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m4 obgyn > Abnormal uterine bleeding > Flashcards

Abnormal uterine bleeding Flashcards

1
Q

Normal menstrual cycle

A

Length: ~21-35 days
Duration: ~3-7 days
Amount of bleeding: ~4 pads/day, no flooding
Pain (discomfort/cramps) - should not interfere with day to day activities
No intermenstrual bleed

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2
Q

Terminology: Hypomenorrhoea

A

Periods < 3 days (30ml) with scanty bleeding per menstrual cycle

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3
Q

Terminology: Hypermenorrhoea

A

Periods > 80ml (>4 soaked pads/days) per menstrual cycle
*frequent, excessive bleeds

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4
Q

Terminology: Menorrhagia

A

Periods > 7 days &/or > 80ml blood loss
*prolonged, heavy bleeds

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5
Q

Terminology: Amenorrhea

A

Absence of menstruation

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6
Q

Terminology: Oligomenorrhoea

A

Infrequent menstruation > 35 days apart

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7
Q

Terminology: Polymenorrhea

A

Frequent menstruation, cycle length < 21 days apart

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8
Q

Terminology: Metrorrhagia

A

Bleeding of normal amounts but at irregular intervals

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9
Q

Terminology: Menometrorrhagia

A

Bleeding that is excessive in amount, prolonged in duration and may occur at regular or irregular intervals

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10
Q

Acute AUB

A

Excessive uterine bleeding requiring immediate intervention to prevent further blood loss

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11
Q

Chronic AUB

A

AUB present for the majority of the past 6 months

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12
Q

Causes of heavy menstrual bleeding

A

TRO red flags first
- Pregnancy
- Ectopic pregnancy
- GTD
- Miscarriages

Structural: PALM
Polyps/Pregnancy (miscarriage/ectopic)
Adenomyosis
Leiomyomas (fibroids)
- Submucosal fibroids
Malignancies (cervical/endometrial) & Hyperplasia

Functional: COEIN
Coagulopathy
Ovulatory dysfunction (DUB)
Endometrial (Hyperplasia/ Polyp/ Cancer)
Iatrogenic (IUCD/ Anti-platelets/ Anti-coagulants)
Not yet classified
- Thyroid disorders
- Infection (Cervicitis/ Endometritis/ PID)
- Trauma
- Sexual abuse
- FB

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13
Q

Endometrial polyps

A

Overgrowth of endometrial lining
- Majority are benign

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14
Q

Symptoms of endometrial polyps

A
  • Intermenstrual bleeding
  • Heavy bleeding
  • Prolonged bleeding
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15
Q

Diagnosis of endometrial polyps

A

TV Ultrasound
GOLD: Hysteroscopy

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16
Q

Treatment of endometrial polyps

A

Conservative
Surgical: Hysteroscopic removal of polyp

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17
Q

Adenomyosis

A

Endometrial tissue grows into myometrium and leads to diffusely enlarged uterus with increased surface area and vascularity
- Benign

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18
Q

Symptoms of adenomyosis

A
  • Heavy menstrual bleeding with dysmenorrhea
  • Deep-thrust dyspareunia (during pre-menstrual period)
  • Chronic pelvic pain
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19
Q

PE in adenomyosis

A

Mobile, diffusely enlarged, soft globular uterus

20
Q

Investigations for adenomyosis

A

TV Ultrasound
- thickening of myometrium
- subendometrial linear striations

Dilatation & curettage hysteroscopy TRO endometrial Ca IVO heavy menstrual bleeding

21
Q

Diagnosis of adenomyosis

A

Histological dx after hysterectomy

22
Q

Treatment of adenomyosis

A

Medical
Non-hormonal -> If patient wishes to conceive:
- Tranexamic acid (anti-fibrinolytic)

Hormonal:
- COCP
- Progestogens (Depo, *Mirena [best tx option], POP)
- GnRH agonist (temporary)

Surgical
- Endometrial ablation
- Hysterectomy (if not fertility sparing)
- Alternative: Uterine artery embolisation

23
Q

What is the best treatment option for heavy menstrual bleeding (non-fertility sparing)?

A

Mirena IUS

24
Q

Leiomyoma/fibroids

A

Benign proliferation of smooth muscle cells in myometrium of uterus

25
Q

Progression of fibroids/leiomyoma

A

Arise during reproductive years -> enlarge during pregnancy -> regress after menopause

26
Q

Risk factors of fibroids

A

Influenced by endogenous > exogenous oestrogen
- Nulliparity
- Family hx
- HTN, obesity

27
Q

What is known to reduce risk of fibroids?

A

OCP

28
Q

Classifications of fibroids/leiomyoma

A
  1. Submucosal
    - Below endometrial surface, bulging into uterine cavity
    - Endometrium is distorted
    - Increased endometrial surface area for more bleeding
  2. Intra-mural
    - Centrally within myometrium
    - May cause bleeding in a big fibroma that involves submucosal component
  3. Pedunculated sub-serosal
    - Attached to uterus by narrow pedicle containing vessels
  4. Cervical
    - Arising from cervix
29
Q

Symptoms of leiomyoma/fibroid

A

If p/w regular, heavy menstrual bleeding (due to increase SA of endometrium)
-> submucosa or intra-mural with submucosa component

If p/w pressure symptoms
- Urinary urgency/ frequency if pressing on bladder
- Posterior cervical fibroid can push uterus forward, compressing mid-urethra and cause urinary retention
- Back pain
-> Increased VTE risk: Very large fibroids can compress on vena cava
-> Sub-serosal

P/w infertility

30
Q

Investigation for fibroid

A

TV Ultrasound to know position of fibroids as it determines the sx

31
Q

Treatment of fibroids

A

Conservative if symptomatic and/or small

Medical (same as above)

Surgery
- Fertility sparing:
Myomectomy to just remove fibroids

  • No need for fertility sparing, definitive: Hysterectomy (eliminates current sx and chance of recurrence)

Other alternatives: Endometrial ablation, uterine artery embolisation

32
Q

Complications of fibroids

A
  • Distortion of uterine wall can lead to difficulty implanting (Subfertility)
  • Early pregnancy loss/ malpresentation
33
Q

Endometrial hyperplasia/malignancy

A

Overabundant growth and proliferation of endometrium resulting from prolonged unopposed estrogen stimulation

34
Q

Risk factors of endometrial hyperplasia

A

Extremes of reproductive age with anovulation
Nulliparity, early menarche
PCOS
Obesity (Increased extra-ovarian aromatization of adrenal androgen to estrogen)
Granulosa-Theca cell Tumors (Estrogen Producing)
Prolonged use of estrogen-only hormonal therapy
Chronic Tamoxifen Use
FHx
Genetic syndrome (HNPCC)

35
Q

How can endometrium hyperplasia present?

A
  1. AUB: HMB/IMB/PMB
  2. Incidental finding of endometrial thickness on US
    For postmenopausal
    - If Less than 5mm -> Observe -> If persistent bleed -> D&C
    - If 5mm or more -> Endometrial sampling with pipelle -> If insufficient/inadequate -> D&C

For premenopausal
>15mm at anytime of the menstrual cycle

  1. Abnormal PAP smear
36
Q

Investigations for endometrium hyperplasia

A
  • TV ultrasound to assess endometrium thickness
  • Endometrial sampling via pipelle
  • Hysteroscopy + D&C (GOLD)
37
Q

Histological results and its risk of malignancy

A

Simple Hyperplasia (with or w/o atypia) / Complex hyperplasia without atypia: risk of malignancy <5% in 25 years = Benign

-1% in 19 years????

Complex Hyperplasia with atypia: risk of malignancy ~20% = Pre cancerous
-> Need to do D&C TRO endometrial Ca!!!

38
Q

Treatment for Simple Hyperplasia (with or w/o atypia) / Complex hyperplasia without atypia

A

Uterus conserving:
1st line: Mirena IUCD
Progestogens: Norethisterone or Medroxyprogesterone daily

39
Q

Treatment for Complex Hyperplasia with atypia

A

Do D&C TRO endometrial ca!!!
1st line: Hysterectomy
2nd line: Mirena IUCD

40
Q

Dysfunctional uterine bleeding

A

Excessive bleeding (amt, freq or duration) from female genital tract, for which no cause can be found after physical examination or investigations
- Dx of EXCLUSION

41
Q

Types of DUB

A
  1. Anovulatory DUB
    a. Adolescence (<20yo)
    - Immature HPO but full of follicles
    b. Perimenopausal woman (>40yo)
    - Depleted follicles but mature HPO
    c. Childbearing age (20-40yo)
    - PCOS
    - Stress, weight gain
    - Thyroid dysfunction
  2. Ovulatory DUB
    - early degeneration or prolonged function of corpus luteum
    - pre-menstrual spotting or prolonged spotting after menstrual flow
42
Q

Treatment for anovulatory DUB

A

Non-hormonal tx
- Tranexemic acid
- NSAIDs

Desire fertility: Ovulation induction (Clomiphene Citrate/ IVF/ GnRH)

Desire contraception:
Follow above

43
Q

Treatment of ovulatory DUB

A

Non-hormonal tx
- Tranexemic acid
- NSAIDs

Desire fertility: Luteal phase progesterone (corpus luteum is deficient -> inadequate progesterone -> endometrial lining cannot be maintained -> sheds immediately -> cycles are irregular/ frequent, hence by giving progesterone it helps to regulate the cycle)

Desire infertility
- Follow above

44
Q

Physical examination for heavy menstrual bleeding

A
  1. General (BMI/ Acne/ Hirsutism/ Thyroid lump/ VFs/ Pallor)
  2. Breast (Galactorrhea)
  3. Abdo PE (Mass/ Size/ Mobility/ Tenderness)
  4. Pelvic PE
    - Inspection
    - Speculum: Cervical lesion/ polyp/ Fibroid at vulva/ Vagina, Discharge
    - VE: Pelvic/ Adnexal mass and tenderness
45
Q

Investigations for heavy menstrual bleeding

A
  1. UPT TRO pregnancy
  2. Bloods
    - FBC TRO anemia
    - PT/ PTT TRO coagulopathy  
    - TFT TRO thyroid dysfunction  
    - Hormonal profile (FSH, LH, estradiol, prolactin, testosterone) if anovulation is suspected  
  3. Imaging
    - Transvaginal ultrasound
    -> structural abnormalities (polyps, fibroids, adenomyosis)
    -> thickening of uterine lining
    -> malignancy
  4. Biopsy
    - Endometrial sampling biopsy
    With pipelle or D&C (Dilatation & Curettage)

m4 obgyn (41 decks)

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