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Reproductive System > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

1
Q

**Abnormal Uterine Bleeding **

Definition

A
  • **Describes any uterine bleeding outside the parameters of normal menstruation that occurs during the reproductive years **
  • Important to differentiate btwn abnormal bleeding associated w/ uterine factors or anovulation (lack of ovulation)
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2
Q

Polymenorrhea

Definition

A

Frequent menstruation w/ bleeding intervals <21 days

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3
Q

Menorrhagia

Definition

Clinical Definition

A
  • Excessive menstrual bleeding
  • Flow (<80 mL) and/or duration (<7 days)
  • Regulatory ovulatory cycles
  • Clinical Definition
    • Bleeding on the heaviest day requiring changing soaked sanitary pads or tampons more than once every 2 hrs
    • Using more than one sanitary pad
    • Using a sanitary pad & tampon at a time
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4
Q

Metrorrhagia

Definition

A

Irregular menstrual intervals

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5
Q

Menometrorrhagia

Definition

A

Irregular menstruation intervals
Excessive flow and/or duration

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6
Q

Oligomenorrhea

Definition

A

Menstruation fewer than 9 times/yr
Avg bleeding intervals >35 days

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7
Q

Hypomenorrhea

Definition

A

Very light or short duration menstruation

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8
Q

Intermenstrual bleeding

Definition

A

Uterine bleeding in btwn apparently ovulatory menses

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9
Q

Amenorrhea

Definition

A

Absence of menses for at least 6 mo or 3 cycles

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10
Q

Postmenopausal bleeding

Definition

A

Uterine bleeding > 12 mo after cessation of menses

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11
Q

What are the 4 most common uterine conditions that cause abnormal uterine bleeding?

A
  • Pregnancy – normal or abnormal
  • Infection
  • Neoplasms
  • Adenomyosis
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12
Q

What are the neoplasms responsible for abnormal uterine bleeding?

A
  • Leiomyomas
  • Endometrial Polyps
  • Endocervical Polyps
  • Cervical Cancer
  • Endometrial Cancer
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13
Q

Leiomyomas

Definition

Bleeding

Types

A
  • Benign myometrial tumors
  • Common but many don’t cause symptoms
  • Menorrhagia more likely to be related to those lying immediately adjacent to the endometrium
  • Types
    • Intramural
    • Pedunculated subserosal
    • Subserosal
    • Submucosal
    • Cervical
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14
Q

**Endometrial Polyps **

Definition

Risk

A
  • Localized overgrowths of the endometrium
  • Project into the uterine cavity
  • Usually benign in pre-menopausal women
  • Risk of associated endometrial malignancy _increases significantly w/ age _
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15
Q

**Endocervical Polyps **

Definition

Symptoms

A
  • Soft, fleshy growths
  • Originate from the mucosal surface of the endocervical canal
  • When symptomatic, manifest as _intra-menstrual or post-coital spotting _
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16
Q

Adenomyosis

Definition

Exam findings

A
  • Benign invasion of endometrium into myometrium
  • 2/3 – menorrhagia & dysmenorrhea
  • Pelvic exam – diffusely enlarged & tender uterus
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17
Q

What are some causes of abnormal uterine bleeding unrelated to uterine pathology?

A

“Dysfunctional Uterine Bleeding”

  • Exogenous hormones
  • Ovulation defects
  • Endometrial atrophy
  • Coagulopathy
18
Q

What are the 5 main ovulation defects that cause abnormal uterine bleeding?

A
  • Oligo-ovulation & Anovulation
  • Polycystic Ovarian Syndrome
  • Systemic diseases that can mimic PCOS
  • Endometrial atrophy
  • Coagulopathy
19
Q

Oligo-ovulation & Anovulation

Definition

Risk

A
  • Irregularity or absence of ovulation
  • Common in women of reproductive-age not using hormonal contraception
  • Episodes of endometrial exposure to unopposed estrogen increase the risk of AUB, endometrial hyperplasia & endometrial cancer
20
Q

What is the mechanism of anovulation & its effect on the endometrium?

A
  • Chronic exposure of endometrium to estrogen w/o postovulatory progesterone
  • Endometrium abnormally thickened & structurally incompetent
  • Asynchronous shedding of portions of the endometrium w/o vasoconstriction
  • Heavy bleeding
  • Blood not lysed by endometrial enzymes –> blood clots –> menstrual cramping
21
Q

Endometrial Atrophy

Definition

A
  • Spotting
  • Indistinguishable from earliest symptoms of endometrial cancer
  • Must be carefully evaluated in perimenopausal & postmenopausal women
  • Hypoestrogenemia – surgical/natural menopause
22
Q

Coagulopathy

Definition

A

Inborn or acquired conditions that interfere w/ normal hemostatic mechanisms in the case of vascular interruption

23
Q

Clinical Evalulation of Abnormal Uterine Bleeding

History

A
  • Most important factor in determining diagnostic approach
  • Usual & recent menstrual patterns
  • Extent of recent bleeding
  • Sexual activity
  • Contraception
  • Personal or FaHx of bleeding disorder
  • Symptoms of pregnancy, infection, changes in body hair, excessive bleeding, systemic disease
  • Current medication & information about previous Pap smears
  • Review of systems
    • Weight gain or loss
    • Abdominal swelling
    • Somnolence
    • Nipple discharge
24
Q

Clinical Evaluation of Abnormal Uterine Bleeding

Lab Testing

A
  • All patients
    • Pregnancy test
    • CBC (including platelets)
    • Pap smear
    • Cervical tests for gonorrhea & chlamydia
  • Appropriate testing for anovulation if applicable
  • Over age 40: endometrial biopsy
  • New-onset menorrhagia
    • Prothrombin time
    • Activation PTT
    • Bleeding time
  • Menorrhagia since menarche
    • Above plus: hematology studies
25
Q

Clinical Evaluation of Abnromal Uterine Bleeding

Imaging

A
  • Endometrial Biopsy
    • Performed in the office
    • Flexible catheter placed through cervical canal into the uterus
  • Transvaginal Ultrasonography & Sonohysterography
  • Office Hysteroscopy
    • Camera & distension media to visualize uterine cavity
26
Q

How do you treat abnormal uterine bleeding unrelated to pregnancy or uterine pathology?

A
  • Correction of underlying systemic abnormalities
  • Returning endometrium to functional status w/ exogenous hormone therapy
  • ex: hypothyroidism, hyperprolactinemia
27
Q

What is the emergency treatment for anovulatory bleeding?

A
  • Expedient cessation of bleeding
  • Achieve structural stability of endometrium as quickly as possible
  • If don’t desire pregnancy
    • Promote universal, synchronous endometrial shedding at regular intervals or stop menstruation all together
  • Combinations of estrogen and/or progestin
28
Q

Endometriosis

Definition

Primary symptoms

Inheritance

A
  • Presence of endometrial glands & stroma outside the endometrial cavity & uterine musculature
  • Primary symptoms: **pain & infertility **
  • Growth is _estrogen dependent _
  • Prevalence increased 7X in 1st degree relatives
29
Q

Classical Theories of Endometriosis (4)

A
  • Transplantation theory
    • Endometrium regurgitated into the peritoneal cavity implants on the peritoneum
  • Coelomic metaplasia
    • Undifferentiated cells of Müllerian origin in the peritoneal cavity can differentiate into endometrial tissue
  • Induction
    • Endometrium or another agent induces metaplasia of the mesothelium to endometriotic tissue
  • Vascular/lymphatic dissemination
    • Explains presence of endometriosis at distant sites
30
Q

Endometriosis

Anatomic sites

A
  • Most common: pelvis near tubal fimbria
    • Ovaries
    • Anterior & posterior cul-de-sac
    • Broad ligament
    • Uterosacral ligaments
  • Most common extragenital location: bowel
31
Q

What types of adhesions are formed from endometriosis? What do they cause?

A
  • Adhesion formation btwn different pelvic or abdominal organs
  • Peritubal or peri-ovarian adhesions & tubal wall fibrosis
    • Decreases tubal motility & access to ovulated oocytes
  • Minor adhesions inside the tubal lumen
    • May impair transport of the oocyte
32
Q

With endometriosis, there are:

Abnormal levels of ___________.

Negative effects on ____________.

A
  • Abnormal levels of cytokines, growth factors, inflammatory cells
  • Negatively affects sperm motility, oocyte maturation, fertilization, embryo survival, tubal function
33
Q

What type of pain is associated w/ endometriosis?

What is it caused by?

A
  • Depth of endometriosis lesions associated w/ pain & dysmenorrhea
  • Pain w/ advanced disease caused by:
    • Extensive adhesions
    • Ovarian cysts
    • Deeply infiltrating endometriosis
34
Q

What are the symptoms of endometriosis?

A
  • Reproductive Tract
    • Infertility
    • Dysmenorrhea
    • Dyspareunia
    • Noncyclic pelvic pain
  • GI
    • Diarrhea and/or constipation
    • Pain w/ bowel movement
    • Abdominal cramps
    • Cyclic rectal bleeding
  • Urinary Symptoms
  • **Low back pain **
35
Q

What are the treatment options for endometriosis?

A

Oral contraceptives & NSAIDs

GnRH agonists

Progestins

Aromatase Inhibitors

Surgical removal

36
Q

________ & _________ are the first line therapy for chronic pain associated w/ endometriosis.

A

Oral contraceptives

NSAIDs

37
Q

GnRH agonists for endometriosis

Examples

Mechanism

A
  • Empiric treatment w/o laparoscopy
  • Highly effective in relieving pain associated w/ endometriosis
    • Intramuscular: Leuprolide acetate
    • SubQ: Goserelin
    • Nasal: Nafarelin
  • Suppress gonadotropin secretion
  • After initial increase in gonadotropins (first 10 days) –> decrease in pituitary secretion secondary to GnRH receptor down-regulation
  • 6 mo course
38
Q

Progestins for endometriosis

Examples

Mechanism

A
  • **Norethindrone Acetate **
  • Most commonly used add-back regimen
  • Low dose estrogen (conjugated equine estrogen) can be added to Norethindrone w/o loss of benefit in symptom control
39
Q

_________ & __________ are the aromatase inhibitors used to treat endometriosis.

A

Letrozole

**Medroxyprogesterone acetate **

40
Q

In patients with endometriosis, success rates w/ IVF appear to be (lower/higher).

A

Lower

Reproductive System (35 decks)

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