Abnormal uterine bleeding Flashcards
what is AUB
is defined as menstrual bleeding that is abnormal and/or irregular in frequency, duration and/or intensity
what is menorrhagia
Heavy menstrual bleeding with blood loss greater than 80 ml/ prolonged >7 days
what is metrorrhagia
Bleeding between menstrual periods
what is menometrorrhagia
prolonged or excessive bleeding occurring at irregular and more frequent than normal intervals
what is oligomenorrhea
Bleeding that occurs less frequently than every 35 days
what is polymenorrhea
Bleeding that occurs more frequently than every 21 days
what is amenorrhea
absence of menstruation for at least 6months
what is mid cyclic spotting
spotting occurring just before ovulation, typically from declining Estrogen levels
how does FIGO classify causes of AUB
- Structural
-polyps
-adenomyosis
-leiomyoma
-malignancy and hyperplasia - Non structural
- coagulopathy
-ovulatory dysfunction
- endometrial
- iatrogenic
- not yet classified
what are common causes of HMB (3)
- uterine fibroids
- adenomyosis
- endometrial polyps
what less commonly causes HMB (3)
- endometrial intraepithelial neoplasia
- cervical polyps
- cervical ca
what is a polyp
an abnormal, estrogen independent benign growths containing glands, stroma and blood vessels projecting from the lining of the uterus (endometrium)
where can polyps arise from (2)
-endocervix
-endometrial
who are polyps common in (2)
- post menopausal women
-reproductive age
what are the associated symptoms of polyps(5)
- irregular bleedings
- intermenstrual bleeding
- postcoital bleeding
- postmenopausal bleeding
- menorrhagia
what are risk factors for polyps (4)
- HTN
- obesity
- postmenopausal hormone therapy
- Tamoxifen
how do you investigate polyps (3)
- pelvic exam
- speculum exam (show a polyp coming out of the cervix)
- USS
how do you manage polyps
Surgical polypectomy using bonneys polypectomy forcep by twisting and excising the poly at its pedicle
what is adenomyosis
a disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
what are associate symptoms of adenomyosis (4)
- dysmenorrhea
- menorrhagia
- chronic pelvic pain
- a tender smooth enlarged globular uterus
who adenomyosis affect
multiparous women
what is a leiomyoma (fibroid)
Benign hormone sensitive smooth muscle tumor of the uterus
what is the most common tumor of the female genital tract
fibroid
where can fibroids be located (4)
- submucosal
- intramural
- subserosal
- pedunculated
what are risk factors for fibroids (6)
- nulliparity
- obesity
- family hx
- african american race
- early menarche
- late menopause
what reproductive anomalies can fibroids cause (2)
- increased risk of pregnancy loss
- infertility
what are associated symptoms of fibroids (6)
- asymptomatic
- menorrhagia
- pressure symptoms ( urinary frequency, retention, incontinence, constipation and features of hydronephrosis)
- enlarged, firm irregular uterus
- pelvic pain
- dysmenorrhea
how can you manage fibroids (3)
Medical management
i) hormonal treatment
- combined oral contraceptive pills
- provera (oppose the proliferative effect of estrogen and cause endometrial thinning, and stabilize the size/ slow down growth of the fibroid)
- depo-provera injection
- GnRH agonist ( after some time GnRH receptors in the pituitary gland become desensitized leading to a significant decrease in LH and FSH, leading to a decrease in the production of estrogen and progesterone creating a hypoestrogenic state similar to menopause) causing the fibroids to shrink (best treatment)
- PCM and ibuprofen as needed
- tranexemic acid
Surgical management
- consider hysterectomy if done with child bearing
how do you manage adenomyosis (2)
- Medical management
i) hormonal rx
- oral contraceptive pills
- provera
- depo provera
- analgesia
- ibuprofen / PCM
- tranexemic acid - Surgical management
- if adnexal mass noted on exam/ persistent/ complex mass noted on USS refer to central hospital where they will consider cystectomy/oophorectomy for possible endometrioma
- consider hysterectomy if done with child bearing/ if failed medical management
what is endometrial hyperplasia
is a precancerous non physiological proliferation of the endometrium causing an increased volume of endometrial tissue with alteration of glandular activity
what are risk factors of endometrial ca (7)
- obesity
- DM
- anovulatory cycles
- nulliparity
- > 35yrs
- early menarche
- late menopause
how is endometrial hyperplasia classified (2)
- Endometrial hyperplasia with atypia
- Endometrial hyperplasia without atypia
what are the different incidence rates for endometrial ca from endometrial hyperplasia (4)
- simple without atypia (1%)
- complex without atypia (3%)
- simple with atypia (8%)
- complex with atypia (29%)
for endometrial hyperplasia with atypia whats the management
hysterectomy +/- BSO if child bearing is complete
what is the management of endometrial hyperplasia without atypia / of fertility is desired
depo provera injection/ provera (10-20 mg PO daily) with endometrial sampling every 3 months until hyperplasia is resolved, and then yearly after
for endometrial ca what will need to be the management (4)
- exploratory laparotomy
- TAH/BSO
- staging
- possible pelvic and periaortic lymph node dissection
malignancy and hyperplasia can cause what
post menopausal bleeding
what are the stages for cancer of the corpus uteri (4)
- tumor is confined to the corpus uteri
1a. less than half the myometrial invasion
1b. invasion is equal to more than half of the myometrium - tumor invades cervical stroma, but does not extend beyond the uterus
- local and or reginal spread of the tumor
3a. tumor invades the serosa of the corpus uteri and or adnexa
3b. vaginal involvement and or parametrial involvement
3c. metastases to pelvic and or para aortic lymph nodes
3c1. positive pelvic nodes
3c2. positive para aortic nodes with or without positive pelvic lymph nodes - tumor invades bladder and or bowel mucosa and or distant metastases
4a. tumor invasion of bladder and or bowel mucosa
4b. distant metastases, including intra abdominal metastases and or inguinal nodes
what is the cause of the coagulopathy
Von willebrand disease
what is vWD
A bleeding disorder characterized by the deficiency or the dysfunction of vWF.
what does vWF do
is involved in platelet adhesion and prevents degradation of factor VIII
what does vWD do
impairs primary hemostasis and intrinsic pathway of secondary hemostasis
what are clinical features of vWD (9)
- Ecchymosis(easy bruising)
- epistaxis
- bleeding of gingiva
- petechiae
- prolonged bleeding from minor injuries
- Bleeding after surgical procedure like tooth removal
- GI bleeding
- Heavy prolonged menstrual bleeding
- Postpartum bleeding
what are other coagulopathy causes (3)
- immune thrombocytopenic purpura
- hemophilia
- myeloproliferative disorders e.g. leukemia
what is ovulatory dysfunction
Includes anything that disrupts the normal function of the ovaries leading to amenorrhea and irregular bleeding
what are causes of ovulatory dysfunction (8)
- Mostly due to hypothalamic-pituitary-ovarian axis abnormalities
- Effect of unopposed estrogen on endometrial lining
- Polycystic ovarian syndrome ( alot of androgens- hirsutism, overweight, acne, infertility, DM, acanthosis nigricans, pelvic pain)
- obesity
- hypothalamic amenorrhea : associated with anorexia, poor nutritional status, excessive stree or exercise
- hypothyroidism (causes an increase thyrotropin releasing hormone which in turn stimulates the release of prolactin which inhibits GnRH/ also causes reduced clearance of estrogen by the liver which can cause a negative feedback loop on the pituitary gland reducing levels of Lh and FSH) : start levothyroxine 1.6mcg/kg/ day and recheck TSh in 6 weeks
- premature ovarian failure: give estrogen therapy (coc), estrogen patches with cyclic progestin
- pituitary lesions : prolactinoma
how does endometrial issues cause AUB (20
- Primary dysfunction of local hemostasis
- Women with structurally sound uterus, regular cycle and no coagulopathies
endometrial is associated with what type of AUB
heavy
what are causes of endometrial issues (2)
secondary to:
- endometritis PID
- uterine arteriovenous malformations
what are the iatrogenic causes
Secondary to procedures or medications prescribed by health care providers:
- Hormonal contraceptives )cocs)
- intrauterine contraceptive devices (copper IUD, mirena)
- anticoagulants
- tricyclic anti depressants
what are some of the not yet classified causes (3)
- Endometrial arteriovenous malformations
- Myometrial hypertrophy
- Cesarean scar defects may also cause AUB in the lower uterine segment causing delayed menstrual bleeding.
( RF: number of previous CSs, uterine position, labor before CS, surgical technique and incision closure.)
