Abnormal uterine bleeding Flashcards
Normal menstrual cycle
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
Terminology: Hypomenorrhoea
Periods < 3 days (30ml) with scanty bleeding per menstrual cycle
Terminology: Hypermenorrhoea
Periods > 80ml (>4 soaked pads/days) per menstrual cycle
*frequent, excessive bleeds
Terminology: Menorrhagia
Periods > 7 days &/or > 80ml blood loss
*prolonged, heavy bleeds
Terminology: Amenorrhea
Absence of menstruation
Terminology: Oligomenorrhoea
Infrequent menstruation > 35 days apart
Terminology: Polymenorrhea
Frequent menstruation, cycle length < 21 days apart
Terminology: Metrorrhagia
Bleeding of normal amounts but at irregular intervals
Terminology: Menometrorrhagia
Bleeding that is excessive in amount, prolonged in duration and may occur at regular or irregular intervals
Acute AUB
Excessive uterine bleeding requiring immediate intervention to prevent further blood loss
Chronic AUB
AUB present for the majority of the past 6 months
Causes of heavy menstrual bleeding
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
Endometrial polyps
Overgrowth of endometrial lining
- Majority are benign
Symptoms of endometrial polyps
- Intermenstrual bleeding
- Heavy bleeding
- Prolonged bleeding
Diagnosis of endometrial polyps
TV Ultrasound
GOLD: Hysteroscopy
Treatment of endometrial polyps
Conservative
Surgical: Hysteroscopic removal of polyp
Adenomyosis
Endometrial tissue grows into myometrium and leads to diffusely enlarged uterus with increased surface area and vascularity
- Benign
Symptoms of adenomyosis
- Heavy menstrual bleeding with dysmenorrhea
- Deep-thrust dyspareunia (during pre-menstrual period)
- Chronic pelvic pain
PE in adenomyosis
Mobile, diffusely enlarged, soft globular uterus
Investigations for adenomyosis
TV Ultrasound
- thickening of myometrium
- subendometrial linear striations
Dilatation & curettage hysteroscopy TRO endometrial Ca IVO heavy menstrual bleeding
Diagnosis of adenomyosis
Histological dx after hysterectomy
Treatment of adenomyosis
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
What is the best treatment option for heavy menstrual bleeding (non-fertility sparing)?
Mirena IUS
Leiomyoma/fibroids
Benign proliferation of smooth muscle cells in myometrium of uterus
Progression of fibroids/leiomyoma
Arise during reproductive years -> enlarge during pregnancy -> regress after menopause
Risk factors of fibroids
Influenced by endogenous > exogenous oestrogen
- Nulliparity
- Family hx
- HTN, obesity
What is known to reduce risk of fibroids?
OCP
Classifications of fibroids/leiomyoma
- Submucosal
- Below endometrial surface, bulging into uterine cavity
- Endometrium is distorted
- Increased endometrial surface area for more bleeding - Intra-mural
- Centrally within myometrium
- May cause bleeding in a big fibroma that involves submucosal component - Pedunculated sub-serosal
- Attached to uterus by narrow pedicle containing vessels - Cervical
- Arising from cervix
Symptoms of leiomyoma/fibroid
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
Investigation for fibroid
TV Ultrasound to know position of fibroids as it determines the sx
Treatment of fibroids
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
Complications of fibroids
- Distortion of uterine wall can lead to difficulty implanting (Subfertility)
- Early pregnancy loss/ malpresentation
Endometrial hyperplasia/malignancy
Overabundant growth and proliferation of endometrium resulting from prolonged unopposed estrogen stimulation
Risk factors of endometrial hyperplasia
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)
How can endometrium hyperplasia present?
- AUB: HMB/IMB/PMB
- 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
- Abnormal PAP smear
Investigations for endometrium hyperplasia
- TV ultrasound to assess endometrium thickness
- Endometrial sampling via pipelle
- Hysteroscopy + D&C (GOLD)
Histological results and its risk of malignancy
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!!!
Treatment for Simple Hyperplasia (with or w/o atypia) / Complex hyperplasia without atypia
Uterus conserving:
1st line: Mirena IUCD
Progestogens: Norethisterone or Medroxyprogesterone daily
Treatment for Complex Hyperplasia with atypia
Do D&C TRO endometrial ca!!!
1st line: Hysterectomy
2nd line: Mirena IUCD
Dysfunctional uterine bleeding
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
Types of DUB
- 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 - Ovulatory DUB
- early degeneration or prolonged function of corpus luteum
- pre-menstrual spotting or prolonged spotting after menstrual flow
Treatment for anovulatory DUB
Non-hormonal tx
- Tranexemic acid
- NSAIDs
Desire fertility: Ovulation induction (Clomiphene Citrate/ IVF/ GnRH)
Desire contraception:
Follow above
Treatment of ovulatory DUB
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
Physical examination for heavy menstrual bleeding
- General (BMI/ Acne/ Hirsutism/ Thyroid lump/ VFs/ Pallor)
- Breast (Galactorrhea)
- Abdo PE (Mass/ Size/ Mobility/ Tenderness)
- Pelvic PE
- Inspection
- Speculum: Cervical lesion/ polyp/ Fibroid at vulva/ Vagina, Discharge
- VE: Pelvic/ Adnexal mass and tenderness
Investigations for heavy menstrual bleeding
- UPT TRO pregnancy
- Bloods
- FBC TRO anemia
- PT/ PTT TRO coagulopathy
- TFT TRO thyroid dysfunction
- Hormonal profile (FSH, LH, estradiol, prolactin, testosterone) if anovulation is suspected - Imaging
- Transvaginal ultrasound
-> structural abnormalities (polyps, fibroids, adenomyosis)
-> thickening of uterine lining
-> malignancy - Biopsy
- Endometrial sampling biopsy
With pipelle or D&C (Dilatation & Curettage)
