Abnormal Uterine Bleeding Flashcards
1
Q
Abnormal Uterine Bleeding: Pregnant Causes
A
- Ectopic pregnancy
- Pregnancy complications
- Hydatiform mole
- Incomplete/threatened abortion
2
Q
Abnormal Uterine Bleeding: Non-Pregnant Causes
A
- Chronic epithelioma
- Endometritis
- Myoma
- Salpingitis
- Endometrial polyp/hyperplasia
- adenomyosis
- Endometriosis
- Carcinoma
- Cervical polyp
- Chronic cervicitis
3
Q
Abnormal Uterine Bleeding: Definitions
A
- Non-pregnant women of reproductive age
- Not consistent with a menstrual cycle
- Acute:
- Episode of heavy bleeding that would require immediate intervention to prevent further blood loss
- Chronic:
- Bldg. from uterus abnormal in volume, regularity, and/or timing
- Present for at least 6mo
4
Q
Who develops AUB?
A
- Rarely seen: prepubertal girls, postmenopausal women who are not on HRT
- Common complaint in reproductive years (10-30%): Adolescence, women of reproductive age, perimenopausal
5
Q
How QoL is affected by AUB
A
- Emotional distress (anxiety)
- Physical distress (pain, discomfort, limitations on activities)
- Chronic anemia & lowered health status
- Possible life threatening Dx
- Financial impact (average loss of 3-42k/yr; lost wages)
6
Q
Cycle Frequency
A
- Frequent (polymenorrhea): 38d
7
Q
Menstrual Bleeding Regularity
A
- Absent (Amenorrhea): no menses
- Regular: variation +/- 2-20d
- Irregular: Variation >20d; oligomenorrhea (35d-6mo)
8
Q
Duration of Menstrual Flow
A
- Prolonged: >8d
- NL: 4.5-8d
- Shortened: <4.5d
9
Q
Amount of Menstrual Blood Loss
A
- Heavy (menorrhagia/hypermenorrhea): >80mL
- NL: 5-80mL
- Light (hypomenorrhea/spotting): <5mL
- Usual 20-60mL
10
Q
Other Menstrual Definitions
A
- Polymenorrhagia: multiple bleeding episodes of >80cc
- Metrorrhagia: (AKA breakthrough bleeding) prolonged bleeding at irregular cycles, other than menstrual cycle
- Menometrorrhagia: Irregular, heavy bldg, (very worrisome)
11
Q
Signs of Normal Menstrual Blood Loss
A
- Change pads/tampons at 3+ hr intervals
- Use fewer than 21 pads/tampons per cycle
- Seldom need to change the pad/tampon during the night
- Have clots <1in in diameter
- Not be anemic
12
Q
Signs of Changes in Menstrual Bleeding
A
- An increase of 2+ pads/tampons/day
- Cycle is lasting longer than usual
- Blood clots have increased in size or number
- Changing of sanitary items interferes with daily activities
13
Q
Signs of Heavy Menstrual Bleeding
A
- Heavy period limiting daily activities
- Heavy bleeding causing missed days
- Changing pad/tampon during night
- Needing 1+ tampons/pads/hr
- Doubling up sanitary protection
- Organizing activities around cycle
14
Q
Checking Bleeding for Uterine Cause
A
- Check UA for blood caused by: cystitis, Calculi, Bladder CA
- Check stool for occult blood caused by: Colon polyps, diverticula, GI cancer, Gastroduodenal ulcers, Hemorrhoids
15
Q
Etiologies of AUB: PALM-COEIN
A
- PALM (Structural causes):
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/hyperplasia
- COEI (non-structural):
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- N: Not classified
16
Q
AUB: Polyps
A
- Endometrial or cervical
- Usually benign
- S/S: Intermittent spotting, post-coital bleeding, may be asymptomatic
- Dx: Visually, ultrasound
- Tx: Refer to be excised by GYN
17
Q
AUB: Adenomyosis
A
- Endometrial tissue on outer walls of uterus (usually posterior wall
- Benign
- > 30yo
- Multiparous
- Hx: C/S, uterine surg.
- S/S: Progressive secondary dysmenorrhea; menorrhagia; soft, slightly enlarged uterus
- Tx: Asymptomatic (none); Symptomatic (OCPs, IUD); Severe (possible hysterectomy)
18
Q
AUB: Leiomyoma
A
- Most are asymptomatic; symptomatic depends on size, location, type
- S/S: Pelvic fullness; pressure; dyspareunia; menorrhagia; AUB
- May be palpable on bimanual or seen on US
- Leiomyomas vary by type and treatment
19
Q
AUB: Malignancy
A
- Uncommon in reproductive years, but possible
- Crucial to identify if present: atypical hyperplasia; malignancy
- S/S: AUB; intermittent spotting; menorrhagia; postcoital bleeding
- Endometrial biopsy;other assessments
20
Q
AUB: Coagulopathy
A
- Most common is vWD
- Also consider leukemias
- Types: postpartum leeding; surgical related bleeding; bleeding with dental work
- 2+ S/S: Bruising 1-2x/month; Epistaxis 1-2x/month; frequent gum bleeding; FH Bldg. disorders
21
Q
AUB: Ovulatory
A
- Most are NOT ovulatory
- Unpredictable timing of bleeding; If they vary in length >10d, usually anovulatory
- Predictable cycles almost always mean regular ovulation.
- Variable amount of flow
- Lack of cyclic progesterone
- Luteal phase disorders
- Endocrinopathies: Hyper/hypothyroid; adrenal hyperplasia; Cushing’s; T2DM; Ptuitary; PCOS; Obesity; Mental stress; anorexia; Weight loss; Exteme exercise; Iatrogenic
22
Q
AUB: Endometrial Causes
A
- If predictable and cyclic menses, probably ovulatory and endometrial problem is likely
- HMB + predictable cycle ~ some problem with local endometrial stasis; r/t insufficient vasoconstrictors
- Non-HMB + Predictable cycle ~ Infection/inflammation
23
Q
AUB: Iatrogenic
A
- Breakthrough bleeding from hormone therapy or contraceptives
- Anticoagulant therapy
- Treatments that interfere with dopamine metabolism
24
Q
AUB: Not Classified
A
- AV malformations
- Myometrial hypertrophy
- Undiscovered disorders
25
AUB in Older Women
- Perimenopause: Impending ovulatory retirement
- Menopause:
* * Endometrial adenocarcinoma
* * Cervical carcinoma
* * Polyps
- Post-menopausal
* * Uterine cancer
* * Ovarian cancer
* * Exogenous estrogen
* * Atrophic vaginitis
26
Workup for AUB
- Hx:
* * Menstrual, obstetrical, contraceptive, sexual, medical, pregnancy, sexual activity, trauma
* * Weight changes, diet, exercise, life events, stresses, drug use
- PE
* * Clots; pain and location; signs of infection (odor, D/C, fever, chills); GI/GU symptoms
* * Speculum: Observe & assess for bldg.; attempt to determine site of bldg.
* * Bimanual: masses, tenderness, fixation of organs
- UPT
27
AUB: Lab Tests
- UPT
- CBC
- TSH
- FSH
- vWF
- Wet prep
- Cervical cultures
- Pap smear
28
Menorrhagia Work-Up: When to Perform Endometrial Biopsy
- >35yo
- <35yo with:
* * Obesity
* * PCOS
* * Long Hx of anovulatory bldg. pattern or prolonged amenorrhea in absence of hypoestrogenism
29
Methods to Investigate for Intrauterine Pathology
- Pelvic US (in office)
- Office biopsy (in office)
- Sonohysterography (in office)
- Hysteroscopy (usually in OR)
30
Pelvic US with HMB
- Unenhanced US: evaluating for fibroids or other pathology
* * measurement of thickness in reproductive age is generall not useful
- Evaluate for uterine pathology: Saline infusion sonography
* * Hysteroscopy may become necessary
31
HMB Work-Up: Unique Issues by Age
- Adolescents: Previously unrecognized coagulopathies; STIs
| - >35yo: Endometrial hyperplasia
32
Transvaginal US with AUB
- 1st step in reducing need for hysteroscopy
- False negative rate ~3-5%
- Will show ovaries, fibroids, increased endometrial thickness and some polyps
- Ideally done on day 4, 5, or 6 of cycle when endometrial lining is at thinnest to visualize for uterine pathology
33
Endometrial Biopsy in AUB
- Simple, inexpensive
- 85% Sensitive
- 97% Specific
- Problems with a pt who has cervical stenosis
- Indications: postmenopausal women w/AUB; development of irregular/excessive bldg.
34
Hysteroscopy in AUB
- Outpatient or 1-day surgery
- Permits direct visualization of cavity
- Small risk of perforation & infection
- Expensive
- Allows MD to: Visualize size, shape, scar tissue, fallopian tubes; may open tubes; identify some causes of miscarriages; find and reposition IUD; remove small fibroids or polyps; endometrial ablation
35
HMB Therapy: Medical
- NSAIDs (25-35% reduction)
- Tranexamic Acid (Lysteda) (40% reduction)
- OCPs (50% reduction)
* * Estrogen only (in hospital usually)
* * Estrogen + Progestin
* * Progestin only
- Mirena IUD (70% reduction)
- GnRH antagonists (LuPron), Danazol
36
HMB Therapy: Surgical
- Endometrial ablation/resection
- Uterine artery embolization of leiomyoma
- Hysterectomy
37
HMB Therapy: NSAIDs
- Pros: easy to obtain; inexpensive; well tolerated; reduces dysmenorrhea
- Cons: Modest efficacy; gastritis
- Commonly Used: IBU 800mg TID; Naproxen 550mg TID; Mefenamic acid (Ponstel) 500mg TID; Meclofenamate Na (Meclomen) 100mg TID
38
HMB Therapy: Combined hormones
- Pros: Effective; cyclic predictabiity; extended regimen can reduce withdrawal bldg.; contraceptive
- Cons: daily use is essential; systemic side effects
39
HMB Therapy: Cyclic Oral Progestins
- Pros: Only 12d/cycle (start on ay 14)
- Cons: Compliance issues due to intermittent; side effects; less effective than COCs
- Options: MDPA 10-30mg/d; NEA 5-15mg/d
40
DMPA for AUB
- Pros: requires 1 injection q90d; 60% effective; highly effective contraception
- Cons: Irregular bleeding; side effects; IM injection; wt. gain; ?bone density loss?
41
Tranexamic Acid (Lysteda) for AUB
- Pros: 40% reduction; Non-hormonal; 1300mg TID (ONLY during period); can work at 1st cycle
- Cons: may be associated with thrombosis
42
GnRH Antagonist (LuPron) for AUB
- Pros: 1 IM injection or q3mo; 90% effective
| - Cons: Hypoestrogenic state (vasomotor Sx; bone loss); Injection; expensive; inappropriate for long-term
43
Mirena for AUB
- Pros: Long term efficacy; highly effective contraception; delivers progestin locally to endometrium; 70-90% reduction
- Cons: expensive
- Indications: MBL >80mL/period; uterus is NL size; No etiology for bldg.
44
Endometrial Ablation for AUB
- Pros: office procedure or outpatient; less time consuming and costly than hysterectomy
- Cons: 5-10% need 2nd; Usually prevents future fertility (NOT effective contraception)
45
Endometrial Destruction
- 1st Gen: Resection; rollerball ablation
- 2nd Gen: Balloon, microwave, others
- Hysterectomy:
* * Abdominal/vaaginal/laparoscopically assisted vaginal/laparoscopic
* * Total/subtotal
46
Ablation: Key Issues
- Must have completed having children
- Must be using reliable contraception (NOT a contraceptive procedure)
- Irreversible
- Small risk of perforation or infection
- 20-30% will need 2nd 3-5yr later
- Less successful in younger women
47
Ablation Vs. Hysterectomy
- Hyst. Better: greater reduction in blood loss; greater satisfaction; les repeat surg.; improved general health
- Abl. better: Shorter duration of surg/hospital stay; back to work sooner; fewer complications
48
Hysterectomy for AUB
- Pros: definitive
| - Cons: Surgical risk; expensive; eliminates future childbearing
49
Uterine Artery Embolization for AUB
- Pros: Effective to control fibroid associated menorrhagia up to 90%; preserves ovarian Fx; less invasive than hysterectomy
- Cons: Serious adverse events possible; may require hospital stay for pain control; significant N/V
50
PCOS
- Oligo/anovulation
* * Leading cause of amenorrhea in women of reproductive age (next to pregnancy)
- Hyperandrogenism
* * Obesity; hirsuitism
- Sonographic features
- Insulin resistance
- Consequences: Infertility; increased rates of T2DM/endometrial hyperplasia; may be increased risk of CV Dz
51
PCOS Treatment
- COC
* * Regulates bleeding patterns
* * Lowers circulating androgens
* * More non-GI side effects
* * No difference in hirsutism or acne
- insulin sensitizers
* * Little effect on bldg.
* * No effect on androgens
* * More GI side effects
* * Improved fasting insulin levels; do NOT raise TGs
