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.
2
Q
AUB can be
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Normal physiologic event → irregular bleeding resulting from anovulation that often accompanies menarche.
Symptomatic of perimenopause.
Pathologic, life-threatening conditions → ectopic pregnancy; endometrial cancer.
3
Q
Understanding AUB:
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Know physiologic basis of normal menstrual physiology.
Functional structure of reproductive tract.
4
Q
Normal Menstruation
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Requires coordination of the hypothalamic-pituitary-ovarian axis. (HPOA)
Wide variation in menstrual cycles – know what is “normal” for each patient.
5
Q
Normal Menstrual Patterns:
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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.
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.
7
Q
AUB present when:
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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.
8
Q
AUB Terminology:
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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.
9
Q
Causes of AUB:
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Physiologic.
Pathologic.
Pharmacologic.
10
Q
Causes of AUB:
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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
11
Q
Women of childbearing age presenting with AUB
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do a pregnancy test first.
12
Q
AUB Etiology
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Pregnancy. Chronic anovulation. Ovulatory problems. Systemic disease. Gynecologic problems. Medications. Coagulation problems
13
Q
AUB Endocrine problems/systemic:
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Adrenal hyperplasia. Cushings syndrome. Diabetes. Polycystic ovary syndrome. Pituitary. Thyroid disease.
14
Q
AUB Medications/substances/herbs:
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Amphetamines. Anticoagulants. Antipsychotics. Benzodiazepines. Corticosteroids. Herbs (ginkgo, ginseng, soy) Hormone therapy. Isoniazide. SSRI antidepressants. Hormonal contraceptives.
15
Q
AUB - Problems with HIPOA
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Systemic illness (e.g., PCOS, pituitary, thyroid) Premature ovarian failure. Postmenarche. Perimenopause. Stress. Eating disorders. Severe dieting and/or weight loss. Excessive exercise.
16
Q
AUB Reproductive tract disease/dysfunction:
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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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Q
AUB - Systemic disease
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Thyroid dysfunction. Hypertension. Liver disease. Coagulation defects. Von Willebrand’s Leukemia. Idiopathic thrombocytopenia
18
Q
CNM/NP Role in Management of AUB
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Complete history & initial physical examination.
Initial lab evaluation.
Referral to appropriate specialist for further evaluation & treatment.
Patient counseling, education, & reassurance.
19
Q
Assessment of AUB
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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.
20
Q
History:
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Patient’s age Incidence of various causes of bleeding problems change depending on woman’s stage of life: Peripubertal. Reproductively mature. Perimenopausal.
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
22
Q
History-taking:
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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.
23
Q
Physical Examination
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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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Q
Physical Examination (cont)
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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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Pelvic exam
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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Speculum exam
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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Bimanual exam:
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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Rectovaginal examination:
Can help to confirm diagnosis of PID or endometriosis.
| Assess rectal lesions & masses.
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Laboratory & Diagnostic Tests
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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
Diagnostic Testing
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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Diagnostic Testing
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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Who needs EMB?
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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Treatment of AUB
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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Dysfunctional Uterine Bleeding (DUB)
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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Ovulatory DUB
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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Anovulatory DUB
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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Failure of HPOA feedback mechanism → no normal folliculogenesis → corpus luteum does not form.
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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Anovulatory DUB
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.
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Objectives in Treating DUB
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Control bleeding.
Prevent recurrence.
Preserve fertility.
Correct associated disorders.
Induce ovulation in women who desire to conceive.
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Factors influencing choice of therapy for treatment of DUB:
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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
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DUB Acute Bleeding Episode:
Medical D&C”:
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DUB No orthostatic hypotension, HgB ≥ 10g/dl, bleeding not profuse:
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.
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DUB After acute bleeding:
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.
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DUB
| Continue to cycle for 3 months
If contraception needed → continue OCP.
| OCP contraindicated → cycle Provera 10 mg. po for 14 days, off 14 days, on 14 days – for 3 months.
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DUB Active bleeding episode - + orthostatic hypotension, Hgb < 10 g/dl, + profuse bleeding
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.
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Why use high dose estrogen to control acute bleeding?
High dose estrogen will allow sufficient endometrium buildup for estrogen/progesterone therapy to be effective.
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Medical Treatment of Non-Emergent DUB
| Hormonal Treatment:
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.
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Recurrent DUB → long-term menstrual cycle control:
Combined oral contraceptive pills.
Progestin therapy.
NSAIDs.
GNRH Analogues
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Progestin Therapy:
| for DUB
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
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Progestin options: For DUB
Provera 10mg X 10 days.
Norethindrone 5mg X 10 days.
Progesterone-in-oil 100-150mg IM X 1 dose.
Progestin IUD
51
Progestin IUD
| for DUB
Delivers progestational agent directly to endometrium.
Reduces menstrual flow → may induce amenorrhea.
Can control:
Anovulatory cycles.
Ovulatory cycles with heavy menstrual bleeding.
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Nonsteroid Anti-inflammatory Agents for DUB
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.
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NSAID Therapy for DUB
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Mefanamic acid (Ponstel) 500 mg TID
Ibuprofen 600 mg TID
Naproxen sodium 550 mg loading dose then 275 mg every 6 hours
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54
GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin) For DUB
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.
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GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin for DUB side effects
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.
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Surgical Treatment of DUB
Surgical treatment should be used:
If anatomic abnormality identified early in diagnostic process.
Failed medical therapy.
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D&C
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.
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Hysteroscopy
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.
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Hysteroscopic Resection
Hysteroscopy → access to endometrial cavity for therapeutic intervention.
Surgical tools can be passed through the operating channel of hysteroscope & submucosal fibroids & endometrial polyps resected.
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Hysterectomy
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.
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Endometrial Ablation
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.
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Balloon ablation (Thermachoice)
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.
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Amenorrhea –
lack of menstruation.
2 categories:
Primary.
Secondary.
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Primary Amenorrhea:
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.
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Primary Amenorrhea:
| 3 most common diagnoses (75% of all cases):
Gonadal failure.
Congenital absence of the uterus & vagina.
Constitutional delay.
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Amenorrhea Gonadal failure:
Congenital defects of gonadotropin production.
Congenital central nervous system (CNS) defects.
Dysfunctional hypothalamic-pituitary-ovarian axis.
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Amenorrhea Congenital anatomic malformation of the reproductive system:
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.
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Secondary Amenorrhea:
Absence of periods for:
At least 3 of the previous cycle intervals.
Or 6 months of amenorrhea.
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Amenorrhea In women of childbearing age, rule out
Pregnancy
Patient history.
Pregnancy test.
Menopause
Age.
Accompanying symptoms.
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Most common causes of secondary amenorrhea: (@75% of all cases):
Chronic anovulation.
Hypothyroidism/hyperprolactinemia.
Weight loss/anorexia.
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Secondary Amenorrhea – Other Causes
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.
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Premature ovarian failure – absence of menstruation & early depletion of follicles before 40. Causes include:
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.
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Medical problems may be a possible cause of amenorrhea:
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Thyroid disorders.
Cushing’s disease.
Crohn’s disease.
Sickle-cell disease.
HIV.
Kidney disease.
Diabetes.
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Athletic amenorrhea: (runners, dancers
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Several possible causes:
Low percentages of body fat.
Weight loss.
Excessive training.
Poor nutritional habits.
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Chronic Amenorrhea – Health Problems
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.
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Menstruation Requires:
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.
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Menstruation Requires
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.
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Evaluation of Amenorrhea:
Initial evaluation should be simple & logical to identify the source of the problem
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Amenorrhea can be caused by:
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.
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Data Collection:
| for amenorrhea
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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.
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Laboratory/Diagnostic Testing: for Amenorrhea
Urine pregnancy test:
Regardless of history.
Easy test.
If positive, eliminates need for further evaluation of amenorrhea.
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If pregnancy has been ruled out:
| Amenorrhea work-up
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Step 1
TSH (thyroid-stimulating hormone).
Rule out thyroid disease.
Prolactin level.
Rule out hyperprolactinemia.
Progesterone challenge test
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Progesterone challenge test:
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.
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Test Results - Step 1 :
| for Amenorrhea
Elevated TSH hypothyroidism needs appropriate treatment.
| Elevated Prolactin → hyperprolactinemia → needs appropriate evaluation/treatment.
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+ withdrawal bleed (progesterone challenge test) with normal TSH & normal prolactin level:
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.
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No withdrawal bleed from progesterone challenge test with normal prolactin level & normal TSH
proceed to Step 2:
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Step 2 for amenorrhea
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.
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If there is no withdrawal bleed defect in the endometrium or outflow tract.
for step 2 for amenorrhea
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
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
proceed to Step 3.
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Step 3
| for amenorrhea
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
Step 3 results for amenorrhea
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.
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Treatment for amenorrhea
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.
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Only hypothalamic amenorrhea may not require extensive medical treatment:
Reversible causes of hypothalamic dysfunction → stress, weight loss for nonorganic reasons, & strenuous exercise programs.
Counseling & behavioral modification.
