Abnormal Uterine Bleeding

Question 1

What volume is normally lost in menstrual bleeding?

Answer 1

30mL.

Question 2

Define Abnormal Uterine Bleeding

Answer 2

• > 80mL
• Cycle length: <24 days or >35 days.
• Intermenstrual or post coital bleeding.

Question 3

Define Dysfunctional uterine bleeding

Answer 3

Excessive bleeding not due to

• pregnancy
• pelvic pathology
• systemic disease.

Classified

• cyclical (ovulatory)
• non cyclical (anovulatory). eg. end + beginning of reproductive life.

Question 4

Menorrhagia

Answer 4

Excessive/prolonged menstrual bleeding - regular intervals.

Question 5

Inter-menstrual bleeding.

Answer 5

Bleeding between regular menstrual cycles.

Question 6

Post coital bleeding

Answer 6

Bleeding up to 24 hours after intercourse.

Question 7

Pre menstrual spotting

Answer 7

Bleeding during the week prior to the period.

Question 8

Metrorrhagia

Answer 8

Uterine bleeding at irregular intervals: normal or less than normal volume.

Question 9

Menometrorrhagia

Answer 9

Uterine bleeding at irregular intervals: prolonged or excessive.

Question 10

Polymenorrheoea

Answer 10

Regular bleeding at intervals <24 days.

Question 11

What are the structural causes of abnormal uterine bleeding?

Answer 11

• PALM -

Polyp
Adenomyosis (growth of endometrial tissue within the myometrium)
Leiomyoma (fibroids)
Malignancy (hyperplasia or carcinoma - endometrial cancer).

• Don’t forget pregnancy!!

Question 12

What are the functional causes of abnormal uterine bleeding?

Answer 12

• COIEN-

Coagulopathy (vWB, thrombocytopenia, ITP, liver/renal failure, acute leukemia).
Ovulatory disorder/hormone disorder (thyroid, diabetes, PCOS, oestrogen secreting tumours).
Iatrogenic (anticoagulants, corticosteroids, contraceptives).
Endometrial (endometriosis, inflammation, infection, abnormalities).
Not yet classified.

• Don’t forget pregnancy!!

Question 13

What time period after cessation of periods is considered AUB in a post menopausal woman?

Answer 13

6 months

Question 14

What is the most common cause of AUB in a post menopausal woman? But what must always be ruled out?

Answer 14

• iatrogenic hormonal withdrawal + atrophic changes to vagina.
  Ruled out: Endometrial Cancer.

Question 15

What investigations are done in AUB for:

• adolescents
• woman of reproductive age
• post menopausal woman

Answer 15

Adolescent:
- FBC
- Iron
- Coags
IMAGING: Trans abdo US. 

Woman of Reproductive Age:
- Beta HCG
- FBC, Iron
- Coags
- TFT, BSL
- Papsmear + thin prep
- TVS --> hysteroscopy if focal lesion found. 
POST COITAL
- Chlamydia PCR/urine PCR
- colposcopy. 

Post Menopausal Woman

• Papsmear
• Colposcopy
• TVS–> Hysteroscopy if focal lesion found, bx if thickness > 5mm.

Question 16

What is the management of the different causes of AUB?

Answer 16

Polyps:

• OCP (control bleeding)
• NSAIDS (decrease PG, decrease uterine activity).
• Surgical removal (uterus - hysterocopy, cx - colposcopy).

Adenomyosis: NSAIDs

Fibroids: GnRH analogue, DEPOT, myomectomy, ablation, artery embolisaiton.

Malignancy: removal/hysterectomy.

Coagulopathy: replacement tx, treat underlying cause.

Ovulatory dysfx: 
- combined OCP
- progesterone pill
- IUD
- Implanon
- NSAIds
If due to anovulation: GnRH analogue. 

Iatrogenic:

• change pill/anticoagulant
• or watch (ie - IUD, first 6m has increased bleeding).

Endometrial

• OCP/GnRH analogue/Progesterone
• Laparoscopic excision/ablation.

If acute

• ABCDs
• IV fluids, cross match , G+H
• High dose oestrogen:
• Tamponade + foleys catheter.

Question 17

What are the different type of fibroids, and how is leiomyoma diagnosed and treated?

Answer 17

Intramural
Submucosa
Sub Serous
Cervical.

Dx

• Bimanual exam (painless enlarged growths).
• US.

Mx
Medical: GnRH analogues, DEPOT –> shrinkage due to low oestrogen.

Surgical: Resection, ablation.