Abnormal Uterine Bleeding

Question 1

What is the difference between primary and secondary amenorhea?

Answer 1

primary - failure of menarche by age 16

secondary - absence of menstruation for 6 mos in a woman who has previously had menses

Question 2

What are the three general etiologies of amenorrhea?

Answer 2

anatomic - usually primary
ovarian failure (hypergonadotropic hypogonadism)
chronic anovulation - usually secondary

Question 3

What are the anatomic causes of amenorrhea?

Answer 3

imperforate hymen, transverse vaginal septum, cervical stenosis, Asherman syndrome, mullerian agenesis

Question 4

What are the ovarian failure (hyper hypo) causes of amenorrhea?

Answer 4

radiation, chemo, advanced oocyte atresia from X ch defects, surgical removal, premature ovarian failure, menopause

Question 5

What are the chronic anovulation causes of amenorrhea?

Answer 5

with estrogen: PCOS, prolactin excess, thyroid abnormality, ovarian tumors
with estrogen absent (hypo hypo): hypothalamic functional disorders (eating disorders), inherited H/P abnormalities or lesions

Question 6

What are indications for evaluation of amenorrhea?

Answer 6

pt and family concerned
no breast dev by age 14
any sexual ambiguity present

Question 7

What is menorrhagia?

Answer 7

cyclic menstrual bleeding, excessive in duration (>7 days) or amount (>80ml)

Question 8

What is oligomenorrhia?

Answer 8

bleeding or light spotting that occurs in intervals longer than 35 days

Question 9

What is metorrhagia?

Answer 9

bleeding that occurs at irregular intervals

Question 10

What is menometorrhagia?

Answer 10

excessive and prolonged bleeding episodes at irregular intervals

Question 11

What is the PALM-COEIN system for AUB classification in reproductive age women?

Answer 11

Polyp
Adenomyosis
Leiomyoma (submucosa or other)
Malignancy and hyperplasia
Coagulopathy 
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
PALM is structural, COEIN is nonstructural

Question 12

When is a pap smear appropriate to order?

Answer 12

can help screen for invasive cervical lesions
pts w abnormal cytologic findings must be evaluated
must useful in diagnosing asymptomatic intraepithelial lesions of cervix

Question 13

When is it appropriate to order serum beta-HCG?

Answer 13

complications of pregnancy and trophoblastic dz

Question 14

When is it appropriate to order transvaginal sonogram?

Answer 14

after transabdominal approach - more detail

saline infusion during imaging is helpful in evaluating endometrial lining

Question 15

When is it appropriate to order an endometrial biopsy?

Answer 15

if no cause found or tissue inadequate for diagnosis, use D&C

Question 16

When is it appropriate to order a hysteroscopy?

Answer 16

visualization by endoscopy - most direct way to assess endometrium
biopsy can be done at same time

Question 17

What are the five sources of female genital tract bleeding?

Answer 17

vulva and vagina
cervix
uterus
uterine tubes
ovaries

Question 18

What is Asherman syndrome?

Answer 18

extensive intrauterine scarring (synechiae) that causes amenorrhea
endometrial damage to basal layer

Question 19

How can uterine leiomyomas be recognized?

Answer 19

enlarged, irregular uterine contour
asymptomatic, or menorrhagia and pelvic pressure
submucosal most likely to cause metorrhagia

Question 20

How are the presentations of threatened abortion vs. ectopic pregnancy different?

Answer 20

threatened abortion: bleeding/pain at <20 wks gestation w/o cervical dilation
sonography! - gestational sac w/i uterus vs. cystic mass in adnexal area

Question 21

What is the ddx of postmenopausal bleeding?

Answer 21

atrophy of endometrium –> chronic inflammatory rxn
exogenous hormones
tumors of reproductive tract - cancer til proven otherwise
vaginal atrophy and vaginal/vulvar lesions
(structural problems, endometrial hyperplasia)

Question 22

What is the ddx for abnormal bleeding in a prepubertal girl?

Answer 22

trauma, foreign body, vaginal tumor, precocious puberty, prolapsed urethra

Question 23

What is the ddx for abnormal bleeding in an adolescent?

Answer 23

anovulation, pregnancy, bleeding dyscrasias, breakthrough on contraceptives

Question 24

What is the ddx for abnormal bleeding in reproductive age women?

Answer 24

anovulation, pregnancy, structural, breakthrough on contraceptives, cancer
pathologic causes more common here

Question 25

What is the ddx of post-coital bleeding?

Answer 25

(cervical cancer), cervical erosion, cervical polyps, cervical or vaginal inf like trichomoniasis