Abnormal uterine bleeding Flashcards
What is the differential diagnosis for AUB?
pregnancy (also pregnancy + mole/GTN)
Leiomyoma
Adenomyosis
Significant adhesive disease giving impression of large uterus
Adnexal mass
Uterine malignancy
What is the management of symptomatic leiomyomas?
eval: H&P, pelvic exam, labs (CBC, hcg, tumor markers if adnexal mass suggested), TVUS, possible CT/MRI, endometrial sampling if indicated (imaging shows intracavitary mass, do hysteroscopy w/ sampling)
- Hormonal menstrual regulation: OCPs, vaginal ring, transdermal patch, depo provera, IUD, GnRH antagonist + add-back for 2yrs
- oral TXA (anti-fibrinolytic): avoid if seizures, recent CVD.
- GnRH agonist (leuprolide/lupron): amenorrhea, 50% size reduction in 3mo, only 1yr use due to osteoporosis. IM monthly for 2-3 doses. short term use doesn’t require add-back.
- UAE (reduce pain/pressure sx and blood flow/myoma size. avoid if future fertility or postmenopausal)
- Myomectomy
- Hysterectomy
What are GnRH-receptor antagonists
Elagolix/E2/NE (BID) and relugolix/E2/NE-MyFembree (daily)
E2=estradiol. NE=norethindrone.
- formulated with low-dose steroidal add-back to limit hypoestrogenic side effects (hot flushes, HA, nausea, night sweats)
ADD-BACK: Oral conjugated estrogen 0.625 and norethindrone acetate 2.5mg daily
- used for fibroid-related AUB and endometriosis.
can use for 2yrs.
What is the counseling for uterine artery embolization?
embolic agent delivered through catheterization of both uterine arteries to cause leiomyoma devascularization and involution.
- Benefits: shorter hospital stay, avoid hyst (re-intervention rate 15%), reduce HMB, fibroid sx. decrease size, dysmenorrhea, bulk symptoms.
- Risks: complications, insufficient data on future fertility, can cause ovarian failure, because no histology cannot r/o malignancy (avoid in menopause).
Complications:
- unplanned hyst (2/2 uterine perforation w/ organ injury or uterine artery perforation/hemorrhage)
- rehospitalization (Bacteremia from arrteriotomy or myometritis)
- ovarian failure
- PE
- Fever 2/2 myoma degeneration or bacteremia from puncture site
- Bleeding/hematoma at arterial puncture site
- Myometrial necrosis
- Perforation of uterine artery w/ intraperitoneal bleeding or broad ligament hematoma
- Perforation of uterus by catheter w/ possible bowel injury.
Who is a candidate for supracervical hysterectomy?
- no prior cervical dysplasia
- no prior abnormal pap
- not if needing hyst for unknown cause of bleeding
- no prior gyn malignancy or EIN
- pt s/p counseling on potential for future cervical disease and need for cervical cytology screening, and no clear medical benefit to cervical preservation
need to cauterize endocervical canal to avoid cyclic bleeding (menstrual shedding of endocervical tissue in upper canal). If comes back w/ bleeding, refer to gyn onc for vaginal trachelectomy (risk of ureteral injury).
How to counsel on route of hysterectomy?
- Vag hyst is best approach
- Abdominal hyst appropriate when eval of pelvis for disease necessary (need to palpate tissues) or malignancy suspected
- LSC approach appropriate if vag hyst not appropriate and inadequate vaginal exposure for TVH, benign uterine mass too large for TVH, adnexal surgery required, pelvic adhesive disease, prior pelvic surgery w/ expected adhesive disease.
- recommend diag lac initially appropriate (to still try to do TVH).
What do you do if large uterus doesn’t fit through Pfannenstiel incision?
- extend pfannenstiel incision to release more lateral abdominal wall tissues (be careful of superficial epigastric vessels)
- Cherney modification of incision :incise lower rectus muscle just at tendon above its attachment to symphysis. risk of injury to inferior epigastric vessels.
- Maylard modification of incision: rectus muscle-splitting to either side. DO NOT separate muscle from fascia. ligate inferior epigastric vessel above and below muscle splitting.
What is the differential diagnosis of AUB?
What is the workup?
PALM-COEIN (structural=PALM-hyperplasia, non-structural COIEN - not classified)
- C=coagulopathy (vWD, platelet abnormalities)
- O-anovulatory dysfunction (perimenopause/adolescenec/pregnancy), hyerandrogen (PCOS, CAH), hypothalamic (anorexia, athlete), hyperPRL, hypothyroid
-I=iatrogenic (chemo/RT, Coumadin,ASA)
***also think atrophy, STI, foreign body, trauma
Workup:
-pap
- labs (CBC, TSH, HCG, screening for bleeding disorders when indicated, chlamydia if indicated), endometrial sampling if appropriate
- imaging: US, saline sonogram, hysteroscopy, MRI
What is the management of acute AUB?
Medical
- Hormonal (OCP or progestins, vaginal ring, depo provera, progestin IUD, GnRH agonist if fibroid related)
- if acute: IV estrogen or OCP taper
- If vWD: ddAVP, desmopressin
- TXA (1300mg TID x 5d)
- Provera (20mg TID for 7d, stops within 3 days)
- NSAIDs
Surgical
- D&C
- hysteroscopy, polypectomy,
- - endometrial ablation (if doesn’t desire pregnancy and no intracavitary mass present)
- myomectomy or hysterectomy
- if due to anovulation (endocrine prob), tx=medical. if fail medical, do hyst NOT ablation bc incr risk for endometrial hyperplasia. ablation can mask symptoms/make future attempts at sampling harder*
What are indications for endometrial ablation?
INDICATIONS
- management of HMB, pre-menopausal, NORMAL endometrial cavity, no future fertility, failed conservative medical management.
**MUST do endometrial sampling before.
** associated with failure rate: large cavity size, adenomyosis, grand multiparty, young age.
** if certain risk factors for endometrial cancer, AVOID. i.e. obesity, chronic anovulation/PCOS, extended tamoxifen use, hx Lynch syndrome.
*still need contraception!
What are contraindications for endometrial ablation?
- endometrial hyperplasia or carcinoma
- active pelvic infection
- prior procedures which thin myometrial wall/incr risk perforation (myomectomy, classical CS)
- current pregnancy
- congenital uterine anoamlies
- endometrial cavity size limitations
- desires future fertility
RELATIVE CONTRAINDICATIONS
- ovulatory dysfunction (ablation can mask future sampling, they’re at risk for endometrial hyperplasia)
- obesity
- tamoxifen use
- pt desires amenorrhea
- young age (higher failure rate if <35)
- acute anteversion/retroflexion
What are benefits and complications of endometrial ablation?
-success rate is 80%!!! 40% will have amenorrhea.
- preserves uterus, quick, easy recovery, office/outpatient surgery, lowers risk of endometriosis, improves dysmenorrhea
RISKS:
- 15% failure rate
- inability to evaluate uterus afterwards
- can cause cervical stenosis and hematometra
- uterine perforation
- pain (Cramping, vaginal discharge)
Late onset endometrial ablation failure
- recurrent vaginal bleeding, new cyclic pelvic pain, post-ablation inability to adequately sample endometrium.
Post-ablation tubal sterilization syndrome:
- pain 2/2 corneal menstrual bleeding blocked by ligated proximal fallopian tube.
What is a normal menses?
occurs q21-35 days and comprises <80 cc in volume.
What is the indication for an endometrial biopsy?
Post-menopausal w/ any bleeding
Post-menopausal w/ endometrial lining >4 mm or an endometrium that is not adequately visualized
45+ w/ AUB
< 45 if:
- exposure to unopposed estrogen (PCOS, obesity)
- persistent AUB
- failure of medical management
- high risk endometrial cancer (Lynch)
How does the progesterone IUD work to decrease bleeding from fibroids?
The levornorgestrel progestin released by the IUD stabilizes the endometrial proliferation induced by estrogen. If the fibroid is small and submucosal, the IUD may help to shrink the fibroid, thereby decreasing menstrual bleeding
Most women with levornorgestrel-releasing IUD continue to ovulate and have physiologic levels of estrogen, unlike DepoProvera, which suppresses estrogen production and ovulation. Therefore, loss of bone mineral density is not a concern with the levornorgestrel-releasing IUD.
What is differential for AUB if age 13-18
Anovulation 2/2 immature hPO axis
Hypothalamic dysfunction (Stress, exercise, eating disorders)
Coagulopathies
Hormonal contraceptives
Infections
Pregnancy
Tumors
What is differential for AUB if age 19-39?
pregnancy
Anovulation (PCOS)
Anatomic lesions (Fibroids/polyps)
HOrmonal contraceptives
Hyperplasia/malignancy
