Abnormal Uterine Bleeding Flashcards
AUB definition
- defined as menstrual bleeding of abnl quantity, duration, or schedule
- common gynecologic complaint accounting for 1/3 of outpatient visits to gynecologists
normal frequency of menses
q 24-38 days
frequent uterine bleeding is defined by what?
< 24 days
0ligomenorrhea or infrequent uterine bleeding
> 38 days
Absence of
menstrual periods greater than 6 months in previously menstruating women = ?
secondary amenorrhea
normal duration of menses
up to 8 days
normal volume of menses
<80 mg blood per cycle
heavy menstrual bleeding (HMB)
> 80 mg per cycle or any volume that interferes with physical, social,
emotional or material quality of life
Intermenstrual Bleeding
-Defined as bleeding that occurs between periods
Cyclic midcycle intermenstrual bleeding
occurs just after ovulation and very common, d/t drop in estrogen after ovulation
Cyclic premenstrual or post menstrual intermenstrual bleeding
usually light spotting and associated
with luteal phase defect or endometriosis
Acyclic intermenstrual bleeding
-unpredictable
-Often benign, but can be associated with endometrial
or cervical cancer.
-Think cervical cancer in post coital bleeding
etiologies of AUB
- local dz
- systemic dz
- medications
- MC etiologies in nonpregnant women are structural uterine pathology (fibroids, polyps, adenomyosis), ovulatory dysfunction, disorders of hemostasis or neoplasia
PALM COEIN
PALM: structural causes
- Polyp
- Adenomyosis
- Leiomyoma (submucosal or intramural)
- Malignancy/hyperplasia
COEIN: nonstructural causes
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not classified yet
Polyps
- endocervical or endometrial
- detected by US or sonohysterography
- often irregular, light bleeding
Adenomyosis
- relationship b/w AUB and adenomyosis is not well understood
- diagnosed w/ US, MRI, or pathology
Leiomyoma
- occurs in black women 2-3 x more often than white women and earlier in 20s than 30s (vit. D?)
- diagnosed w/ exam, US, MRI, CT
- heavy, regular bleeding
Malignancy and hyperplasia
- relatively uncommon cause of AUB
- must be r/o in all cases
- screening tests vary by hx, age, presenting sx
Coagulopathy
- MC causes: ITP, VonWillebrand’s, Glanzman’s, Thallasemia major or Fanconi’s anemia
- test for bleeding time, INR, PRR, platlets, and VonWillebrand’s
- in adolescents w/ AUB, 10% will have coagulopathy
- usually ovulatory cycles w/ severe menorrhagia, more commonly in early menarche or perimenopausal as estrogen wanes
Annovulatory
- MC cause of AUB
- hallmark is infrequent periods
- physiologic: adolescence, perimenopause, laction/preg.
- pathologic: hyperandrogenic, hypothalamic, thyroid dz, primary pit., premature ovarian failure, meds/herbal supplements
Endometrial
-Predictable and cyclic menstrual bleeding, typical of ovulatory
cycles
- No other definable causes are identified, usually diagnosis of
exclusion
-Usually HMB is main symptoms- primary disorder of
mechanisms regulating local endometrial “hemostasis” itself
Iatrogenic
-MC cause of breakthrough bleeding (BTB) is the use of gonadal steroid therapy
-Systemically administered single-agent or combination gonadal steroids—including
estrogens, progestins, and androgens—impact the control of ovarian steroidogenesis via
effects on the hypothalamus, pituitary, and/or ovary itself, and also exert a direct effect
on the endometrium
-also anticonvulsants and abx, smoking, IUDs, antidepressants, anticoagulants
Not yet classified
Several uterine entities might contribute to, or cause, AUB in a given individual; however, this has not been demonstrated conclusively because these entities—such as chronic endometritis, arteriovenous malformations, and myometrial hypertrophy—have been poorly defined, inadequately examined, or both
initial hx on w/u of AUB
● Acute vs Chronic
● Characterize bleeding pattern
● Menstrual bleeding hx (incl. severity and assoc pain)
● FamHx: AUB/ bleeding disorders
● Meds: warfarin, heparin, NSAID, OCP, ginkgo, ginseng, motherwort
PE on w/u of AUB
● PCOS: obesity, hirsutism, acne
● Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy
● DM: acanthosis nigricans
● Bleeding disorder: petechiae, pallor, signs of hypovolemia
● Pelvic exam - is it from the uterus?!?
Labs to run in w/u of AUB
● Pregnancy test (always get)
● CBC (Strong recommendation)
● Targeted screening for bleeding disorder (when indicated)
● TSH
● Gonorrhea/Chlamydia in high risk patients
Imaging in w/u of AUB
● TVUS (first line) ● Sonohysterography or SIS ● Hysteroscopy ● MRI Endometrial biopsy (EMB)
Acute AUB
episode of bleeding in a woman of reproductive age, who is not pregnant, that, is of sufficient quantity to require immediate intervention to prevent further blood loss.
chronic AUB
Bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.
Ddx in AUB
- ectopic pregnancy
- miscarriage
- implantation of pregnancy
- cervical, vaginal or uterine pathology
*do transvaginal US
conditions that determine an ectopic pregnancy until proven otherwise
bleeding + pos hCG + pain
When to get imaging
- abnl pelvic exam (enlarged uterus or adnexal mess) –> needs US
- persistent bleeding after treatment
- US can’t be used to r/o endometrial CA in premenopausal women (must have EMB)
- not necessary if source of bleeding is visible on PE, ovulatory dysfunction or infection
When to get an EMB
- women > 45 as first line test
- women w/ persistent bleeding refractory to medication regardless of age
- women < 45 w/ risk factors for endometrial CA
risk factors for endometrial CA
◦ obesity (body mass index > 30 kg/m2)
◦ nulliparity
◦ hypertension
◦ irregular menstruation ◦ polycystic ovary syndrome
◦ diabetes
◦ hereditary nonpolyposis colorectal cancer
◦ family hx of endometrial cancer
approach to treatment for chronic AUB
- primary etiology treated first (including PCOS or chronic endometriosis); consider treating structural lesions that can be resectable vis hysteroscopy
- initial approach: usually pharmacological, possibly IUD.
- surgical tx usually secondary
approach to treating HMB and AUB-O
- usually combined monophasic OCPs or IUD is used unless contraindication or not desiring contraception
- can also use high dose progestin-only contraceptives
chronic tx options
- expectant management: check CBC q 6-12 mo.
- NSAIDs
- antifibrinolytics agents (lysteda)
- hormonal methods: combos, levonorgestrel IUD, cyclic progestin, GnRH agonists
- metformin and other insulin-sensitizing drugs for irregular bleeding in women w/ PCOS
treatment of annovulatory AUB
- thyroid dysfunction tx will resolve AUB once nl functions after 2 mo.
- hyperpolactinemia tx w/ cabergoline or bromocriptine. When prolactin is nl, nl menses returns in 2 cycles
tx of hemorrhage
- usually at extremes of age
- r/o pregnancy, trauma, coagulopathy
- replace blood products as needed
- EMB depending on age and hx
- high dose IV conjugated estrogen to slow bleeding then switch to oral
- oral high does E + P if stable
- cycle w/ hormonal contraceptives 2 mo.
surgical management options for hemorrhage
- D&C: temporary reduction in bleeding allows tissue sampling and retains fertility
- endometrial ablation (for post childbearing)
- uterine artery embolization (for leiomyomas post childbearing)
- hysterectomy (definitive)
dysmenorrhea
severe, painful cramping sensation in the lower abdomen often
accompanied by other symptoms – sweating, tachycardia, headaches, n/v, diarrhea, tremulousness, all occurring just before or during menses
primary vs. secondary dysmenorrhea
- Primary: no obvious pathologic condition, onset < 20 years old
- Secondary: associated with pelvic conditions or pathology
pathogenesis of primary dysmenorrhea
elevated PG F2α in secretory endometrium (increased uterine contractility)
tx of primary dysmenorrhea
- NSAIDs – PG synthetase inhibitors – 1st line treatment of choice
- alternative: OCPs and other analgesics
etiologies of secondary dysmenorrhea
- Cervical Stenosis
- Endometriosis and Adenomyosis
- Pelvic Infection
- Adhesions
- Pelvic Congestion
- Stress and Tension
cervical stenosis
- Severe narrowing of cervical canal may impede menstrual outflow
- congenital or iatrogenic
- can cause increase in intrauterine pressure during menses
- can lead to endometriosis
cervical stenosis
- hx
- dx
- tx
-hx: scant menstrual flow, severe cramping throughout menses
-dx: inability to pass a thin probe through the internal os OR HSG
demonstrates thin cx canal
-tx: cervical dilation via D&C or laminaria placement
Pelvic congestion
- d/t engorgment of pelvic vasculature
- hx: burning or throbbing pain, worse at night and after standing
- dx: laproscopic visualization of engorgement or varicosities of broad ligaments and pelvic sidewall veins
evaluation of pelvis pain
● Detailed hx, targeted PE, labs (UA, UCx, CBC, HCG, tumor markers), diagnostic imaging studies (US, MRI, CT) as appropriate
● Consider age of patient
● “OLDCAAR”: onset, location, duration, context, associated sx, aggravating/relieving factors
● Temporal characteristics: cyclic (e.g. dysmenorrhea), intermittent (e.g. dyspareunia), non-cyclic
● Risk factors
● GYN and Non-GYN causes
DDx of pelvic pain - GYN
- Uterus: fibroids, adenomyosis, endometritis
- Fallopian tubes: PID/salpingitis, hydrosalpinx, ectopic
- Ovaries: cysts – functional, pathological, TOA, torsion; mittleschmerz
- Other: endometriosis, adhesions, IUD/infection, severe prolapse
DDx of pelvic pain - non- GYN
Urologic:
- UTI/urethritis, interstitial cystitis (IC), OAB, urethral diverticulum,
nephrolithiasis, malignancy
GI:
- constipation, IBS, IBD (Crohn’s, UC), bowel obstruction, diverticulitis,
malignancy, appendicitis Musculoskeletal:
- trigger points, fibromyalgia, hernias, neuralgia, low back pain
Other:
- psychiatric – depression, somatization; abdominal cutaneous nerve entrapment in surgical scar; celiac disease
definition of endometriosis
-A dz characterized by the presence of endometrium-like epithelium and stroma outside the endometrium and myometrium
peritoneal endometriosis
Intrapelvic endometriosis can be located superficially on the peritoneum
deep endometriosis
can extend 5 mm or more beneath the peritoneum
endometrioma
endometriosis presenting as an ovarian endometriotic cyst
activities negatively impacted by sx of endometriosis
Sexual life - 50% Relationship Family - 36%
Performance at work/school/university -35%
Housekeeping-34%
Attendance at work/school/university -32% Social activities -29% Sports -21%
Other-9%
prevalence of endometriosis
-1:10 during reproductive years
Retrograde menstruation (Sampson’s Theory) of the pathogenesis of endometriosis
Endometrial fragments transported through fallopian tubes at time of menstruation and implant at intraabdominal sites
**most accepted theory
Müllerian (Coelomic) metapalasia theory (Meyer’s Theory) of the pathogenesis of endometriosis
Metaplastic transformation of pelvic peritoneum
Lymphatic spread (Halban’s Theory) of the pathogenesis of endometriosis
Substances released/shed from endometrium induce formation of
endometriosis
sx of endometriosis
• severe dysmenorrhoea • deep dyspareunia • chronic pelvic pain • ovulation pain • cyclical or perimenstrual symptoms (e.g. bowel or bladder associated) with or without abnormal bleeding • infertility • chronic fatigue
diagnosis of endometriosis
- inspection of pelvis at laparoscopy is gold standard investigation unless dz is visible in vagina or elsewhere
- diagnostic delay is on average 7 years
how to confirm the diagnosis of endometriosis
positive histology confirms it but negative histology doesn’t exclude it
Key considerations in the management of endometriosis
- Severity of the symptoms
- Extent of the disease
- Desire for future fertility
- Age of the patient
- Threat to GI or urinary tract
1st line medical treatment of endometriosis
- NSAIDS
- OCP’s , cyclic or continuous
- Progestins (i.e. Medroxyprogesterone acetate) Depression, loss of bone calcium
*strongly consider laparoscopy to both diagnose and treat the disease.
2nd line medical treatment of endometriosis
- Mirena IUD (levonorgestrel)
- GnRH agonists (Lupron) (should not be done without laparoscopy first)
- High dose progestins – suppress gonadotropin release
- Danazol – androgenic derivative which suppresses LH and FSH (rarely used now)
fertility preserving surgical tx for endometriosis
Laparoscopic (or rarely, laparotomy) with ablation or excision of
endometrial implants and adhesions
Endometriomas >3 cm in diameter should be removed surgically
most definitive surgical tx for endometriosis
Hysterectomy (most often laparoscopic) with ablation or excision of all
endometrial implants and adhesions.
Removal of ovaries has been traditional, but newer studies suggest
retention of ovaries is reasonable in many cases. Always a risk of recurrence!
