AUB Flashcards
Classification of abnormal uterine
bleeding
Abnormal rhythm
Abnormal amt
Combination (rhythm and amount)
Abnormal rhythm bleeding examples 1 2 3 4
Irregularity of cycle
Intermenstrual bleeding (metrorrhagia)
Postcoital bleeding
Postmenopausal bleeding
Abnormal amount example
Increased amount = ______
Decreased amount =_______
menorrhagia
hypomenorrhoea
Combination (rhythm and amount)
Irregular and heavy periods = _____
Irregular and light periods =_______
metromenorrhagia
oligomenorrhoea
Up to _____ of women in the reproductive age
group complain of increased menstrual loss
20%
The mean blood loss in a menstrual cycle is
________
30–40 mL
Heavy menstrual bleeding (menorrhagia)—
HMB—is a menstrual loss of more than______
80 mL per
menstruation
Two common organic causes of HMB are _____ and ______
fibroids
and adenomyosis (presence of endometrium in the
uterine myometrium
Most girls reach menarche by the age of ________
13 (range 10–16 years).
Dysfunctional bleeding
is common in the first ______ after menarche due
to many anovulatory cycles resulting in irregular
periods, heavy menses and probably dysmenorrhoea
2–3 years
A normal endometrial thickness, as measured by
ultrasound, is between_______
6 and 12 mm
The menstrual
cycle is confirmed as being________(biochemically)
if the serum progesterone (produced by the corpus
luteum) is >20 nmol/L during the mid-luteal phase
(5–10 days before menses).
ovulatory
The incidence of malignant disease as a cause of bleeding increases with age, being greatest after the age of _________ while endometrial cancer
is predicted to be less than 1 in 100 000 in women
under the age of 3
45,
Dysfunctional
uterine bleeding is more common in the extremes of the
reproductive era, while the incidence of cancer as a
cause of bleeding is greatest in the _____ and _____
perimenopausal and
postmenopausal phases.
What is HMB
- blood loss >80 mL per menstrual cycle
- bleeding that persists >7 days
- bleeding that is unacceptable to the woman
Menorrhagia 4 is essentially caused by excessive local
production of ______in the endometrium
and myometrium and/or excessive _______
prostaglandins
local fibrinolytic activity.
By far the most common single ‘cause’ of
menorrhagia is ______
ovulatory dysfunctional uterine
bleeding (DUB).
_______ occurs at the
extremes of the reproductive period—around
menarche and perimenopausall
Anovulatory DUB
MCC of Anovulatory DUB
fibromyomatas (fibroids),endometriosis, adenomyosis (‘endometriosis’ of the
myometrium), endometrial polyps and PID
__________reserved for women who fail
conservative treatment or who are at increased risk
of endometrial cancer
UTZ
When to request biopsy in UTZ
If it is >12 mm for premenopausal women
or >5 mm for perimenopausal women, endometrial
biopsy (with or without hysteroscopy) is indicated
____ and _______remain the
gold standard for abnormal uterine bleeding.
Hysteroscopy and D&C
______excessive bleeding, whether heavy, prolonged or
frequent, of uterine origin, which is not associated
with recognisable pelvic disease, complications of
pregnancy or systemic disease
DUB
DUB is MC in what cycle?
It is more common in ovulatory
(regular) rather than anovulatory (irregular)
cycles.
Peak incidence of ovulatory DUB in late_____
30s and 40s (35–45 years).
_______DUB has two peaks: 12–16
years and 45–55 years. The bleeding is
typically irregular with spotting and variable
menorrhagia
Anovulatory
The serum progesterone and the pituitary
hormones___ and ______ will confirm
anovulation
(LH and FSH)
DUB Tx
_________ is usually employed
if the uterus is of normal size and there is no
evidence of anaemia
Conservative management
Consider surgical management if____ and _____
fertility is
no longer important and symptoms cannot be
controlled by at least 3–4 months of hormone
therapy
Mx of acute heavy bleeding
• oral high-dose progestogens (e.g. norethisterone
5–10 mg 4 hourly until bleeding stops then 5 mg bd
or tds for 14 days
MX of chronic bleeding
For anovulatory women:
- cyclical oral progestogens for 12 days
* tranexamic acid
MX of chronic bleeding
For ovulatory women:
• cyclical prostaglandin inhibitor (e.g. mefenamic acid)
or (one of)
• oral contraceptive
• antifibrinolytic agent (e.g. tranexamic acid 1 g (o) qid,
days 1–4)
• progesterone-releasing IUDs (e.g. Mirena
The agent of first choice in DUB is usually
________, which reduces blood loss by 20–25%
as well as helping dysmenorrhoea
mefenamic acid
Hormonal agents for DUB include
1
2
3
progestogens, combined
oestrogen–progestogen oral contraceptives and
danazol.
The_______constitutes important first-line
therapy in both ovulatory and anovulatory patients,
but at least 20% of patients do not respond
COC
In the adolescent with anovulatory DUB, __________ may be required for 6 months
until spontaneous regular ovulation eventuates
cyclical
oral progestogens
The most effective agent for both ovulatory and
anovulatory DUB is tranexamic acid, which inhibits
___________
endometrial plasminogen activation
Dose of Tranex for DUB
The dose is 1 g
(up to 1.5 g if necessary) orally qid for the first 4 days
It is regarded
as the most efficacious of the hormone treatments
with a mean blood loss of 94% of women with
menorrhagia.
The intra-uterine progesterone implant system
Mirena
Sx Mx
• endometrial ablation or electrodiathermy
excision—to produce _________
amenorrhoea
It is preferred to drug
therapy for women with endometrial hyperplasia
with atypia—endometrial ablation is not
appropriate
hysterectomy
Emergency menorrhagia (acute flooding) 4 First line
• tranexamic acid 10 mg/kg IV, every 8 hours until
bleeding stops
or
• tranexamic acid 1–1.5 g (o) 6 to 8 hourly until
bleeding stops
If above unavailable or not tolerated, other options
are:
• norethisterone 5–10 mg 4 hourly (o) till bleeding
stops, then 5 mg bd or tds (or 10 mg daily) for
14 days
or
• medroxyprogesterone acetate 10 mg (o) 4 hourly
until bleeding stops for 7 days then 20 mg daily
for 21 days
or
• COCP e.g. until bleeding stops then re-evaluate
after 48 hours
General guidelines for surgical intervention
- no longer wish to be able to conceive
- are perimenopausal
- have poorly controlled symptoms
- have adverse effects from the drugs
- have significant uterine pathology
Patients under 35 years:
Cause of cycle irreg
• the cause is usually hormonal, rarely organic, but
keep malignancy in mind
management options for cycle irreg in under 35
— explanation and reassurance (if slight
irregularity)
— COC pill for better cycle control—any pill can
be used
— progestogen-only pill (especially anovulatory
cycles) norethisterone (Primolut N)
5–15 mg/day from day 5–25 of cycle
MCC of Intermenstrual bleeding
and postcoital bleeding
factors such as
cervical ectropion (often termed cervical erosion),
cervical polyps, the presence of an IUCD and the oral
contraceptive pill.
Cervical ectropion, which is commonly found
in women on the pill and postpartum, can be left
untreated unless _____ and ______
intolerable discharge or moderate postcoital bleeding (PCB) is present
________ are benign tumours of smooth muscle of the
myometrium
Fibroids
Pelvic ultrasound (investigation of choice) . Endometrial thickening >4 mm demands \_\_\_\_\_\_\_\_ If >7 mm, \_\_\_\_\_\_\_\_
endometrial sampling.
endometrial cancer should be excluded
Med Mx of uterine fibroids
• Consider COCP (30 mcg oestrogen can reduce
bleeding
_________—especially if >42 years can
shrink fibroids (maximum 6 months)—use only
immediately pre-operative
• GnRH analogues
Sx Mx of fibroids
— myomectomy (remove fibroids only, esp. child-bearing years) — hysteroscopic resection/endometrial ablation — hysterectomy
This should be the diagnosis until proved otherwise
for postcoital, intermenstrual or postmenopausal
bleeding
Cervical CA
MC Sx of cervical CA
- Postcoital bleeding
- Intermenstrual bleeding
- Vaginal discharge—may be offensive
PE of cervical CA
- Ulceration or mass on cervix
* Bleeds readily on contact—may be friable
This is the diagnosis until proved otherwise in any
woman presenting with postmenopausal bleeding.
Endometrial cancer
T or F
Endometrial cancer is not excluded by a
normal cervical smear
T
Primary amenorrhoea is the failure of the menses
to start by _______
16 years of age
Secondary amenorrhoea is
the absence of menses for over______
6 months in a woman
who has had established menstruation
The main approach in the patient with primary
amenorrhoea is to differentiate it from ________ in which there are no signs of sexual
maturation by age
delayed
puberty,
Amenorrhea
It is important to keep in mind
the possibility of an ____ and _______, which can suppress hypothalamic
GnRH production.
imperforate hymen and also
excessive exercise
Causes of primary amenorrhoea include 1 2 3 4 5
genital
malformations, ovarian disease, pituitary tumours,
hypothalamic disorder and Turner syndrome
Diagnostic tests for amenorrhea include
serum FSH, LH, prolactin,
oestradiol and also chromosome analysis.
In secondary amenorrhoea, consider a physiological cause such as 1 2 3
pregnancy or the menopause, failure of some part of the hypothalamic–
pituitary–ovarian–uterine axis (e.g. PCOS) or a
metabolic disturbance
_________is the term for infrequent
and usually irregular periods, where the cycles are
between 6 weeks and 6 months
Oligomenorrhoea
Premature ovarian failure
Apart from iatrogenic causes this may be caused by
idiopathic early menopause and _______
autoimmune ovarian
failur
Remember that ____can obscure the
organic causes of menorrhagia
mental dysfunction
_______is more effective than the traditional
curettage. Studies have shown that usually less
than 50% of the uterine cavity is sampled by
curettage.
Hysteroscopy
