continuous combined
-Tamoxifen following breast Cancer. (breast/colon/endometrial)

Rare:
-Offensive vaginal discharge- Could be associated with cervical cancer
-Any new onset of GI symptoms- ovarian cancer.
-Growth on vulva
-Co morbidities
-BMI –more common in obese women due to increase in weak oestrogens in subcutaneous fat

Question 17

Examination in PMB

Answer 17

-Abdominal exam
=Large masses could suggest ovarian cancer as a rare cause of Post Menopausal bleeding

-Speculum exam= to check for atrophic vaginitis
=Any polyps on cervix
=Any sign of Cervical cancer/ growth on cervix- rare cause of PMB
=Hair distribution: extension towards umbilicus and onto inner thighs associated with hiruitism and disorders of androgen excess
=Clitoris: cliteromegaly implies virilisation
=Vulval and labial skin: rashes, warts, ulceration, excoriations, atrophy, lumps
=Perineum: scars (fine white lines)
=Gently part labia, inspect introitus for discharge, skin colour (pale with punctuate red areas suggests atrophic vaginitis) and swellings

-PV examination- adnexal masses, enlarged uterus
=Vaginal walls: atrophic vaginitis and discharge
=Cervix: shape of os, swelling, warts, ectopy
=High Vaginal Swab (HVS): vaginal fornice
=Endocervical Swabs: cervical canal (Chlamydia trachomatis, N gonorrhoeae)

Question 18

Investigations in PMB

Answer 18

-Transvaginal Ultrasound Scan
=Cut off threshold 4mm or less to exclude endometrial cancer
-Endometrial Biopsy (pipelle)
-Hysteroscopy

Question 19

What does TVS do for PMB?

Answer 19

-TVS can reliably assess thickness and can identify a group of women with PMB who have a thin endometrium (≤4 mm) and are therefore unlikely to have endometrial cancer
-Endometrial sampling is therefore not recommended below this cut-off value

Question 20

Describe hystreroscopy

Answer 20

Hysteroscopy is direct visualisation of the uterine cavity via a fine bore scope to identify pathology, take directed biopsies and carry out therapeutic procedures, such as polypectomy. Hysteroscopy is indicated for wome
= those with recurrent or prolonged bleeding
=where random endometrial sampling has been non diagnostic or inaccessible endometrial cavity
=Women on Tamoxifen irrespective of Endometrial thickness

Question 21

Overview of polyps

Answer 21

-Growths attached to inner wall of uterus that expand into uterus

-Irregular spotting and intermenstrual bleeding, often near menopause with hormone therapy

-Hysteroscopy
-Pelvic USS: endometrial thickening
-Sonohysterography= polyp

-Removal/ watchful waiting/ lab

Question 22

Overview of adenomyosis

Answer 22

-Endometrial tissue within myometrium

-Dysmenorrhoea, dyspareunia, sometimes bowel/ bladder change due to bulk effect, age 40-50, multiparous women towards end of reproductive years

-Diffusely large uterus (bimanual) and tender, boggy
-Pelvic/transvaginal USS (1): enlarged, globular or asymmetrical uterus
-MRI: areas of high signal in myometrium

-Tranexamic acid, GnRH agonists, uterine artery embolisation, hysterectomy (definitive)

Question 23

Overview of leiomyosis

Answer 23

-Benign smooth muscle tumours of uterus, oestrogen and progesterone dependent

-Asymptomatic, bulk-related symptoms (cramping pain during menstruation, urinary, bowel constipation, bloating), dyspareunia, back pain, abdominal discomfort and bloating, subfertility, polycythaemia, black women, later reproductive years, regress after menopause

-Transvaginal USS
-Examination= firm, enlarged, irregularly shaped non-tender uterus on examination/ central irregular abdominal mass
=IDA

-Asymptomatic= monitor
-IUS if no distortion of cavity and <3cm, mefenamic acid, tranexamic acid, COCP, oral progestogen, injectable progesterone
-GnRH agonist (reduce size, short term as menopausal symptoms)
-Surgical: myomectomy (abdominally, laparoscopically, hysteroscopically), hysteroscopic endometrial ablation, hysterectomy. Uterine artery embolization

Question 24

Types of fibroids/ layers

Answer 24

-Subserosal
=These develop near the outer serosal surface of the uterus and extend outside the uterus into the peritoneal cavity. They are commonly asymptomatic or minimally symptomatic even when relatively large. When they are sufficiently large they may cause symptoms due to pressure on adjacent structures.

-Intramural
=These develop within the myometrium without extending predominately into the uterine cavity or peritoneal cavity. They may cause heavy menstrual bleeding and dysmenorrhea by interfering with the constriction of blood vessels during menstruation.

-Submucosal
=These develop near the inner mucosal surface of the uterus and extend into the uterine cavity. Even relatively small submucosal fibroids may cause significant heavy menstrual bleeding, dysmenorrhea, or reduce fertility

Question 25

Risk factors for fibroids

Answer 25

-Increasing age — risk increases with age during reproductive years until the menopause.
-Early menarche — risk increased if menarche before age of 11 years.
-Nulliparity.
-Older age at first pregnancy — fibroids may enlarge during the first trimester of pregnancy, and tend to shrink post-partum.
-Comorbidities — obesity (weight gain and central distribution of body fat); diabetes; hypertension.
-Ethnicity — higher risk in black and Asian women compared with white women. In addition, fibroids are more likely to be symptomatic, occur at an earlier age, be larger, and multiple in these ethnic groups.
-Family history — risk is higher in women who have an affected first-degree relative.

Question 26

Overview of endometrial malignancy/ hyperplasia as menorrhagia cause

Answer 26

-older age (usually >50 years), bleeding between cycles, obesity, nulliparity, early menarche, unopposed oestrogen use, tamoxifen use, infertility, smoking, family history of endometrial cancer, personal or family history of hereditary non-polyposis colon cancer (HNPCC)

Question 27

Overview of coagulopathy

Answer 27

-von Willebrand’s disease
-personal/family history of bleeding disorder (e.g., von Willebrand disease [vWD]), easy bruising, bleeding gums, epistaxis, heavy menses from menarche onset, ecchymoses

-PT prolonged or normal, aPTT prolonged or normal, vWF antigen or function assay, factor 8 activity

Question 28

Overview of endometriosis

Answer 28

-Growth of endometrium-like tissue outside the uterus, hormone mediated and associated with menstruation= chronic inflammation and scar tissue formation

-Chronic pelvic pain, dysmenorrhoea, dyspareunia, cyclical bowel and urinary (blood and pain), infertility (1 in 10)

-Abdominal and pelvic exam= mass, reduced organ mobility and enlargement, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions
-Transvaginal USS
-Laparoscopic investigation

-NSAIDs, hormonal contraception, surgical excision or ablation, hysterectomy