Abnormal Uterine Bleeding Flashcards
Normal menstrual cycle
21-35 days with avg duration of menses 5d; blood loss <80ml,
Abnormal bleeding accounts for
1/3rd outpt gynecology visits overall and >70% gynecologic consults for peri and postmenopausal pts
Menorrhagia
Heavy/prolonged menses
Polymenorrhea
cycle length <21 days
Oligomenorrhea
cycle length >35 days
Intermenstrual bleeding
Bleeding at any time other than nl menses; includes metrorrhagia (irregular intermenstrual bleeding)
Dysfunctional uterine bleeding (DUB)
Dx of exclusion in pts w/abnl uterine bleeding not due to pregnancy, pelvic pathology, medications, or systemic disease
Differential diagnosis of causes of abnormal bleeding
Genital tract lesions
Malignancy, benign lesions (including polyps, leiomyomas, adenomyosis, endometriosis, ectopion), infection, pregnancy
Differential diagnosis of causes of abnormal bleeding
Trauma
Foreign body, pelvic trauma, sexual intercourse, abuse
Differential diagnosis of causes of abnormal bleeding
Medications
Contraception, HRT, steroids, antipsychotics, phenytoin, anticoagulants, supplements (ginseng, gingko, soy)
Differential diagnosis of causes of abnormal bleeding
Systemic disease
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
Evaluation
General approach
medical and menstrual hx to characterize menstrual pattern, menopausal status, and nature of bleeding; r/o nongenital sources (urinary/rectal).
Evaluation
Menstrual pattern
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
Evaluation
Menopausal status
Perimenopausal: + onset of clinical/endocrinologic changes (hot flashes, vaginal dryness, irregular menses) but menes persistent.
Menopausal: >12 months amenorrhea
Evaluation
MEdical history
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
Evaluation
Exam
Pelvic exam to r/o genital tract lesion, eval uterus/adnexa, PAP +/- chlamydia test
Evaluation
Initial studies
Must r/o pregnancy (B-HCG); CBC, TSH; if uterine enlargement or irregularities -> TVUS; consider w/u for nongenital tract cuases
Evaluation
Endometrial biopsy
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
Management
Premenopausal
Based on ovulatory status, later cards
Management
Premenopausal Ovulatory
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
Management
Anovulatory
- check TSH and PRL -> Rx underlying condition
- Assess for hypothalamic dysfunction (stress, eating d/o, chronic disease) -> trial OCPs
- Consider PCOS and its Ddx, chronic anovulation (FSH -/decreased); for either dx can consider treatment with OCPs, levonorgestrel IUD, q3mos progesterone w/d
Management
Perimenopausal
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
Management
Postemnopausal
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
Management
Postmenopausal pts on HRT
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
When to refer
Premenopausal
For endometrial bx in pts <45 w/persietent abnl bleeding, hx unopposed estrogen exposure, or no response to Rx
When to refer
Sev/heavy bleeding
which does not respond to initial tx, consideration of surgical tx
When to refer
Persistent AUB
After initial Rx should undergo TVUS -> if abnormal , refer for hysteroscopy +/- bx or sonohysterography/hysteroscopy
