Abnormal Uterine Bleeding Flashcards
AUB Objectives
- Review characteristics of the normal menstrual cycle
- Define Abnormal Uterine Bleeding (AUB)
- Understand the PALM-COINE classification system used for assessment, differential diagnosis, and mngmnt of AUB
- Identify the laboratory/diagnostic tests commonly used in the assessment, differential diagnosis, and mngment of AUB
- Review the assessment, dx, and mngmt of amenorrhea
Normal Uterine Bleeding
- Frequency
- Normal:
- Abnormal
- Absent:
- Infrequent:
- Frequent:
- Duration
- Normal
- __ days or fewer
- Shortest to longest cycle variation __-__ days or fewer
- Abnormal
- Prolonged:
- Shortest to longest cycle variation __-__ days or more
- Normal
- Flow Volume
- Normal
- _____
- _____
- Frequency
- 24-38 days
- No bleeding
- More than 38 days
- Less than 24 days
- 24-38 days
- Duration
- Normal
- 8
- 7-9
- Abnormal
- Prolonged: more than 8 days
- 8-10
- Normal
- Flow Volume
- Normal
- Light
- Heavy
Heavy Menstrual Bleeding (HMB)
Quantitative
- Changing pads/tampons > __ hrs, use of > __ tampons for a single menses, have to change at ____, ____ > 1 inch, an____
Qualitative
- Excessive menstrual los which intereferes with a woman’s?
- >3 hrs, >20, night, clot, anemia
- physical, social, emotional, and/or material quality of life
Normal Bleeding Chart
Variation in cycle duration varies more at what ages ranges? (2)
- *18-25 years < __ d
- 26-41y, < __ d
- 42-45 y, < __
18-25 and 42-45
- 9
- 7
- 9
Intermenstrual Bleeding (IMB) Chart
Bleeding between cyclically regular onset of menses
- N____
- R____
- Cyclic (Predictable) (3)
- None
- Random
- Early, Mid, Late Cycle
Unscheduled Bleeding on Progestin + Estrogen Gonadal Steroids
(birth control pills, rings, patches, or injections)
- Not Applicable =
- None or Present =
- not on gonadal steroid medication
- on gonadal steroid medication
AUB: Chronic
Bleeding changes in _____, _____, ______, or ______ relative to the person’s _____
**> ___ months of excessive duration, volume, frequency, or unpredictability
Ph_____ v. P______ v. Ph______
duration, amount, frequency, regularity, norm
3m**
Physiologic, Pathologic, Pharmacologic
Most Common Cause of AUB
=
PREGNANCY
(or some complication of pregnancy)
***ALWAYS RULE OUT PREGNANCY FIRST!!!***
AUB: PALM-COEIN Classification System
for causes of AUB in the Reproductive years
-
STRUCTURAL
- P
- A
- L
- M
-
NON-STRUCTURAL
- C
- O
- E
- I
- N
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and Hyperplasia
- Coagulopathy
- Ovulatory Dysfunction
- Endometrial
- Iatrogenic
- Not otherwise classified
Structural changes: tx usually surgical
AUB: Structural POLYPS
**CC: Bleeding with s___, ___ing, ____ing, _______ bleeding
Bleeding with sex, lifting, straining, intermenstrual bleeding
AUB Structural: ADENOMYOSIS
Where does it occur?
**CC:
**Exam:
In the muscle layer - endometrial implants
Regular, prolonged HMB, painful menses (dysmenorrhea), painful sex (dyspareunia), chronic pevlic pain
Uterus is boggy, globular, tender
CC: PAIN!
AUB: Structural: LEIOMYOMA (Fibroid, Myoma)
=
**CC:
**PE:
Actual growths (not made of endometrial tissue, made of stroma and fibrous tissue)
Can occur at any layer
Regular, prolonged HMB (bulk symptoms: urinary frequency, pain with sex, pelvic pressure) -presses on bladder
Uterus is firm, enlarged, non-tender, irregular, bulky
AUB Structural: MALIGNANCY (and Hyperplasia)
Risk Factors
- Overexposure to endogenous _______
- O_____, ___parity, ___ menopause, ____ menarche, chronic __ovulation, P _ _ _
- _____ Hx/ Genetics
- Medications (1)
- A___/____menopausal
**CC:
- estrogen*
- Obesity, nulliparity, late, early, anovulatin, PCOS
- Family
- Selective Estrogen Receptor Modulate (SERMS)
- Age/Postmenopausal
HMB, prolonged, irregular, IMB or postmenopausal bleeding
AUB Non-Structural: COAGULOPATHY
Clotting Disorders
- 13% of AUB pts
- Adolescents w AUB: 20-30% ___ ______
**Clinical Presentation**
- _ _ _, pro_____, since _____
- PMH: _ _ Hemorrhage, s____ related bleeding, bleeding w ____ work, br_____, n____ bleeds, bleeding g____
- FmH: Bleeding ______
Lab Tests (4)
Management (1)
- Von Willibrands
- HMB, prolonged, menarche
- Postpartum, surgery, dental, bruising, nose bleeds, gums
- Disorder
- Von Willibrand panel/Ristocetin Co-Factor, PTT, PT
- REFER to hematology
AUB: Non-Structural: IATROGENIC
M_____/D_____ that contribute to unscheduled bleeding
- Hormonal ______/_ _ \_
-
Anti_____/Anti_____\_
- Atypical antipsychotics: r_____, pali_____, tri___\_
- Anti______\_
- H____/S______: g_____, ch_____, p_____ enzymes
**Clinical Presentation:
Medications/Devices
- Contraceptives/IUDS
- Antidepressants/Antipsychotics
- Risperidone, paliperidone, tricyclic
- Anticoagulants
- Herbs/Supplements: ginseng, chastberry, pineapple enzymes
HMB/prolonged, IMB, amenorrhea
AUB Non-Structural: OVULATORY DYSFUNCTION (Anovulatory Bleeding)
- Pathophysiology: _____ axis disruption (suppression of ______)
-
(S____/N____/E____/Sl____/Tr____, BMI >__, Endocrinopathies: _____ Disorders, ______ Disorders (Hyper______), Hyper______ Disorder
- Abnormal pattern of _____ stimulation that is dis_____ and un_____
- __stable, v____ endometrium; ____- vessels prone to ______
- ___ Luetal/Secretory phase: potential for endometrial ___________
-
Clinical Prestation
- Abnormal cycle _____, in__________ >38d
- Abnormal amount of flow: _______ (light or HMB)
- _ _ _
- HPO, GnRH
-
Stress, Nutrition, Exercise, Sleep, Travel, >30, <18, Thyroid, Piuitary Hyperprolactinemia, Hyperandrogenic
- hormone, disorganized, unpredictable
- Unstable, vascular: fragile, rupture
- No, hyperplasia
- intervals, infrequency
- Amenorrhea
- IMB
AUB Non-Structural: ENDOMETRIAL
Dx of ______ for _ _ _**
- Clinical presentation**: _ _ _ when all other underlying causes are?
- Increased endometrial _______ activator activity
- Individual diff in ______ production
- Local _______ events and/or deficient ____ processes within the endometrium
Exclusion, HMB
- HMB, when all other causes are ruled out
- plasminogen
- prostaglandin
- inflammatory, repair
Algorithm
Not listed, first test for amenorrhea -> pregnancy test
History
- Best initial menstrual hx question:
- Focused Hx: _MP, _MP, fr____, d_____, r_____, v_____
- Risk for ____, Risk for ______
- _______ Use
- Other meds: anti______, p______ meds, h_____ preparations
- PmHx: s______
- Family Hx: inherted _______, _____ disorders, c_____
- S____, S_____, E_____, N_____, T______
- What does a typical menstrual cycle look like for you?
- LMP, PMP, frequency, duration, regularity, volume
- STIs, pregnancy
- Contraceptive
- Anticoagulants, Psychotropic, Herbal
- Surgeries
- bleeding (coagulopathies), endocrine (thyroid), cancers
- Stress, Sleep, Exercise, Nutrition, Travel
Physical
- ______ disturbance: if something growing on pituitary and compressing optic nerve
- Th_____
- Signs of _____: pale skin, poor cap refill
- Signs of hyer_____: hirsuitism, acne, acanthosis nigricans
- Breast development, dis____
- ___: under or overweight
- Pelvic Exam: _____ inspection/_____ exam
- C_____ bleeding is uterine
- R/O tr____, signs of ______
- Bi_____ exam: evaluate for st_____ anomaly
- Visual
- Thyroid
- Anemia
- Androgenism
- discharge
- BMI
- VIsual, Speculum
- Confirm
- trauma, infection
- Bimanual, structural
Labs/Diagnostics
- U _ T
- _ _ _ w/platelets; I___/Ferrin
- _ SH
- Pro____
- ___ smear
- G____/Ch____ testing: point of care testing of vaginal ____
- Coagulation studies (3)
- Hormone lvls PRN: (4)
- PRN Uterine Evaluation: Transvaginal _____ or Endometrial _____ (EmBx)
- UPT (urine pregnancy test)
- CBC, Iron
- TSH
- Prolactin
- Pap
- Gonorrhea, Chlamydia, discharge
- Von Willibrand-Ristocetin factor, PT, PTT)
- FSH, LH, mid-luteal progesterone, testosterone
- US, Biopsy
PRN Uterine Evaluation
- Based on Pelvic Exam
- Increased risk for _____ abnormality?
- _______ Ultrasound (TVUS)
- (Hysteroscopy, Saline Infusion sonohysteroscopy-SIS, MRI)
- Based on Family Hx or HX or unopposed estrogen
- Increased risk for?
- Order Endometrial _____
- Age > __, all ___menopausal, any age if _____ w 3+ yrs of AUB
- Pelvic Exam
- structural
- transvaginal
- Fam Hx or unopposed estrogen
- endometrial hyperplasia or neoplasia
- Biopsy
- 45, postmenopausal, obese
Medical Therapies for HMB
**Long term/Chronic Management (3)**
**Combined contraceptive (oral, patch, ring)**
Depo Provera 150mg
LNG-US (Mirena, Skyla, Kyleena, or Liletta)
Usually hormonal method
Amenorrhea
**Secondary:**
Primary:
No menses x > 3 consecutive cycles once regular menses established (or 6 mos of missed menses in 1 yr)
Absence of menarche by age 16 (eval if > 15 or >3 yrs since breast development (the larche)
CC Amenorrhea: HX and PE
- History: 24yo
- Typical cycle: ___-__ days, __-__ days of moderate bleeding
- __ consecutive months no menses
- BMI: __, light exercise 2x/wk
- PmHx, Fhx, Meds: None/noncontributory
- Increased st___ x 3 months
- PE
- _____ Field problems
- Thyroid: nod____, en_____
- Breast: g_____
- Skin: moist/dry; ac____ nig_____
- Hyper_____: hir___, alopecia, acne
- BMI: Obesity/Underweight (Low body fat)
- _____ Exam prn
- Hx
- 35-45, 4-6
- 4
- 31
- stress
- PE
- Visual
- nodules, enlargement
- galactorrhea
- acanthosis nigricans
- androgenism, hirsuitism
- Pelvic
Secondary Amenorrhea: Routine Labs/Diagnostic Tests
- Potential Etiology: (3)
- **ROUTINE**: (3)
- PRN (3)
- Brain, Thyroid, Ovaries
- UPT, TSH, PROLACTIN
- Progesterone (mid luteal phase), FSH (abnl>40mlIU/mL), LH, Free testosterone, Uterine evaluation: Endometrial Biopsy
Amenorrhea Management
Hx: stress/lack of sleep; PE WNL (BMI 31)
Labs: UPT neg, TSH/Prolactin AWNL
- Restore R_____
- Uterine protection from unopposed ____/hyper____: use _ _ _ or Levonorgestrel _ _ _
- N_____/Ex_____ for weight loss
- Stress ____, Sleep _____
- Future f________
- Regularity
- estrogen/hyperplasia, CHC, IUD
- Nutrition/Exercise
- reduction, hygiene
- fertility
AUB: Adolescents 13-18
- **R/O (4)**
-
AUB-O: Physiologic _______
- Immature ____ Axis (1st 3-5 yrs of menstruation)
- >80% MENSTRUAL CYCLES ARE ANOVULATORY IN FIRST YEAR
- AUB-C:
- AUB-I:
- Pregnancy, Infection, Trauma or non-uterine
-
Anovulation
- HPO
- Coagulopathy: Inherited bleeding disorder (Von Willibrands)
- HC (hormonal contraceptives)
AUB: Reproductive Age Women 19-45
- **R/O** (4)
- Structural (3)
- AUB-O _________: PCOS, Hypothyroidism, Obesity, stress/nutritio/exercise/sleep
- AUB-I: (3)
- Pregnancy, Infection, Trauma, Non-uterine
- Polyps, Leiomyoma, Fibroids, Adenomyosis
- Anovulatory
- HC, IUDs, Psychotropics
AUB: Age 45-Menopause
R/O (4) ANDDD _______
Physiologic: ______ transition 2/2 Anovulation
AUB-L:
AUB I:
AUB-M:
Pregnancy, infection, trauma, or non-uterine AND Malignancy
Menopause
Leiomyoma (fibroids)
Hormone therapy
Endometrial malignancy/hyperplasia
AUB-Acute: Emergent
- _______ (Soaking > 2 pads/hr x > 2 hrs or _____ blood from os)
- ___ not stable
- ______ (or Severe) ______ (Hgb _<_8g/dl)
- Requires?
- Hemorrhaging
- VS
- Symptomatic Anemia
- Inpatient tx/transfer to ED: fluids, blood transfusion, prn IV E or P