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Gyn Theory > AUB > Flashcards

AUB Flashcards

1
Q

What is considered normal bleeding?(onset of menses)

A

Onset of menses by age 14

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2
Q

What is considered abnormal uterine bleeding (AUB)?

A

Any bleeding irregular in amount, frequency, duration or timing
(Can indicate life threatening event: ex ectopic pregnancy or endometrial cancer)

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3
Q

Can the cause of AUB be physiologic, pathological or pharmacologic?

A

All the above

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4
Q

Physiologic reasons for AUB

A
  • pregnancy complications (most common)
  • lactation
  • peri menarche
  • perimenopause
  • BMI >40 (obesity) or <18 (underweight)
  • excessive exercise
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5
Q

Pathological causes of AUB

A
  • endocrine disorders (thyroid)
    -systemic disease (cancer, radiation, chemo)
  • reproductive tract dx (endometriosis, leiomyomas)
  • hypothalamic-pituitary-ovarian axis dysregulation (PCOS, stress)
    -excessive stress
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6
Q

Pharmacologic causes of AUB

A

-LARCS (IUD)
-SSRI
-Substances
-Herbs

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7
Q

When is AUB most common?

A

-first 2 yrs after menarche
-3 yrs prior to menopause
childbearing years are most stable bleeding patterns

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8
Q

Mnemonic for structural & nonstructural causes of AUB

A

PALM-COEIN

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9
Q

Structural causes of AUB

A

-Polyps (endo cervical & endometrial)
-Adenomyosis
-Leiomyoma (fibroids)
-Malignancy (endometrial cancer)

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10
Q

Nonstructural causes of AUB

A

-Coagulopathy
-Ovulatory dysfunction
-Endometrial
-Iatrogenic (medications/IUDs)
-Not otherwise classified

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11
Q

AUB-P (Polyp)

A

-type of structural AUB
-benign growths
-appearance: bright red
-endocervical polyps= easily friable; observed w/ speculum
-endometrial polyps= vascular source; hyperplastic growth

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12
Q

AUB-A (Adenomyosis)

A

-type of structural AUB
-small area of endometrial tissue embedded in myometrium
-diagnosed via pelvic u/s or MRI
-s/sx heavy menses & dysmenorrhea

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13
Q

AUB-L (leiomyoma)

A
  • type of structural AUB
  • aka fibroids
    -benign tumor of myometrium
    -primary reason for hysterectomy
    -asymptomatic but can cause excessive bleeding
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14
Q

Subcategories of leiomyomas (fibroids)

A
  • pedunculated abdominal
  • subserosal
  • pedunculated vaginal
  • intramural (myometrium)
  • submucosal (endo+ myometrium leading to more bleeding)
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15
Q

AUB-M (malignancy & atypical hyperplasia)

A
  • structural AUB
  • more common in obese or those w/ PCOS
  • common symptom: unexpected vaginal bleeding (postmenopausal)
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16
Q

AUB-C (coagulopathy)

A

-heavier flow d/t clotting disorders or anticoagulants
-ex: Von Willebrand’s disease

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17
Q

AUB-O (ovulatory dysfunction)

A
  • ex: anovulatory, PCOS, & amenorrhea
  • lack of progesterone d/t lack of ovulation leads to unstable & excessively vascular endometrium under the influence (control) of unopposed estrogen
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18
Q

AUB-E (endometrial)

A
  • mechanism not understood; dx made through exclusion
  • r/o ectopic pregnancy
  • r/o endometriosis
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19
Q

AUB-I (iatrogenic)

A
  • medications or devices (IUDs) act on endometrium causing AUB (especially 1st month)
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20
Q

AUB-N (not otherwise classified)

A

-yet to be identified causes of AUB

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21
Q

Objective hx intake for AUB

A
  • bleeding pattern
  • family hx
  • chronic illness
  • med hx (endocrine, bleeding, or systemic dx)
    -current meds
  • sexual hx/contraceptive use
22
Q

Lab testing for AUB

A
  • beta hCG for childbearing people
  • TSH, T4 level
  • CBC (platelets, hbg)
  • pap (unless not sexually actively
    -PT and aPTT if coagulation disorder suspected
  • FSH
  • Prolactin
  • testosterone
23
Q

Diagnostic testing for AUB

A

-transvaginal u/s: determines endometrial pathology & to measure endometrial stripe
-sonohysterogram: detects polyps
-endometrial (EMB) biopsy: recommended for >45yrs

24
Q

Goals of managing AUB

A
  1. normalize bleeding
  2. correct anemia via iron therapy
  3. prevent cancer
  4. restore quality of life
25
Q

Urgent treatment for AUB d/t heavy bleeding

A
  1. high doses of estrogen
  2. intrauterine tamponade/blood products
  3. uterine curettage
26
Q

Long term treatment for AUB d/t heavy bleeding

A
  1. ablation of endometrium
  2. hysterectomy
27
Q

Medication management of AUB d/t heavy bleeding

A
  1. COC
  2. MPA (medroxyprogesterone acetate)
  3. TXA (transexamic acid) [thrombosis risk]
  4. NSAIDs
28
Q

Define amenorrhea

A

Absence of menstural bleeding for at least 3 months

29
Q

Primary vs Secondary Amenorrhea

A

Primary- absence of menstural cycle by age 14
Secondary- absence of menstruation for 3 months

30
Q

Causes of primary amenorrhea

A

-anatomic defects
-ovarian disorders
-testicular feminization
-anterior pituitary disorders
-chromosomal abnormalities
*always r/o pregnancy

31
Q

Causes of secondary amenorrhea

A

-anovulation
-premature ovarian insufficiency
-menopasue
-PCOS, thyroid (endocrine)
-CNS disorders (stress, eating disorders)
-pituitary tumor
-prolonged hormonal contraception w/ endometrial atrophy
-cervical stenosis d/t multiple infections

32
Q

Diagnostic testing for management of amenorrhea

A
  1. Labs
    - hCG test to r/o pregnancy
    -TSH, prolactin level
  2. progesterone challenge (stimulates action of progesterone after ovulation to start uterine lining shedding)
    -MPA
33
Q

What are the 2 premenstural disorders

A
  1. Premenstural Syndrome (PMS)
  2. Premenstural Dysphoric Disorder (PMDD)
34
Q

Definition of premenstural syndrome (PMS)

A
  • mild to mod physical & psychological symptoms during luteal phase of menses
    -s/sx can occur up to 7 days before menses & regress from cycle days 4-13
    1. abdominal bloating
    2. pelvic pain
    3. depression/anxiety
    4. irritability/insomnia
    5. low self esteem/poor self image
35
Q

Definition of premenstural dysphoric disorder (PMDD)

A

-5+ s/sx present the well before menses and absent in follicular phase
-criteria confirmed over at least 2 cycles

36
Q

Differential dx w/ PMDD and PMS

A
  • r/o baseline depression
  • r/o thyroid (hypothyroidism)
  • r/o musculoskeletal pain, IBS, other bowel dx w/ PMS
  • r/o mood dx w/ PMDD
37
Q

Tx for PMS/PMDD

A
  1. OTC NSAIDs for pelvic pain
  2. oral contraceptives (drospirenone)
  3. dietary counseling for GI s/sx
  4. exercise
  5. CBT for mood
  6. severe: SSRIs (zoloft, prozac)
  7. spironolactone –> bloating/fluid retention
    _________________________________________
    Last options:
  8. GnRH agonist & COC
  9. bilateral salping-oophorectomy
38
Q

Define hyperandrogenic disorders

A
  1. endocrine abnormalities w/ too much androgen produced by ovaries or adrenal glands
39
Q

Signs of hyperandrogenic disorders

A
  1. mensutral dysfunction
  2. acne
  3. virilization (development of male characteristics)
  4. PCOS
  5. metabolic syndrome
40
Q

Clinical manifestations of polycystic ovarian syndrome (PCOS)

A

most common endocrine problem
1. menstural irregularities
2. hirsuitism
3. alopecia
4. acne
5. infertility
6. virilization
7. polycystic ovaries (not common)
8. most pts obese
irregular bleeding leads to thicker lining d/t infrequent shedding

41
Q

Ferriman Gallwey Hirsuitism Scale 9 body areas

A
  1. upper lip
  2. chin
  3. chest
  4. abdomen
  5. pelvis
  6. upper arms
  7. thighs
  8. upper back
  9. lower back
42
Q

Complications of PCOS

A
  • ovulatory dysfunction leads to menstural irregularity and infertility
  • heavier menses d/t unopposed estrogen
  • increased risk of endometrial cancer
43
Q

Diagnostic test for PCOS

A
  1. FSH, LH, prolactin, TSH, fasting lipid profile, glucose –> test for ovulatory dysfunction
  2. AMH (Anti Mullerian Hormone) test infertility
  3. DHEAS (male sex hormone) high levels in PCOS
  4. U/S of endometrium
44
Q

Diagnosis criteria for PCOS

A

2 of the following:
1. ovarian dysfunction: oligomenorrhea or anovulation
2. signs of hyperandrogenism
3. polycystic ovaries

45
Q

Goals of treating PCOS

A
  1. decrease androgen level
  2. improve/relieve cosmetic concerns
  3. restore fertility if desired
46
Q

Treatment of PCOS

A
  1. lifestyle changes (weight loss decreases androgen levels and risk for metabolic disease)
  2. mechanical hair removal
  3. progestins: MPA, implant, levo-IUD to prevent endometrial hyperplasia
  4. COC
  5. spironolactone/flutamide (anti androgens)
  6. metformin (help weight loss, decrease androgen levels)
47
Q

Characterisitcs of metabolic syndrome

A

think PCOS
- waist circumference >35 in (abd obesity)
- increase insulin resistance/impaired glucose tolerance fasting glucose >100
- HTN
- HDL < 50

48
Q

Diagnostic testing for postmenopausal bleeding

A
  1. pelvic u/s to assess uterine lining
    - lining should be <5 mm in menopausal women
  2. endometrial biopsy (EMB)
49
Q

Why are cramps painful w/ dysmenorrhea

A
  • painful cramping occurs w/ mensturation
  • irregular bleeding leads to irregular/excessive prostglandin release from endometrial cells at start of menses stimulating uterine contractility causing hypoxia of muscle resulting in pain
50
Q

Primary dysmenorrhea vs secondary dysmenorrhea

A
  1. primary: no evidence of pelvic pathology w/ cyclic (repeated) pain w/ each cycle
  2. seocndary: evidence of pelvic pathology (endometriosis, leimyomata (fibroids) and pain occuring w/ & w/o cycle
51
Q

Risk factors for dysmenorrhea

A
  1. age <30
  2. BMI <20
  3. smoking
  4. early menarche
  5. hx of sexual abuse
  6. premenstural molimina
  7. longer duration of bleeding
  8. irregular or heavy flow
  9. hx of pelvic surgery
52
Q

Treatment for dysmenorrhea

A

Pharm:
- NSAIDs
- COC
- vaginal ring/patch
- progestin only pills
- progestin implants
- levo IUD
- depo prevera
Nonpharm:
- Vitamine E, B1, fish oil and ginger pwder
- excerise
- TENS (electrical nerve stimulation)
- low fat, vegetarian diet
- heat

Gyn Theory (4 decks)

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