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Abnormal Uterine Bleeding Flashcards

1
Q

Abnormal Uterine Bleeding (AUB)

A

Common reason women seek health care.
20% gyn visits.
25% gyn surgeries.
Any uterine bleeding that is irregular in amount, duration, or timing.
May or may not be related to menstrual cycle.

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2
Q

AUB can be

A

Normal physiologic event → irregular bleeding resulting from anovulation that often accompanies menarche.
Symptomatic of perimenopause.
Pathologic, life-threatening conditions → ectopic pregnancy; endometrial cancer.

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3
Q

Understanding AUB:

A

Know physiologic basis of normal menstrual physiology.

Functional structure of reproductive tract.

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4
Q

Normal Menstruation

A

Requires coordination of the hypothalamic-pituitary-ovarian axis. (HPOA)
Wide variation in menstrual cycles – know what is “normal” for each patient.

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5
Q

Normal Menstrual Patterns:

A

Cycle length: 21-40 days; average 29.5 days.
Duration: 3-8 days.
Blood loss – 40-80cc.
Ovulatory bleeding: spotting around ovulation → 14 days before next menses.

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6
Q

Age-related menstrual changes:

A

Adolescence
May be anovulatory for more than half of 1st postmenarcheal year.
Perimenopause
Gradual ↓ in length and quantity during the 5 years preceding menopause.
Can have anovulatory cycles.

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7
Q

AUB present when:

A

Interval between the start of successive menses is ≤ 21 days.
Duration of menstrual flow > 7 days.
Menstrual blood loss > 80 cc.
Deviations from a previously established menstrual pattern:
Sudden ↑ of 2 or more sanitary pads per day.
Menses lasting ≥ 3 days longer than usual.
Intermenstrual bleeding.
Interval between menses ≥ 4 days less than usual.

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8
Q

AUB Terminology:

A

Intermenstrual bleeding: Uterine bleeding between regular menses.
Menorrhagia or hypermenorrhea: Prolonged (more than 7 days) or excessive (greater than 80cc) uterine bleeding occurring at regular intervals.
Metrorrhagia: Bleeding occurring at irregular, frequent intervals, the amount being variable.
Oligomenorrhea: Infrequent, irregular uterine bleeding occurring at intervals greater than 45 days.
Polymenorrhea: Frequent, regular episodes of uterine bleeding occurring at intervals of less than 18 days.

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9
Q

Causes of AUB:

A

Physiologic.
Pathologic.
Pharmacologic.

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10
Q

Causes of AUB:

A

Disruptions of endocrine function at any level of HPOA → disrupt normal menstrual physiology → cause a disturbance of menstrual cycle’s regularity, frequency, duration, or volume

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11
Q

Women of childbearing age presenting with AUB

A

do a pregnancy test first.

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12
Q

AUB Etiology

A 
Pregnancy.
Chronic anovulation.
Ovulatory problems.
Systemic disease.
Gynecologic problems.
Medications.
Coagulation problems
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13
Q

AUB Endocrine problems/systemic:

A 
Adrenal hyperplasia.
Cushings syndrome.
Diabetes.
Polycystic ovary syndrome.
Pituitary.
Thyroid disease.
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14
Q

AUB Medications/substances/herbs:

A 
Amphetamines.
Anticoagulants.
Antipsychotics.
Benzodiazepines.
Corticosteroids.
Herbs (ginkgo, ginseng, soy)
Hormone therapy.
Isoniazide.
SSRI antidepressants.
Hormonal contraceptives.
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15
Q

AUB - Problems with HIPOA

A 
Systemic illness (e.g., PCOS, pituitary, thyroid)
Premature ovarian failure.
Postmenarche.
Perimenopause.
Stress.
Eating disorders.
Severe dieting and/or weight loss.
Excessive exercise.
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16
Q

AUB Reproductive tract disease/dysfunction:

A 
Atrophy.
Cancer.
Endometrial hyperplasia.
Endometriosis.
Infections.
Leiomyomas (leiomyomatas, myomas, fibroids)
Cause 1/3 of presenting cases.
Outflow tract obstruction.
Ovarian tumors.
Polyps.
Trauma.
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17
Q

AUB - Systemic disease

A 
Thyroid dysfunction.
Hypertension.
Liver disease.
Coagulation defects. 
Von Willebrand’s
Leukemia.
Idiopathic thrombocytopenia
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18
Q

CNM/NP Role in Management of AUB

A

Complete history & initial physical examination.
Initial lab evaluation.
Referral to appropriate specialist for further evaluation & treatment.
Patient counseling, education, & reassurance.

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19
Q

Assessment of AUB

A

A well-taken history will lead the clinician almost to the end of the diagnostic path, even before the patient has been examined & without a single laboratory test or diagnostic procedure has been performed.

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20
Q

History:

A 
Patient’s age
Incidence of various causes of bleeding problems change depending on woman’s stage of life:
Peripubertal.
Reproductively mature.
Perimenopausal.
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21
Q

Chief Complaint:

A

Description of vaginal bleeding – timing, amount, color, character, onset, duration of problem.
Does bleeding occur at regular or irregular intervals?
Associated symptoms, what relieves or worsens condition.
May ask patient to complete a bleeding assessment diary → may give better idea of amount of bleeding

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22
Q

History-taking:

A 
General medical/surgical history to include:
Detailed menstrual history.
Contraceptive history.
Sexual history.
Gyn history
Pap test history.
Gyn surgeries.
Sti’s or other infections of genital tract/organs.
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23
Q

Physical Examination

A

General physical examination should be done with special attention to:
Body weight:
Underweight – can cause irregular bleeding.
Obesity – can cause anovulation.
Signs of endocrine disorders:
Delayed or precocious sexual development.
Galactorrhea.
Signs of androgen excess:
Changes in hair growth or distribution.
Acne.

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24
Q

Physical Examination (cont)

A

Thyroid
22% of women with AUB have thyroid disease.
Lymph nodes
Help to rule out gynecologic cancers & pelvic infections.
Symptoms of coagulation disorders:
Petechiae.
Ecchymoses.

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25
Q

Pelvic exam

A

Inspection:
Note origin of bleeding – rectal, vaginal, labial, or uterine.
Note location of any lesions.
Observe the introitus for bruising and laceration.
Observe for signs of estrogen deficiency – urogenital atrophy or atrophic vaginitis can cause AUB.

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26
Q

Speculum exam

A

Evaluate source, amount, color, character, & odor of any observed bleeding.
Note any lesions, lacerations.
Note abnormal vaginal discharge.
Bleeding can be related to vaginitis, cervicitis.

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27
Q

Bimanual exam:

A

Note size, shape, consistency of any masses.
Note tenderness with palpation. Evaluate cervical motion tenderness.
R/O pregnancy, uterine & ovarian pathology, PID.

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28
Q

Rectovaginal examination:

A

Can help to confirm diagnosis of PID or endometriosis.

Assess rectal lesions & masses.

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29
Q

Laboratory & Diagnostic Tests

A 
Choice of lab tests guided by H&P.
Most lab work used to rule out pathology.
Urine pregnancy test as indicated.
Vaginal labs:
Pap smear.
STI testing, vaginal/cervical culture.
Wet mount – evaluate for vaginitis.
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30
Q

Diagnostic Testing

A

Transvaginal ultrasound
Identify pelvic masses.
R/O pregnancy, threatened abortion,
ectopic pregnancy.
Measure endometrial thickness – if endometrial hyperplasia or cancer is suspected.
Endometrial thickness > 5mm suspicious of endometrial hyperplasia.
More predictive in postmenopausal women than younger women

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31
Q

Diagnostic Testing

A

Colposcopy with cervical biopsy as needed.

Endometrial Biopsy (EMB)
Simple procedure, usually well tolerated.
Flexible suction curette sampling device used to obtain endometrial sample.
R/O endometrial cancer.
NSAID 30-45 minutes prior to procedure → decrease cramping & uterine spasm.

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32
Q

Who needs EMB?

A

Any woman older than 40 with new onset AUB.
Any woman with a history of prolonged exposure to unopposed estrogen, regardless of age.
20-25% endometrial cancer → premenopausal women.

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33
Q

Treatment of AUB

A

AUB treated by treating underlying cause – organic, systemic, iatrogenic.

Surgically – D&C, removal of fibroids/polyps, hysterectomy, endometrial ablation, uterine artery embolization.

Medically – hormonally (COC, Depo), LNG-IUS, cyclic progesterone.

If all causes of AUB have been ruled out – diagnosis of dysfunctional uterine bleeding (DUB) can be made.

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34
Q

Dysfunctional Uterine Bleeding (DUB)

A

Diagnosis of exclusion – excessive bleeding with no demonstrable organic cause.
Associated with abnormalities in the hormonal secretory activities of the endometrium.
Usually of endocrine origin.
Occurs more frequently during puberty & in perimenopausal years.
Two types:
Anovulatory (90%)
Ovulatory (10%)

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35
Q

Ovulatory DUB

A

Occurs in peak reproductive years.
Bleeding predictable but excessive & prolonged.
Etiology not clearly understood – Possible causes:
Constant low level of estrogen with a prolonged progesterone secretion → causes irregular shedding of endometrium.
Imbalance in prostaglandins → endometrium fails to produce adequate amounts of the vasoconstrictive prostaglandin PGF2.
Treatment: oral contraceptives x 3 cycles; most ovulatory women will revert back to normal menstrual cycle.

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36
Q

Anovulatory DUB

A

Anovulation – most common hormonal disorder leading to DUB.

Most common in peri-menarcheal & peri-menopausal years.

Can occur at any time – can be caused by increased stress.

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37
Q

Failure of HPOA feedback mechanism → no normal folliculogenesis → corpus luteum does not form.

A

Causes failure of normal cyclical progesterone secretion.
Leads to a state of continuous estrogen production & continued proliferation of endometrium – “hyperplasia”.
Overgrown endometrium sheds erratically & unpredictably as areas outgrow their blood supply.

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38
Q

Anovulatory DUB

A

Usually self-limited & normally cycling woman will revert back to her underlying menstrual cycle without treatment.

Intervention needed when abnormal bleeding episode is unusually heavy or recurrent.

39
Q

Objectives in Treating DUB

A 
Control bleeding.
Prevent recurrence.
Preserve fertility.
Correct associated disorders.
Induce ovulation in women who desire to conceive.
40
Q

Factors influencing choice of therapy for treatment of DUB:

A 
Woman’s age.
Severity of bleeding.
Number of children.
Desire for future fertility.
Presence of associated pelvic pathology.
Medical treatment preferred if more children are desired & there are no associated pelvic lesions
41
Q

DUB Acute Bleeding Episode:

A

Medical D&C”:

42
Q

DUB No orthostatic hypotension, HgB ≥ 10g/dl, bleeding not profuse:

A

2.5mg Premarin po q 4-6 hours.
Antiemetics may be needed secondary to high estrogen dosing.
Acute bleeding should lighten up after 3-4 doses.

43
Q

DUB After acute bleeding:

A

LoOvral – 1 active pill qid X 4 days, TID X 3 days, BID X 2 days, 1 pill daily X 3 weeks.
Then one pill-free week → will have withdrawal bleed.

44
Q

DUB

Continue to cycle for 3 months

A

If contraception needed → continue OCP.

OCP contraindicated → cycle Provera 10 mg. po for 14 days, off 14 days, on 14 days – for 3 months.

45
Q

DUB Active bleeding episode - + orthostatic hypotension, Hgb < 10 g/dl, + profuse bleeding

A

Intravenous estrogen – 25mg every 4 hours. Maximum of 3 doses. (may need antiemetic)
Simultaneously → start with oral LoOvral therapy.
Cycle for 3 months – either OCPs or Provera.

46
Q

Why use high dose estrogen to control acute bleeding?

A

High dose estrogen will allow sufficient endometrium buildup for estrogen/progesterone therapy to be effective.

47
Q

Medical Treatment of Non-Emergent DUB

Hormonal Treatment:

A

Goal of hormonal treatment is to promote:
Universal, synchronous endometrial bleeding.
Structural stability.
Vasomotor rhythmicity.

Oral contraceptive or progestin therapy.

Age & need for contraception help determine medication choice.

48
Q

Recurrent DUB → long-term menstrual cycle control:

A

Combined oral contraceptive pills.
Progestin therapy.
NSAIDs.
GNRH Analogues

49
Q

Progestin Therapy:

for DUB

A

With anovulation – course of progestin will transform endometrium to secretory pattern & lead to synchronous withdrawal bleed.

Withdrawal bleed can be very heavy – especially if condition present for long

50
Q

Progestin options: For DUB

A

Provera 10mg X 10 days.
Norethindrone 5mg X 10 days.
Progesterone-in-oil 100-150mg IM X 1 dose.
Progestin IUD

51
Q

Progestin IUD

for DUB

A

Delivers progestational agent directly to endometrium.
Reduces menstrual flow → may induce amenorrhea.
Can control:
Anovulatory cycles.
Ovulatory cycles with heavy menstrual bleeding.

52
Q

Nonsteroid Anti-inflammatory Agents for DUB

A

Prostaglandin synthetase inhibitors – decrease prostaglandin production within the endometrium & reduce menstrual blood loss.

20-50% decline in menstrual bleeding after treatment with NSAID.

Given to cycling women with heavy periods for first 3 days of flow.

Can be combined with OCs or progestins to enhance efficacy.

53
Q

NSAID Therapy for DUB

A 
Mefanamic acid (Ponstel) 500 mg TID
Ibuprofen 600 mg TID
Naproxen sodium 550 mg loading dose then 275 mg every    6 hours
54
Q

GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin) For DUB

A

Suppresses HPOA & creates ‘medical menopause’.

Use with extreme caution in women who are at risk for osteoporosis.

GnRH analogues effective for menstrual suppression → side effects of estrogen deficiency problematic.

55
Q

GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin for DUB side effects

A

Common side effects: hot flashes, emotional swings, reduced sexual drive, headache, nausea & vomiting, memory loss, changes in the skin & hair, rapid heartbeat, vaginitis, & weight changes.

For long term therapy, OCs or long-acting progestins are preferable.

56
Q

Surgical Treatment of DUB

A

Surgical treatment should be used:
If anatomic abnormality identified early in diagnostic process.
Failed medical therapy.

57
Q

D&C

A

Has been replaced with EMB as a diagnostic tool in assessing the endometrium.
Reserved for acute heavy bleeding unresponsive to emergent medical care.
Has only a temporary effect – 65% of patients will have a recurrence of bleeding by 3 months.

58
Q

Hysteroscopy

A

Endometrial cavity evaluated by direct visualization → treatment focused on area of abnormality.Complements D&C & used in conjunction with one another whenever anatomic abnormality is suspected.

59
Q

Hysteroscopic Resection

A

Hysteroscopy → access to endometrial cavity for therapeutic intervention.

Surgical tools can be passed through the operating channel of hysteroscope & submucosal fibroids & endometrial polyps resected.

60
Q

Hysterectomy

A

Traditionally, treatment of choice for chronic dysfunctional bleeding – especially when preservation of fertility was not an issue.

Newer surgical treatments & medical treatment options → rate of hysterectomy for DUB has declined.

Still important therapeutic option in properly selected patients.

61
Q

Endometrial Ablation

A

Surgical procedure  endometrial cavity destroyed by either electrocauterization or laser vaporization.
Not for women who desire to keep fertility.
Destroys uterine lining – benefit women who have heavy menstrual bleeding but do not have other underlying uterine problems, such as polyps, hyperplasia of the endometrium, or cancer.
Uses hysteroscope to view uterine cavity → uses electric or laser device to heat & destroy the endometrium.

62
Q

Balloon ablation (Thermachoice)

A

Balloon at the tip of a catheter tube filled with fluid & inflated until it conforms to the walls of the uterus.
Probe in the balloon heats fluid to destroy endometrial lining.

63
Q

Amenorrhea –

A

lack of menstruation.
2 categories:
Primary.
Secondary.

64
Q

Primary Amenorrhea:

A

No period by age 14 in the absence of growth or development of secondary sexual characteristics.

No period by age 16 regardless of the presence of normal growth & development with the appearance of secondary sexual characteristics.

65
Q

Primary Amenorrhea:

3 most common diagnoses (75% of all cases):

A

Gonadal failure.
Congenital absence of the uterus & vagina.
Constitutional delay.

66
Q

Amenorrhea Gonadal failure:

A

Congenital defects of gonadotropin production.
Congenital central nervous system (CNS) defects.
Dysfunctional hypothalamic-pituitary-ovarian axis.

67
Q

Amenorrhea Congenital anatomic malformation of the reproductive system:

A

Absence of vagina & uterus.
Uterine hypoplasia – an abnormally small uterus.
Usually have normal ovarian function → have skeletal growth & development of secondary sex characteristics but no menarche.

68
Q

Secondary Amenorrhea:

A

Absence of periods for:
At least 3 of the previous cycle intervals.
Or 6 months of amenorrhea.

69
Q

Amenorrhea In women of childbearing age, rule out

A

Pregnancy
Patient history.
Pregnancy test.

Menopause
Age.
Accompanying symptoms.

70
Q

Most common causes of secondary amenorrhea: (@75% of all cases):

A

Chronic anovulation.
Hypothyroidism/hyperprolactinemia.
Weight loss/anorexia.

71
Q

Secondary Amenorrhea – Other Causes

A

Functional hypothalamic amenorrhea:
Disturbances in the hypothalamus, pituitary, & thyroid system.
Can be influenced by nutrition, emotions, environmental stressors!
Polycystic Ovary Syndrome – PCOS
Elevated prolactin levels – galactorrhea
Can be caused by pituitary tumor.
Some drugs will  prolactin levels – oc’s, antipsychotic drugs.

72
Q

Premature ovarian failure – absence of menstruation & early depletion of follicles before 40. Causes include:

A

Adrenal, pituitary, or thyroid deficiencies.
Low levels of certain growth factors, called inhibins, that are produced by the ovaries.
Hypergonadotropic hypogonadism – no development of functional ovaries; i.e., Turner’s Syndrome.
Radiation therapy & anti-cancer agents.
Autoimmune diseases.

73
Q

Medical problems may be a possible cause of amenorrhea:

A 
Thyroid disorders.
Cushing’s disease.
Crohn’s disease.
Sickle-cell disease.
HIV.
Kidney disease.
Diabetes.
74
Q

Athletic amenorrhea: (runners, dancers

A 
Several possible causes:
Low percentages of body fat.
Weight loss.
Excessive training.
Poor nutritional habits.
75
Q

Chronic Amenorrhea – Health Problems

A

Infertility.

Osteoporosis – secondary to  estrogen levels
Amenorrhea is common in young female athletes & those with eating disorders.
Bone growth at its peak in adolescence & young adulthood → long-term consequences with losing bone density at this time.

76
Q

Menstruation Requires:

A

An intact outflow tract:
Requires patency & continuity of vaginal orifice, vaginal canal, & endocervix with uterine cavity.

Development of the endometrium of the uterus:
Stimulated & regulated by the sex hormones – estrogen & progesterone.
Secretion of these hormones originates in ovary & dependent on the cyclic process of follicle development, ovulation, & corpus luteum function.

77
Q

Menstruation Requires

A

Maturation of the follicular cycle that is provided by stimuli originating in the anterior pituitary.
Releases gonadotropins:
Follicle-stimulation hormone – FSH.
Luteinizing hormone – LH.

Regulation of the anterior pituitary of the basal hypothalamus.
Gonadotropin-releasing hormone – GnRH.

78
Q

Evaluation of Amenorrhea:

A

Initial evaluation should be simple & logical to identify the source of the problem

79
Q

Amenorrhea can be caused by:

A

Disorders of the outflow tract or uterine target organ.
Disorders of the ovary.
Disorders of the anterior pituitary.
Disorders of central nervous system (hypothalamic) factors.

80
Q

Data Collection:

for amenorrhea

A 
History & physical exam → evaluate for:
Evidence of psychological dysfunction or emotional stress.
Family history of apparent genetic anomalies.
Signs of a physical problem:
Nutritional status.
Abnormal growth & development.
Presence of a normal reproductive tract.
Evidence of CNS disease.
81
Q

Laboratory/Diagnostic Testing: for Amenorrhea

A

Urine pregnancy test:
Regardless of history.
Easy test.
If positive, eliminates need for further evaluation of amenorrhea.

82
Q

If pregnancy has been ruled out:

Amenorrhea work-up

A 
Step 1
TSH (thyroid-stimulating hormone).
Rule out thyroid disease.
Prolactin level.
Rule out hyperprolactinemia.
Progesterone challenge test
83
Q

Progesterone challenge test:

A

Assesses:
Level of endogenous estrogen.
Competence of the outflow tract.
Give a progestational agent with no estrogenic activity.
Within 2-7 days after the conclusion of progestational medication, the patient will either bleed or not bleed.

84
Q

Test Results - Step 1 :

for Amenorrhea

A

Elevated TSH  hypothyroidism  needs appropriate treatment.

Elevated Prolactin → hyperprolactinemia → needs appropriate evaluation/treatment.

85
Q

+ withdrawal bleed (progesterone challenge test) with normal TSH & normal prolactin level:

A

Confirms presence of a functional outflow tract & a uterus lined with reactive endometrium  sufficient endogenous estrogen.
Presence of estrogen  confirms minimal function of the ovary, pituitary, & CNS.
Can make a reliable diagnosis of anovulation  provide appropriate treatment.

86
Q

No withdrawal bleed from progesterone challenge test with normal prolactin level & normal TSH

A

proceed to Step 2:

87
Q

Step 2 for amenorrhea

A

Give estrogen & progestin cycle – 21 days of 1.25mg of conjugated estrogens + provera 10mg daily for the last 5 days.
Challenges capacity of uterus & outflow tract with exogenous estrogen.

With withdrawal bleed  endometrium & outflow tract have normal functional abilities if properly stimulated by estrogen.

88
Q

If there is no withdrawal bleed  defect in the endometrium or outflow tract.
for step 2 for amenorrhea

A

Possible defects:
Congenital abnormality of uterus or outflow tract.
Asherman’s Syndrome – secondary amenorrhea from the destruction of the endometrium  intrauterine scarification & adhesion formation – overzealous curettage, uterine surgery (c-section, myomectomy, metroplasty)

89
Q

With + stimulation of endometrium with exogenous estrogen  need to determine if lack of estrogen is due to a fault in the ovary or CNS-pituitary axis

A

proceed to Step 3.

90
Q

Step 3

for amenorrhea

A

Evaluate FSH & LH levels:
Normal levels  needs evaluation of anterior pituitary gland (coned-down view of Sella Turcica)
If normal, diagnosis of hypothalamic amenorrhea can be made.
If abnormal  needs MRI for evaluation of pituitary tumor.

91
Q

Step 3 results for amenorrhea

A

FSH & LH levels:
Low levels  same evaluation as for normal levels.

High levels  diagnosis of ovarian failure can be made.At step 3 there are numerous tests that can also be performed to confirm or rule out various disease &/or genetic problems.

92
Q

Treatment for amenorrhea

A

Once cause of amenorrhea is identified → detailed pathology & treatment are handled by specialists.

Hormonal therapy with oral contraceptives may be initiated to provide estrogen source & provide cyclic shedding of the endometrium.

93
Q

Only hypothalamic amenorrhea may not require extensive medical treatment:

A

Reversible causes of hypothalamic dysfunction → stress, weight loss for nonorganic reasons, & strenuous exercise programs.

Counseling & behavioral modification.

women health (11 decks)

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