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Family Medicine Boards 2020 > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

1
Q

What is the most effective medical therapy for reducing heavy menstrual bleeding?

A

20 mcg per day levonogestrel IUD (mirena)

SOR A criteria

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2
Q

What is the most effective treatment for heavy menstrual bleeding

A

hysterectomy

SOR A criteria

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3
Q

What is first line imaging choice for abnormal uterine bleeding?

A

TV-US

SOR C criteria

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4
Q

Who should have endometrial biopsy for abnormal uterine bleeding?

A

> 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

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5
Q

What are two tests you should get in all women with abnormal uterine bleeding

A

CBC, pregnancy test

SOR C criteria

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6
Q

What classification system should be used in all women with abnormal uterine bleeding?

A

PALM-COEIN - you’ll have to explain it on a different flash card

SOR C criteria

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7
Q

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
A
  • Endometrial biopsy
  • TVUS

SOR B criteria

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8
Q

In women who have postmenopausal vaginal bleeding, what is the first step in screening? What is the second step?

A

step 1: endometrial biopsy
SOR A criteria

Step 2: Saline infused US
SOR B criteria

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9
Q

What is the PALM-COEIN classification system for abnormal uterine bleeding?

A

PALM: structural

  • polyp
  • adenomyosis
  • leiomyoma
  • malignancy and hyperplasia

COEIN: nonstructural cuases

  • coagulopathy
  • ovulatory
  • endometrial
  • iatrogenic
  • not yet classified
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10
Q

How do you use history of distinguish between anovulatory and ovulatory bleeding?

A

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

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11
Q

Definition amenorrhea

A

absence of periods for > 3 cycles = 90 days

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12
Q

Definition of oligomenorrhea

A

menses occurring at intervals of more than 38 days

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13
Q

Definition of metrorrhagia

A

menses at irregular intervals with excessive bleeding or lasting > 8 days

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14
Q

What are some causes of anovulatory bleeding?

A
  • uncontrolled DM
  • eating disorder
  • hyper/hypothyroidism
  • hyperprolactinemia
  • medication: antipsychotic/antiepileptic
  • PCOS
  • Pregnancy
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15
Q

What are the steps to evaluation and management in anovulatory bleeding?

A

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

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16
Q

What should you do with the following endometrial biopsy result?

Hyperplasia without atypia

A

Treat with depo provera OR levonogestrel IUD OR daily megestrol

Repeat EMB in 3-6 months

Refer to gyn if hyperplasia persists

17
Q

What should you do with the following endometrial biopsy result?

Hyperplasia with atypia

A

Refer to gynecologist

18
Q

Onset of heavy menses at menarche is often the first sign of what disorder?

A

Von Wilebrand Disease

19
Q

Approach to evaluation of ovulatory abnormal uterine bleeding in women with low endometrial cancer risk

A

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
20
Q

Which imaging study is superior in detection of intracavitary lesions and is better for premenopausal women?

TVUS vs Saline infusted sonohysterography (SISH)

A

Saline infusted sonohysterography (SISH)

21
Q

Medical treatment options for abnormal uterine bleeding

A
  • levonogestrel IUD
  • OCP
  • progestins (continuous dosing)
  • NSAIDs: decrease prostacyclin, use while bleeding
  • Tranexamic acid, only while bleeding
22
Q

Steps in evaluation of secondary amenorrhea

A
  1. rule out pregnancy
  2. TSH to eval hypo/hyperthyroid. Prolactin to eval for pituitay tumor
  3. Determine relative estrogen status with progesterone challenge test
23
Q

What is the progesterone challenge test and what do you do with results?

A
  • > 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
24
Q

What is the estrogen/progestin challenge test and what do you do with results?

A

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

25
Q

How do you diagnose hypothalamic amenorrhea

A
  • 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

26
Q

How do you diagnose PCOS?

A

Rotterdam Criteria: presence of two of the following three findings

  1. Hyperandrogenism - clinical or chemical (inc testosterone or DHEA)
  2. Ovulatory dysfunction - oligo or amenorrhea
  3. Polycystic ovaries
27
Q

What screening is recommended in women with PCOS?

A
  • BP
  • lipid level
  • screen for type 2 DM (2 hr gtt preferred). Repeat q3-5 years
  • Depression
  • OSA

SOR C

28
Q

What is first line medication in women with PCOS?

A

OCPs - in those who don’t desire pregnancy
Monophasic 25 mcg pill is best

SOR A

29
Q

Treatment of PCOS

  • oligomenorrhea and amenorrhea
  • hirsutism
  • insulin resistance
  • infertility
A
  • oligomenorrhea and amenorrhea: OCP or monthly progesterone
  • hirsutism: OCPs, spironolactone, finasteride
  • insulin resistance: metformin
  • infertility: Letrozole > clomiphene (SOR A)
30
Q

Should you get an FSH in a women in her 40s to identify menopaus as a cause of irregular or abnormal bleeding?

A

No - choosing wisely

31
Q

How long can women on hormone therapy be observed for postmenopausal bleeding?

A

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.

Family Medicine Boards 2020 (46 decks)

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