Abnormal Uterine Bleeding Flashcards
What is the most effective medical therapy for reducing heavy menstrual bleeding?
20 mcg per day levonogestrel IUD (mirena)
SOR A criteria
What is the most effective treatment for heavy menstrual bleeding
hysterectomy
SOR A criteria
What is first line imaging choice for abnormal uterine bleeding?
TV-US
SOR C criteria
Who should have endometrial biopsy for abnormal uterine bleeding?
> 45 years old
< 45 years old with significant hx of unopposed estrogen exposure, persistent bleeding, or in whom medical management is ineffective
SOR C criteria
What are two tests you should get in all women with abnormal uterine bleeding
CBC, pregnancy test
SOR C criteria
What classification system should be used in all women with abnormal uterine bleeding?
PALM-COEIN - you’ll have to explain it on a different flash card
SOR C criteria
What is the best initial study in abnormal uterine bleeding in
- women > 45 or significant estrogen exposure hx
- women < 45 without significant estrogen exposure hx
- Endometrial biopsy
- TVUS
SOR B criteria
In women who have postmenopausal vaginal bleeding, what is the first step in screening? What is the second step?
step 1: endometrial biopsy
SOR A criteria
Step 2: Saline infused US
SOR B criteria
What is the PALM-COEIN classification system for abnormal uterine bleeding?
PALM: structural
- polyp
- adenomyosis
- leiomyoma
- malignancy and hyperplasia
COEIN: nonstructural cuases
- coagulopathy
- ovulatory
- endometrial
- iatrogenic
- not yet classified
How do you use history of distinguish between anovulatory and ovulatory bleeding?
Anovulatory: irregular or infrequent, flow ranges from light to excessively heavy. Progesterone deficient, estrogen dominant state
Ovulatory: regular intervals, excessive volume (need to change every 1-2 hours), passage of clots > 1 inch, or duration 8 days
Definition amenorrhea
absence of periods for > 3 cycles = 90 days
Definition of oligomenorrhea
menses occurring at intervals of more than 38 days
Definition of metrorrhagia
menses at irregular intervals with excessive bleeding or lasting > 8 days
What are some causes of anovulatory bleeding?
- uncontrolled DM
- eating disorder
- hyper/hypothyroidism
- hyperprolactinemia
- medication: antipsychotic/antiepileptic
- PCOS
- Pregnancy
What are the steps to evaluation and management in anovulatory bleeding?
Determine need for endometrial biopsy: > 45, < 45 with other risks of endometrial cancer
if < 45 and low risk of cancer
–> long term medical therapy.
–> if continued abnormal bleeding, perform Endometrial biopsy
–> if EMB normal, perform TVUS or Saline infused US to r/o structural cause
–> if unclear, hysteroscopy
What should you do with the following endometrial biopsy result?
Hyperplasia without atypia
Treat with depo provera OR levonogestrel IUD OR daily megestrol
Repeat EMB in 3-6 months
Refer to gyn if hyperplasia persists
What should you do with the following endometrial biopsy result?
Hyperplasia with atypia
Refer to gynecologist
Onset of heavy menses at menarche is often the first sign of what disorder?
Von Wilebrand Disease
Approach to evaluation of ovulatory abnormal uterine bleeding in women with low endometrial cancer risk
If menstrual cycle is regular but heavy or > 8 days duration
- -> H&P to rule out systemic disease or enlarged uterus
- -> obtain HCG, CBC, TSH
- -> if adolescent or adult with + screen for possible bleeding disorder, eval for disorder in partnership with hematologist
- -> consider TVUs, SISH, or EMB
Which imaging study is superior in detection of intracavitary lesions and is better for premenopausal women?
TVUS vs Saline infusted sonohysterography (SISH)
Saline infusted sonohysterography (SISH)
Medical treatment options for abnormal uterine bleeding
- levonogestrel IUD
- OCP
- progestins (continuous dosing)
- NSAIDs: decrease prostacyclin, use while bleeding
- Tranexamic acid, only while bleeding
Steps in evaluation of secondary amenorrhea
- rule out pregnancy
- TSH to eval hypo/hyperthyroid. Prolactin to eval for pituitay tumor
- Determine relative estrogen status with progesterone challenge test
What is the progesterone challenge test and what do you do with results?
- > Give medroxyprogesterone 10 mg PO x 10 days
- > ANY bleeding more than spotting within 2-7 days is positive
- -> Positive test: meaning anovulation with progresterone deficiency - not adqquately produced in luteal phase. Give OCP or progestin. Risk of endometrial cancer increased.
- -> Negative test: Could be outflow tract or hypogonadism. You would do estrogen/progestin challenge test next
What is the estrogen/progestin challenge test and what do you do with results?
Helps distinguish outflow tract obstruction vs hypogonadism after a negative progestin challenge test.
No withdrawal bleeding –> outflow obstruction
+ withdrawal bleeding –> measure FSH and LH
- FSH and LH high = primary ovarian insufficiency
- Normal or low –> get MRI –> Once lesions are excluded = hypothalamic amenorrhea
How do you diagnose hypothalamic amenorrhea
- Low or normal FSH/LH
- normal prolactin
- low levels of estrogen
- MRI negative for pituitary lesions
Usually in anorexia/bulimia, stress, high-intensity exercise, chronic illness
How do you diagnose PCOS?
Rotterdam Criteria: presence of two of the following three findings
- Hyperandrogenism - clinical or chemical (inc testosterone or DHEA)
- Ovulatory dysfunction - oligo or amenorrhea
- Polycystic ovaries
What screening is recommended in women with PCOS?
- BP
- lipid level
- screen for type 2 DM (2 hr gtt preferred). Repeat q3-5 years
- Depression
- OSA
SOR C
What is first line medication in women with PCOS?
OCPs - in those who don’t desire pregnancy
Monophasic 25 mcg pill is best
SOR A
Treatment of PCOS
- oligomenorrhea and amenorrhea
- hirsutism
- insulin resistance
- infertility
- oligomenorrhea and amenorrhea: OCP or monthly progesterone
- hirsutism: OCPs, spironolactone, finasteride
- insulin resistance: metformin
- infertility: Letrozole > clomiphene (SOR A)
Should you get an FSH in a women in her 40s to identify menopaus as a cause of irregular or abnormal bleeding?
No - choosing wisely
How long can women on hormone therapy be observed for postmenopausal bleeding?
They may be observed for 1 year before diagnosing AUB
- irregular bleeding is common after HT is initiated and improves within 6-12 months for most women.
