Abnormal Uterine bleeding

Question 1

Abnormal uterine bleeding scope of the problem

Answer 1

1/3 gynecologic visits due to abnormal bleeding, indication for more than .5 of all hysterectomies performed in the Us

Question 2

Menorrhagia, metrorrhagia, menometrorrhagia, intermenstrual bleeding

Answer 2

Menorrhagia- excessive menstrual bleeding in terms of flow (>80 ml) and or duration (>7 days), this implies regular ovulatory cycles

Metrorrhagia- irregular menstruation intervals

Menometrorrhagia- irregular menstruationintervals with excessive flow or duration

Intermenstrual bleeding- uterine bleedig in between apparently ovulatory menses

Meno- too much, metro- irrgular intervals

Question 3

Abnormal bleedin PALM COEIN

Answer 3

Polyps, Adenomysosi, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, endometrial, iatrogenic, Not yet clssified

Question 4

Benign neoplasms -polyps

Answer 4

Endometrial polyps (fleshy outgrowths of endometrium), Endocervical polyps (outgrowths of cervical mucosa)

Usually benign

Question 5

Neoplasms

Answer 5

Both myometrial processes (adenomyosis and leiomyomas) and endometrial processes (polyps) can result in abnormal uterine bleeding

the myometrium can act as a reservoir of growth factors or immune cells that then may act on the endometrium in a paracrine or local endocrine fashion

Question 6

Adenomyosis

Answer 6

Benign invasion of endometrium into the myometrium
Cause menorrhagia and dysmenorrhea
clincally pts have an enlarged tender uterus

Question 7

Leiomyoma (uterine fibrinoids)

Answer 7

Very common
Associated with symptoms (menorrhagia/menometrorhagia– refractory anemia), intermenstrual spotting, pelvic pain, dysmenorrhea, mass symptoms (urinary pressure/urgency, constipation, flank pain, increasing abdominal girth, symptoms depend upon location

Most prevalent during the reproductive years, typically regress of become asymptomatic after the onset of menopause, are rarely observed before puberty, treatment depends on location and patients desires for fertility

Parity decreases risk , obesity increases risk, genetically component, hormonally responsive

Question 8

Malignant neoplasmas

Answer 8

Endometrial cancer, typically diagnosed with endometrial biopsy or endometrial curettage, hysteroscopy specimen, cervical cancer

Question 9

Anovulation and abnormal uterine bleeding

Answer 9

Chronic exposure to estrogen without the benefit of cyclic exposure to postovulatory progesterone can result in a thickened, structually incompetent endometrium

rsulting in asynchronous shedding of portions of the endometrium unaccompanied by vasoconstriction, the bleeding associated with unopposed estrogen exposure is often heavy

unopposed exposure to estrogen predisposes to endometrial hyperplasia and cancer, overall risk of progression to cancer based upon duration of unopposed estrogen exposure, progesterone antagonizes estrogen stimulation of proliferation, progesterone is protective and progestins can be used therapeutically

Question 10

Endometrial atropy

Answer 10

often described as spotting, related to hypoestrogenism (common in postmenopausal patients), clinically indistinguishable from the earliest symptoms of endometrial cancer and thus must be carefully evaluated in the perimenopausal women

Post menopausal bleeding is endometrial cancer until proven otherwise

Question 11

Iatrogenic causes of abnormal bleeding

Answer 11

Gonadal steroid hormones, gonadal steroid related therapy (SERMs, aromatase inhibitors, GnRH agonists), anticoagulants, intrauterine device, medications that interfere with ovulation, affect dopamine metabolism or cause hyperprolactinemia

Question 12

Evaluation of abnormal bleeding

Answer 12

evaluation of anovulation if indicated, over age 40 or history suggestive of unopposed exposure to estrogen - endometrial biopsy, now-onset menorrhagia or starting at menarche - coagulation studies

Question 13

hormonal treatments for abnormal uterine bleeding

Answer 13

depend on symptoms and causes- anovulatory patients- restore regular exposure to estradiol and progesterone

ovulatory patients with leiomyoma or adenomyosis, hormonal suppression (oral contraceptive pills, GnRH agonists, GnRH antagonists, progesterone receptor modulators, aromatase

Question 14

surgical treatments for abnormal uterine bleeding

Answer 14

Endometrial polyps- operative hysteroscopy, uterine fibrinoids (myomectomy (abdominal laparaoscopic, hysteroscopic), uterine artery embolization, magnetic resonance imaging guided focused ultrasound surgery, endometrial ablation

Question 15

infertility

Answer 15

trying for a year for younger, 6 months for older than 35

Question 16

Ovulation disorders

Answer 16

usually determed by menstrual history, anovulation, oligoovulation, early ovulation/ dysfunctional cycle

Question 17

PCOS

Answer 17

wt loss,
Clomiphene citrate, low cost, clinically safe

It is a sERM (which tells the hypothalamus to make more Gnrha nd pit to make more FSH and LH

But theres antiestrogen effects ( endometrial lining, cervical mucus), 4-10% incidence multtiple pregnancy

Question 18

Aromatase inhibitor

Answer 18

Not fda approved for ovulation induction off label use, lower multiple rates due to monofollicular ovulaiton induction

lower estrogen to make follicle lower risk of multiple pregnancy

Question 19

ovarian reserve with incresaing age

Answer 19

Acceleration of follicular loss, reduced oocyte pool, decreased egg quality

Question 20

Ovarian reserve testing

Answer 20

Antimullerian hormone, antral follicle counts, Day 3 FSH /estradiol

Question 21

treatments for infertility

Answer 21

Intrauterine insemination, with unexplained infertility, male factor, pts with ovulation induction medication prior to IUI
Invitrofertilization (2-3%)

Question 22

Endometriosis

Answer 22

Endometrial tissue implants outside the uterus

Endometrial glands, can result in adhesions, pain and infertility, results in generalized inflammatory state

Dysmenorrhea, dyspareunia, infertility, dyschezia, meds involve hormonal suppression and NSAIDs

Scar tissue, ovarian cysts,

Question 23

Medical endometriosis

Answer 23

hormonal suppression to minimize stimulation of endometriosis tissue (OCPs, GnRH agonists, aromatase inhibitors, oral GnRH antagonists

Decrease inflammation and prostaglandins