Abnormal Uterine Bleeding Flashcards
**Abnormal Uterine Bleeding **
Definition
- **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)
Polymenorrhea
Definition
Frequent menstruation w/ bleeding intervals <21 days
Menorrhagia
Definition
Clinical Definition
- 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
Metrorrhagia
Definition
Irregular menstrual intervals
Menometrorrhagia
Definition
Irregular menstruation intervals
Excessive flow and/or duration
Oligomenorrhea
Definition
Menstruation fewer than 9 times/yr
Avg bleeding intervals >35 days
Hypomenorrhea
Definition
Very light or short duration menstruation
Intermenstrual bleeding
Definition
Uterine bleeding in btwn apparently ovulatory menses
Amenorrhea
Definition
Absence of menses for at least 6 mo or 3 cycles
Postmenopausal bleeding
Definition
Uterine bleeding > 12 mo after cessation of menses
What are the 4 most common uterine conditions that cause abnormal uterine bleeding?
- Pregnancy – normal or abnormal
- Infection
- Neoplasms
- Adenomyosis
What are the neoplasms responsible for abnormal uterine bleeding?
- Leiomyomas
- Endometrial Polyps
- Endocervical Polyps
- Cervical Cancer
- Endometrial Cancer
Leiomyomas
Definition
Bleeding
Types
- 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
**Endometrial Polyps **
Definition
Risk
- 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 _
**Endocervical Polyps **
Definition
Symptoms
- Soft, fleshy growths
- Originate from the mucosal surface of the endocervical canal
- When symptomatic, manifest as _intra-menstrual or post-coital spotting _
Adenomyosis
Definition
Exam findings
- Benign invasion of endometrium into myometrium
- 2/3 – menorrhagia & dysmenorrhea
- Pelvic exam – diffusely enlarged & tender uterus
What are some causes of abnormal uterine bleeding unrelated to uterine pathology?
“Dysfunctional Uterine Bleeding”
- Exogenous hormones
- Ovulation defects
- Endometrial atrophy
- Coagulopathy
What are the 5 main ovulation defects that cause abnormal uterine bleeding?
- Oligo-ovulation & Anovulation
- Polycystic Ovarian Syndrome
- Systemic diseases that can mimic PCOS
- Endometrial atrophy
- Coagulopathy
Oligo-ovulation & Anovulation
Definition
Risk
- 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
What is the mechanism of anovulation & its effect on the endometrium?
- 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
Endometrial Atrophy
Definition
- Spotting
- Indistinguishable from earliest symptoms of endometrial cancer
- Must be carefully evaluated in perimenopausal & postmenopausal women
- Hypoestrogenemia – surgical/natural menopause
Coagulopathy
Definition
Inborn or acquired conditions that interfere w/ normal hemostatic mechanisms in the case of vascular interruption
Clinical Evalulation of Abnormal Uterine Bleeding
History
- 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
Clinical Evaluation of Abnormal Uterine Bleeding
Lab Testing
- 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
Clinical Evaluation of Abnromal Uterine Bleeding
Imaging
-
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
How do you treat abnormal uterine bleeding unrelated to pregnancy or uterine pathology?
- Correction of underlying systemic abnormalities
- Returning endometrium to functional status w/ exogenous hormone therapy
- ex: hypothyroidism, hyperprolactinemia
What is the emergency treatment for anovulatory bleeding?
- 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
Endometriosis
Definition
Primary symptoms
Inheritance
- 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
Classical Theories of Endometriosis (4)
-
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
Endometriosis
Anatomic sites
- Most common: pelvis near tubal fimbria
- Ovaries
- Anterior & posterior cul-de-sac
- Broad ligament
- Uterosacral ligaments
- Most common extragenital location: bowel
What types of adhesions are formed from endometriosis? What do they cause?
- 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
With endometriosis, there are:
Abnormal levels of ___________.
Negative effects on ____________.
- Abnormal levels of cytokines, growth factors, inflammatory cells
- Negatively affects sperm motility, oocyte maturation, fertilization, embryo survival, tubal function
What type of pain is associated w/ endometriosis?
What is it caused by?
- Depth of endometriosis lesions associated w/ pain & dysmenorrhea
- Pain w/ advanced disease caused by:
- Extensive adhesions
- Ovarian cysts
- Deeply infiltrating endometriosis
What are the symptoms of endometriosis?
-
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 **
What are the treatment options for endometriosis?
Oral contraceptives & NSAIDs
GnRH agonists
Progestins
Aromatase Inhibitors
Surgical removal
________ & _________ are the first line therapy for chronic pain associated w/ endometriosis.
Oral contraceptives
NSAIDs
GnRH agonists for endometriosis
Examples
Mechanism
- 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
Progestins for endometriosis
Examples
Mechanism
- **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
_________ & __________ are the aromatase inhibitors used to treat endometriosis.
Letrozole
**Medroxyprogesterone acetate **
In patients with endometriosis, success rates w/ IVF appear to be (lower/higher).
Lower
