Abnormal Uterine Bleeding

Question 1

Normal menstrual cycle

Answer 1

21-35 days with avg duration of menses 5d; blood loss <80ml,

Question 2

Abnormal bleeding accounts for

Answer 2

1/3rd outpt gynecology visits overall and >70% gynecologic consults for peri and postmenopausal pts

Question 3

Menorrhagia

Answer 3

Heavy/prolonged menses

Question 4

Polymenorrhea

Answer 4

cycle length <21 days

Question 5

Oligomenorrhea

Answer 5

cycle length >35 days

Question 6

Intermenstrual bleeding

Answer 6

Bleeding at any time other than nl menses; includes metrorrhagia (irregular intermenstrual bleeding)

Question 7

Dysfunctional uterine bleeding (DUB)

Answer 7

Dx of exclusion in pts w/abnl uterine bleeding not due to pregnancy, pelvic pathology, medications, or systemic disease

Question 8

Differential diagnosis of causes of abnormal bleeding

Genital tract lesions

Answer 8

Malignancy, benign lesions (including polyps, leiomyomas, adenomyosis, endometriosis, ectopion), infection, pregnancy

Question 9

Differential diagnosis of causes of abnormal bleeding

Trauma

Answer 9

Foreign body, pelvic trauma, sexual intercourse, abuse

Question 10

Differential diagnosis of causes of abnormal bleeding

Medications

Answer 10

Contraception, HRT, steroids, antipsychotics, phenytoin, anticoagulants, supplements (ginseng, gingko, soy)

Question 11

Differential diagnosis of causes of abnormal bleeding

Systemic disease

Answer 11

Coagulopathy in up to 20% of women w/heavy bleeding (vonwillebrand, decrease platelets, leukemia), ESLD, endocrine disease (thyroid, cushing, adrenal hyperplasia, increase prolactin), hypothalamic suppression (wt loss, excess exercise, stress), ESRD

Question 12

Evaluation

General approach

Answer 12

medical and menstrual hx to characterize menstrual pattern, menopausal status, and nature of bleeding; r/o nongenital sources (urinary/rectal).

Question 13

Evaluation

Menstrual pattern

Answer 13

Ovulatory: regular cycle length, + cervical mucus, + premenstrual sx -> determine bleeding pattern (menorrhea, polymenorrhea, oligomenorrhea, or intermenstrual bleeding)

Anovulatory: (more common in pts p/w AUB): Irregular flow/duration of menses, premenstrual sx often absent

Question 14

Evaluation

Menopausal status

Answer 14

Perimenopausal: + onset of clinical/endocrinologic changes (hot flashes, vaginal dryness, irregular menses) but menes persistent.

Menopausal: >12 months amenorrhea

Question 15

Evaluation

MEdical history

Answer 15

Coagulopathy, ESLD, ESRD/HD, endocrine disease; sexual hx; Fhx: Menstrual irregularity, fibroids/endometrial disease/CA; Meds: see above; in on HRT or OCPs, review adherence (Irregular use may -> spotting); ROS: wt loss, stress, endocrine sx

Question 16

Evaluation

Exam

Answer 16

Pelvic exam to r/o genital tract lesion, eval uterus/adnexa, PAP +/- chlamydia test

Question 17

Evaluation

Initial studies

Answer 17

Must r/o pregnancy (B-HCG); CBC, TSH; if uterine enlargement or irregularities -> TVUS; consider w/u for nongenital tract cuases

Question 18

Evaluation

Endometrial biopsy

Answer 18

Indicated in perminopausal women >45 w/AUB, women <45 y w/persistent abnl bleeding, hx unopposed estrogen, or no response to Rx, and postemenopausal women who do not undergo TVUS for eval of endometrium

Question 19

Management

Premenopausal

Answer 19

Based on ovulatory status, later cards

Question 20

Management

Premenopausal Ovulatory

Answer 20

Varis by bleeding pattern; menorrhagia: r/o bleeding d/o, with transvaginal ultrasound (TVUS) for fibroids/uterine pathology -> if negative, trial OCPs, levonorgestrel IUD or NSAIDs; polymenorrhea: trial OCPs, consider eval for luteal phase defect; oligomenorrhea: seen w/ prolonged follicular phase -> trial OCP’s or q3mos progesterone; intermentrual: r/o cervical pathology, consider IUD removal and/or trial OCPs

Question 21

Management

Anovulatory

Answer 21

1. check TSH and PRL -> Rx underlying condition
2. Assess for hypothalamic dysfunction (stress, eating d/o, chronic disease) -> trial OCPs
3. Consider PCOS and its Ddx, chronic anovulation (FSH -/decreased); for either dx can consider treatment with OCPs, levonorgestrel IUD, q3mos progesterone w/d

Question 22

Management

Perimenopausal

Answer 22

If no genital tract lesion per hx/PE and negative BHcg, -> eval to r/o endometrial hyperplasia/CA (see indications ofr TVUS vs Bx)

NI/atrophic-> observe vs trial OCPs or levonorgestrel IUD
Atypia/carcinoma -> refer to Gyn
Hyperplasia -> refer to Gyn; treat with progesterone DandC if persistent

Question 23

Management

Postemnopausal

Answer 23

Bleeding usually 2/2 vaginal/endometrial atrophy, but CA must be excluded -> TVUS or endometrial bx to r/o malignancy (cause of 5-10% of AUB)

Endometrial bx: if abnl refer to as above; if normal but bleeding persists -> TVUS, refer for hysteroscopy or sonohysterography; if nl and bleeding resolves can observe, o/w repeat bx

TVUS: Endometrial stripe < 4mm c/w atrophic, endometrium; > or equal to 4mm or irregular appearance -> bx, refer per pathology as above

Question 24

Management

Postmenopausal pts on HRT

Answer 24

Increases incidence of AUB (40-60%) particularly soon after initiation; asses HRT adherence (poor adherence can increase bleeding) and RFs for endometrial CA -> use shared decidion making and clinical judgement (observation vs endometrial assessment

If bleeding (1) lasts greater than or equal to 6 mos (2) present prior to HRT initiation (3) heavy/persistent despite Increase progesting dose or (4) develops after period of amenorrhea while on HRT -> initiate w/u

Question 25

When to refer

Premenopausal

Answer 25

For endometrial bx in pts <45 w/persietent abnl bleeding, hx unopposed estrogen exposure, or no response to Rx

Question 26

When to refer

Sev/heavy bleeding

Answer 26

which does not respond to initial tx, consideration of surgical tx

Question 27

When to refer

Persistent AUB

Answer 27

After initial Rx should undergo TVUS -> if abnormal , refer for hysteroscopy +/- bx or sonohysterography/hysteroscopy