Abnormal Uterine Bleeding Flashcards
What is the normal blood loss during menses
5-80 mL
Discuss your Approach to Abnormal uterine bleeding
Excluding bleeding from
1. Vulva (trauma, lesions, tumour)
2. Vagina (infection, laceration etc)
3.. Cervix (cancer)
4. Tubes
5. Ovaries
Discuss the management of heavy menstrual bleeding
Acute:
Bloodloss
-Large bore IV line and normal saline
-Crossmatch
Medical
-Conjugate equine oestrogen IV for 1 day
-COC 1 tab for 7days
-POP 1 tablets for 7days
-Tranexamic acid 1g IV
Surgical
-uterine artery embolisation
Chronic
-come for majority of 6months
-medical: COCs, Progesterone injections
-fine underlying cause
Outline the classification of abnormal uterine bleeding (9)
PALM COEIN
Structural:
Polyps
Adenomyosis
Leiomyomata
Malignancy and hyperplasia
Non structural:
Coagulopathy
Ovulatory dysfunction
Endometrial and endometriosis
Iatrogenic
Not classified yet
Sescribe endometrial polyps
Hyperplastic outgrowths of endometrial glands
Common 10-24% of hysterectomies due to polyps
Asymptomatic or causebAUB
What investigations do you do for endometrial polyps
US
Diagnostic hysteroscopy
Management of endometrial polyps
Conservative unless :
Symptomatic
Multiple polyps
Postmenopausal
Prolapsed through cervix
Infertile patient
Descuss Adenomyosis
Endometrial glands grow into myometrium causing hypertrophy of myometrium and a globular uterus
20-35 % we,en normally multiaparous
List the symptoms of Adenomyosis (3)
HMB
Dysmenorrhea
Chronic pelvic pain
What investigations would you do for Adenomyosis suspicion
US
MRI for difficult cases
Discuss your management for Adenomyosis
Completed family:
-hysterectomy
-uterine artery embolisation
Desire fertility
-analgesia
-coc, progesterone injectables, mirena
What are fibroids
Tumours of the myometrium (20-40% are women over the age of 35) so it’s common in older women kahle kahle
Ass with increase oestrogen exposure
-obesity
-nilliparous
-persistent anovulation
Outline 3 risk factors of fibroids
Obesity
Nulliparous
PCOS/ persistent anovulation
Prolonged oestrogen exposure
List the types of fibroids
Submucosal
Intramural
Subserosal
List the symptoms of fibroids (5)
1.Abdominal swelling / fullness
2.Urinary retention or frequency
3.Leg oedema due to pressure in vessels
4.Heavy menstrual bleeding (most common), May be ass/w dysmenorrhea
5. Infertility
6. Miscarrriage/ preterm labour
What are the causes of pain in fibroids/leiomyomas (5)
- Pressure on surrounding organs
- Subserosal fibroids can be torted and cause acute pain
- Malignant transformation
- Submucosal pedunculated prolapses out the cervix
- Red degeneration which is when during pregnancy, the gravity uterus compresses the venous outflow of blood which causes blood vessels to burst and it becomes red due to the blood.
Discuss management of fibroids
Conservative
-if small and asymptomatic
-regular reassessment
Medical:
GnRH agonists; used to shrink fibroids before surgery
Trial of mirena to treat AUB if surgery not desired
Surgery:
Myomectomy to preserve fertility (<17weeks uterus, small number fibroids, Subserosal&intramural)
Hysterectomy
Uterine artery embolisation
What is the criteria for diagnosis g coagulopathy/ coagulation dysfunction in a woman with AUB
✔️Heavy menstrual bleeding since menarche
One of the following:
✔️PPH
✔️Bleeding during or after surgery
✔️Bleeding due to dental procedures
Two or more of the following:
✔️Bruising 1-2 times per month
✔️Epistaxis 1-2 times per month
✔️Frequent gum bleeds
✔️Family history of coagulopathy
What are the causes of coagulopathy that can lead to AUB (4)
Von Wilebrand disease (common)
Thrombocytopenia
Renal/hepatic failure
Leukaemia
List the causes of ovulatory dysfunction
Perimenopause
PCOS
Stresss
Overweight/Obesity
Hyperprolectilemia
Hypothyroidism
Medication affecting prolactin/dopamine levels
Which two hormones in the bodyinhibit GnRH and therefore lead to ovulatory dysfunction
Cortisol
Prolactin
List some of the risk factors for PCOS (3)
Genetic predisposition
Obesity
Insulin resistance
How would you make the diagnosis of PCOS
- Anovulation or oligoovulation
- Increase in androgens clinically or biochemically so features like acne, hirsutism and male pattern balding
- Poly cystic ovaries on US
≥ 12 follicles of 8mm or more
OR
Ovarian volume of 10cm2 or more
How would you manage a patient with PCOS
Metabolic syndrome or Insulin resistance/obesity- weight loss, lifestyle, metformin, statin, HPT
Hyper androgens- COCs, POP, Mirena
Menstrual dysfunction-COCs, if fertility required letrozole for ovulatory induction,
Refer for fertility
What is the main complication of COC
DVTs esp in obese
Describe endometriosis
Tissue containing endometrial glands, storm and haemosiderin outside the uterine lining
-ovary
-Peritoneum
-bowel
-lower genital tract (cervix, vagina, vulva, perineum)
-urinary tract
So you get heavy menstrual bleeding but normal ovulation and regular cycles
Outline the symptoms of endometriosis (4)
-Pain (dysmenorrhea, dyspareunia, pelvic pain)
-Menstrual dysfunction (heavy bleeding, spotting, frequent cycles)
-Infertility
-Urinary and bowel symptoms (haematturia, dysuria, rectal bleeding, diarrhoea, constipation, painful defeacation
What investigations would you do to diagnose endometriosis
-US useful in ovarian endometriomas
-Laparoscopy is the gold standard
-Presumptive dx based on clinical features
Discuss the management of endometriosis
-Medical
NSAIDs- especially when fertility is desired
COCs
Progesterone only pill/injection, or mirena
GnRH analogues
Danazol
-Surgical
BO
Bowel resection
List some of the common causes of Iatrogenic causes of AUB
Hormonal contraception
Copper IUD
Anticoagulants
Dopamine anytagonists: sedatives,antipsychotics, Metochlopromide
What is a hysteroscopy
Hysteroscope is a procedure that allows a surgeon to look inside a uterusused for treating and diagnosing causes of abnormal uterine bleeding eg polyps, fibroids and adhesions (which you can remove during the operative hysteroscopy)
What is an HSG test
Hysterosalpingography is an X-ray dye used to check whether Fallopian tubes are blocked. Blocked Fallopian tubes =difficulty falling pregnant.
What are the main indications for hysteroscope (diagnostic and operative) (4*2)
Abnormal uterine bleeding
Heavy menstrual
Irregular spotting between periods
Bleeding after menopause
Cause of Infertility
Locating an IUD and removing it (Operative)
Removing polyps, fibroids and adhesions (operative)
Inserting IU device (operative)
Uterine biopsy (operative)
What are the three medical conditions that can be corrected by hysteroscopy
Polyps
Fibroids
Adhesions - Ashermans syndrome
Septum’s
What are the contraindications for a hysteroscopy
Pregnant
Pelvic inflammation
List some of the complications of a hysterectomy (6)
1.Infection
2.Heavy bleeding
3.Intrauterine scarring
4.Injury to cervix, uterus, bowel or bladder
5.Reaction to substance used to expand your uterus
6.Reaction to anaesthesia
After how long can you have sex after a hysterectomy
2 weeks
List some of the iatrogenic causes of abnormal uterine bleeding
Hormonal methods of contraception
Copper IUD
Anticoagulants
Dopamine antagonists :
-Dopamine
-Antipsychotics
-Metochlopromide
Differentiate between acute and chronic uterine bleeding
Acute uterine bleeding is an episode of bleeding in a woman of reproductive age who is not pregnant , the bleeding is sufficient to require immediate intervention to prevent further blood loss in the opinion of health care provider
Chronic uterine bleeding is breeding abnormal in frequency, duration and volume and has been present for the majority of 6 months.
List the causes of PMB
- Atrophy
- Genital malignancies: Cervical, Endometrial, Ovarian, Vulval, Vaginal cancers
- Polyps
- Endometrial hyperplasia
- Iatrogenic :HRT
- Trauma
- Infections eg cervicitis
How do you manage the ff causes of PMB:
a)Atrophy
b) cervical & uterine cancer
c) hyperplasia
a) Atrophy- topical hormonal cream, HRT, lubricants for sex
b) Cervical & uterine ca- refer to gynae oncology
c) hyperplasia - Progestin tx either orally or IM depot or Mirena. Hysterectomy in complex hyperplasia
Which cancer is most common in post menopausal women
Cervical cancer
List the causes of irregular menstruation
(Think ovulatory dysfunction )
PCOS
Premenopause
Post menopause
Hyperprolactineamia
Hypothyroidism
Poor nutrition
Systemic disease eg renal, liver
List the causes of intermenstrual bleeding
Polyps (cervical&endometrial)
Cervicitis
Cervical cancer
C/S scar
Cervical ectropion
