AUB

Question 1

Define the PALM-COEIN system for classifying AUB.

Answer 1

PALM: anatomic causes of AUB

• polyps
• adenomyosis
• leiomyomata
• malignancy/hyperplasia

COEIN: non-anatomic causes of AUB

• coagulopathy
• ovulatory disorders
• endometrial disorder
• iatrogenic
• not classified

Question 2

How can you distinguish a leiomyoma from an adenomyoma on ultrasound?

Answer 2

Leiomyomas have more distinct borders, and blood vessels tend to cluster around the mass
Adenomyomas have indistinct borders, and blood vessels tend to run right through the mass

Question 3

What kind of fibroids is most likely to contribute to AUB?

Answer 3

Submucosal fibroid

Question 4

What is the mechanism of anovulatory AUB?

Answer 4

Unchecked estrogen secretion leads to increased endometrial growth with incomplete and irregular shedding of the endometrium

Question 5

List three common causes of anovulatory AUB.

Answer 5

Endocrinopathies: PCOS (and other disorders of androgen excess), thyroid disorders, hyperprolactinemia, hypothalamic hypogonadism
Beginning & end of reproductive years
Obesity (associated with anovulatory bleeding independent of PCOS)

Question 6

Are menstrual irregularities more likely to occur with hypothyroidism or hyperthyroidism?

Answer 6

Hypothyroidism (although menstrual irregularities can occur with both)

Question 7

What is the hormonal mechanism of anovulatory AUB in:

• Adolescence
• Perimenopause
• Obesity

Answer 7

Adolescence - maturation of HPO axis
Perimenopause - fluctuating FSH secretion, estrogen levels
Obesity - lower SHBG therefore increased free hormones including estrogen, increased peripheral aromatization of androgens to estrogens

Question 8

Which is more common: ovulatory or anovulatory AUB?

Answer 8

Ovulatory AUB

Question 9

What initial blood work would you order to work up anovulatory AUB?

Answer 9

TSH
PRL
Total testosterone, 17-OHP (if signs of androgen excess present)
OGTT, lipid panel (if suspicious of insulin resistance/metabolic syndrome related to PCOS)
FSH (if < 40 years old)
CBC
Coagulation studies (if suspicious of coagulopathy)
Chlamydia screening if high risk

Question 10

What is the appropriate follow-up test for a patient with elevated 17-OHP?

Answer 10

ACTH stimulation test (give 25 mcg cosyntropin = synthetic ACTH, then measure 17-OHP)

Question 11

What are the three general goals in managing AUB?

Answer 11

Control acute bleeding
Prevent future bleeding
Prevent long-term consequences of AUB (anemia, endometrial hyperplasia or cancer)

Question 12

List three medical & three surgical treatment options for acute AUB.

Answer 12

Medical - IV estrogen, COCs, oral progestins, tranexamic acid
Surgical - D&C, endometrial ablation, UAE

Question 13

You prescribe cyclic medroxyprogesterone for a patient with simple hyperplasia without atypia. Describe how you would instruct her to take the pills, what precautions you would advise her to take, when you would repeat endometrial sampling, and what you would advise her to do if her repeat sample is normal.

Answer 13

Take 10 mg medroxyprogesterone daily for 12-14 days/month
Not a contraceptive; therefore if sexually active, she should use condoms
Repeat endometrial biopsy in 3-6 months
If biopsy normal, she should consider continuing treatment if the likely cause of the hyperplasia persists

Question 14

What medical treatment options exist for endometrial hyperplasia with atypia? Be specific - include names & doses.

Answer 14

Oral (continuous, not cyclic) or intrauterine progestins
Medroxyprogesterone acetate 10-20 mg daily x3-6 months
Megestrol acetate 40-80 mg daily x3-6 months
Micronized progesterone 100-200 mg daily x3-6 months
LNG IUS 52 mg

Question 15

What proportion of patients with heavy menstrual bleeding have an underlying disorder of hemostasis? What is the most common such disorder?

Answer 15

20%

Von Willebrand disease, followed by platelet dysfunction (coagulation factor deficiencies are much more rare)

Question 16

Which class of medications used for management of heavy menstrual bleeding should be avoided in women with von Willebrand disease?

Answer 16

NSAIDs

Question 17

What are two risks associated with pregnancy following endometrial ablation?

Answer 17

Abnormal placentation

Preterm delivery

Question 18

List five contraindications to endometrial ablation.

Answer 18

Pregnancy or desire for future pregnancy
Uterine cancer or hyperplasia
PID
Hydrosalpinx
Current UTI
Prior classical cesarean section or full-thickness myomectomy
IUD in situ
Uterine anomaly