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N825 > Abnormal Uterine Bleeding > Flashcards

Abnormal Uterine Bleeding Flashcards

1
Q

Abnormal Uterine Bleeding: Pregnant Causes

A
  • Ectopic pregnancy
  • Pregnancy complications
  • Hydatiform mole
  • Incomplete/threatened abortion
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2
Q

Abnormal Uterine Bleeding: Non-Pregnant Causes

A
  • Chronic epithelioma
  • Endometritis
  • Myoma
  • Salpingitis
  • Endometrial polyp/hyperplasia
  • adenomyosis
  • Endometriosis
  • Carcinoma
  • Cervical polyp
  • Chronic cervicitis
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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
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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
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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)
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6
Q

Cycle Frequency

A
  • Frequent (polymenorrhea): 38d
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7
Q

Menstrual Bleeding Regularity

A
  • Absent (Amenorrhea): no menses
  • Regular: variation +/- 2-20d
  • Irregular: Variation >20d; oligomenorrhea (35d-6mo)
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8
Q

Duration of Menstrual Flow

A
  • Prolonged: >8d
  • NL: 4.5-8d
  • Shortened: <4.5d
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9
Q

Amount of Menstrual Blood Loss

A
  • Heavy (menorrhagia/hypermenorrhea): >80mL
  • NL: 5-80mL
  • Light (hypomenorrhea/spotting): <5mL
  • Usual 20-60mL
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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)
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
Q

AUB in Older Women

A
  • Perimenopause: Impending ovulatory retirement
  • Menopause:
    • Endometrial adenocarcinoma
    • Cervical carcinoma
    • Polyps
  • Post-menopausal
    • Uterine cancer
    • Ovarian cancer
    • Exogenous estrogen
    • Atrophic vaginitis
26
Q

Workup for AUB

A
  • 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
Q

AUB: Lab Tests

A
  • UPT
  • CBC
  • TSH
  • FSH
  • vWF
  • Wet prep
  • Cervical cultures
  • Pap smear
28
Q

Menorrhagia Work-Up: When to Perform Endometrial Biopsy

A
  • > 35yo
  • <35yo with:
    • Obesity
    • PCOS
    • Long Hx of anovulatory bldg. pattern or prolonged amenorrhea in absence of hypoestrogenism
29
Q

Methods to Investigate for Intrauterine Pathology

A
  • Pelvic US (in office)
  • Office biopsy (in office)
  • Sonohysterography (in office)
  • Hysteroscopy (usually in OR)
30
Q

Pelvic US with HMB

A
  • 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
Q

HMB Work-Up: Unique Issues by Age

A
  • Adolescents: Previously unrecognized coagulopathies; STIs

- >35yo: Endometrial hyperplasia

32
Q

Transvaginal US with AUB

A
  • 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
Q

Endometrial Biopsy in AUB

A
  • 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
Q

Hysteroscopy in AUB

A
  • 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
Q

HMB Therapy: Medical

A
  • 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
Q

HMB Therapy: Surgical

A
  • Endometrial ablation/resection
  • Uterine artery embolization of leiomyoma
  • Hysterectomy
37
Q

HMB Therapy: NSAIDs

A
  • 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
Q

HMB Therapy: Combined hormones

A
  • Pros: Effective; cyclic predictabiity; extended regimen can reduce withdrawal bldg.; contraceptive
  • Cons: daily use is essential; systemic side effects
39
Q

HMB Therapy: Cyclic Oral Progestins

A
  • 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
Q

DMPA for AUB

A
  • Pros: requires 1 injection q90d; 60% effective; highly effective contraception
  • Cons: Irregular bleeding; side effects; IM injection; wt. gain; ?bone density loss?
41
Q

Tranexamic Acid (Lysteda) for AUB

A
  • Pros: 40% reduction; Non-hormonal; 1300mg TID (ONLY during period); can work at 1st cycle
  • Cons: may be associated with thrombosis
42
Q

GnRH Antagonist (LuPron) for AUB

A
  • Pros: 1 IM injection or q3mo; 90% effective

- Cons: Hypoestrogenic state (vasomotor Sx; bone loss); Injection; expensive; inappropriate for long-term

43
Q

Mirena for AUB

A
  • 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
Q

Endometrial Ablation for AUB

A
  • 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
Q

Endometrial Destruction

A
  • 1st Gen: Resection; rollerball ablation
  • 2nd Gen: Balloon, microwave, others
  • Hysterectomy:
    • Abdominal/vaaginal/laparoscopically assisted vaginal/laparoscopic
    • Total/subtotal
46
Q

Ablation: Key Issues

A
  • 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
Q

Ablation Vs. Hysterectomy

A
  • 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
Q

Hysterectomy for AUB

A
  • Pros: definitive

- Cons: Surgical risk; expensive; eliminates future childbearing

49
Q

Uterine Artery Embolization for AUB

A
  • 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
Q

PCOS

A
  • 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
Q

PCOS Treatment

A
  • 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

N825 (16 decks)

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