AUB (based on CompreGyne) Flashcards
What is the definition of oligomenorrhea?
Oligomenorrhea is defined as infrequent uterine bleeding with intervals between episodes varying from 35 days to 6 months.
What is considered amenorrhea?
Amenorrhea is the absence of menses for at least 6 months.
What is the normal mean interval between menses?
The normal mean interval between menses is 28 days (±7 days).
What menstrual cycle intervals are considered abnormal?
Menstrual cycle intervals of 21 days or less or 35 days or more are considered abnormal.
What is the normal mean duration of menstrual flow?
The normal mean duration of menstrual flow is 4 days.
How many days of menstrual bleeding is considered abnormally prolonged?
Menstrual bleeding lasting longer than 7 days is considered abnormally prolonged.
What is the average menstrual blood loss (MBL)?
The average menstrual blood loss is 35 mL.
What MBL is considered heavy menstrual bleeding?
Menstrual blood loss of 80 mL or greater is considered heavy menstrual bleeding.
What classification system is used to categorize the causes of abnormal uterine bleeding (AUB)?
The FIGO PALM-COEIN classification system.
What does PALM stand for in the PALM-COEIN system?
PALM stands for Polyp, Adenomyosis, Leiomyoma, and Malignancy/Hyperplasia.
What does COEIN stand for in the PALM-COEIN system?
COEIN stands for Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified.
What is the notation system for AUB classification?
AUB is followed by PALM-COEIN with subscript 0 (absence) or 1 (presence) of the abnormality.
What are endometrial polyps composed of?
Endometrial polyps contain glands, stroma, and blood vessels covered with epithelium.
What hormone is thought to play a key role in the development of endometrial polyps?
Estrogen.
What risk factors increase the likelihood of malignancy in endometrial polyps?
Symptomatic vaginal bleeding, postmenopausal status, tamoxifen use, and obesity.
What imaging modality is used to detect small, asymptomatic endometrial polyps?
Transvaginal ultrasound.
What condition is characterized by endometrial glands and stroma in the uterine myometrium?
Adenomyosis.
What is the most significant risk factor for adenomyosis?
Multiparity.
What imaging findings are indicative of adenomyosis?
Enlarged, asymmetric uterus on ultrasound and thickening of the junctional zone ≥12 mm on MRI.
What are uterine leiomyomas also known as?
Fibroids.
What factor contributes to fibrosis in leiomyomas?
Transforming growth factor beta.
How are leiomyomas classified based on location?
They are classified as intracavitary (type 0), submucosal (type 1 or 2), intramural, or subserosal.
What is the most common presenting symptom of endometrial cancer?
Abnormal uterine bleeding.
What syndrome is associated with a high risk of endometrial cancer?
Lynch syndrome (hereditary nonpolyposis colorectal cancer).
What are common coagulation disorders that may present as AUB?
Von Willebrand disease, hemophilia A and B, and inherited deficiencies of clotting factors V, VII, X, XI, XIII.
What is the primary cause of ovulatory dysfunction in adolescents?
Immaturity of the hypothalamic-pituitary-ovarian axis.
What is the most common cause of anovulation in reproductive-age women?
Polycystic ovary syndrome (PCOS).
What hormonal imbalances can cause anovulatory bleeding?
Thyroid hormone abnormalities, hyperprolactinemia, and hypercortisolism.
What medications can cause iatrogenic AUB?
Hormonal contraceptives, selective estrogen receptor modulators, and gonadotropin-releasing hormone agonists.
What key historical details should be obtained from a woman presenting with abnormal uterine bleeding?
Frequency, duration, and amount of bleeding; changes in menstrual pattern; presence of oligomenorrhea, polymenorrhea, heavy menstrual bleeding, or intermenstrual bleeding.
How can women effectively track their abnormal uterine bleeding?
Using a calendar to record bleeding episodes or a smartphone application, though none are validated.
What duration of symptoms defines chronic abnormal uterine bleeding?
Symptoms present for the majority of the preceding 6 months.
What duration of symptoms warrants investigation for abnormal uterine bleeding?
Symptoms lasting 3 months sufficiently indicate the need for investigation.
Why is a woman’s estimate of blood loss unreliable?
There is poor correlation between estimated and actual blood loss due to variations in absorption by different sanitary products.
What objective criteria are used to determine menorrhagia?
Blood loss greater than 80 mL.
What laboratory tests are useful for assessing menorrhagia?
Hemoglobin concentration, serum iron levels, serum ferritin levels.
What additional lab tests are useful in the initial workup of abnormal uterine bleeding?
β-hCG, TSH, PRL; androgen levels if PCOS is suspected.
What lab tests should be ordered for adolescents with heavy menstrual bleeding and women with systemic disease?
CBC, platelet count, PT/PTT, von Willebrand factor, ristocetin cofactor.
What historical clues suggest a coagulation disorder in a woman with heavy menstrual bleeding?
History of postpartum hemorrhage, surgical bleeding, dental bleeding, easy bruising, epistaxis, gum bleeding, family history of bleeding.
What is the most common coagulation disorder associated with heavy menstrual bleeding?
Von Willebrand disease.
What are the first steps in evaluating abnormal uterine bleeding in a woman with regular cycles?
Determine whether she is ovulating and assess risk factors for endometrial hyperplasia or malignancy.
When is endometrial sampling indicated for abnormal uterine bleeding?
In women over 45 years old with heavy menstrual bleeding or those at risk for endometrial disease.
What are the preferred methods for endometrial sampling?
Office-based Pipelle biopsy or dilation and curettage (D&C) if biopsy is inconclusive.
What imaging modalities are used to assess the uterine cavity in abnormal uterine bleeding?
Sonohysterogram (SHG) or flexible hysteroscopy.
Why is MRI preferred over ultrasound for evaluating fibroids?
MRI provides superior assessment of fibroid position, size, number, and myometrial invasion.
What is the primary treatment for endometrial polyps causing abnormal uterine bleeding?
Surgical removal via hysteroscopy.
What are the medical treatment options for abnormal uterine bleeding?
Estrogens, progestogens, NSAIDs, antifibrinolytic agents, GnRH agonists.
What is the preferred initial treatment for adolescents with anovulatory bleeding?
Cyclic progestogen (e.g., medroxyprogesterone acetate, 10 mg for 10 days each month).
What is the preferred treatment for perimenopausal women with abnormal uterine bleeding?
Low-dose oral contraceptives (20 μg) in nonsmoking women.
What are the treatment options for chronic anovulatory bleeding?
Oral contraceptives or cyclic progestogens; ovulation induction if conception is desired.
What is the treatment goal for women with AUB-E (abnormal uterine bleeding of endometrial origin)?
Reduce excessive bleeding using progestogens, oral contraceptives, or levonorgestrel intrauterine system (LNG-IUS).
What are the benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in AUB?
Reduces menstrual blood loss by up to 100% in 1 year, increases hemoglobin, decreases dysmenorrhea, and is effective for fibroids and adenomyosis.
What is the mechanism of NSAIDs in reducing menstrual blood loss?
Inhibits prostaglandin synthesis, reducing endometrial blood flow.
What NSAIDs have been shown to reduce menstrual blood loss?
Mefenamic acid, ibuprofen, meclofenamate sodium, naproxen sodium.
What is the role of antifibrinolytic agents in the management of heavy menstrual bleeding?
They inhibit fibrinolysis, reducing blood loss by approximately 50%.
What antifibrinolytic agents are commonly used for menorrhagia?
Tranexamic acid, ε-aminocaproic acid (EACA), para-aminomethyl benzoic acid (PAMBA).
When are antifibrinolytic agents contraindicated?
In patients with renal failure, pregnancy, or history of thrombosis.
What is a major risk of combining tranexamic acid with oral contraceptives?
Increased risk of thrombosis and myocardial infarction.
What is the quickest way to stop acute bleeding in a hemodynamically unstable woman?
Curettage
What is the preferred approach for older women or those with medical risk factors who cannot tolerate high-dose hormonal therapy?
Curettage
What is the most effective pharmacologic regimen to stop acute bleeding that does not require curettage?
High-dose estrogen
Why is high-dose estrogen effective in stopping acute bleeding?
Estrogen in pharmacologic doses causes rapid endometrial growth, covering denuded epithelial surfaces.
What is the recommended dose of oral conjugated equine estrogen (CEE) for acute bleeding?
10 mg/day in four divided doses
How might high-dose CEE alter platelet activity?
It may promote platelet adhesiveness and reduce bleeding time.
What is the advantage of IV estrogen over oral estrogen for acute bleeding?
IV estrogen has a more rapid onset, but no significant advantage over oral estrogen if tolerated.
What should be considered if bleeding does not decrease within the first 24 hours of high-dose estrogen therapy?
An organic cause, and curettage should be considered.
Why is progestogen added after initial estrogen therapy for acute bleeding?
Most cases of acute heavy bleeding result from anovulation, requiring progestogen to stabilize the endometrium.
What is the typical progestogen regimen following estrogen therapy for acute bleeding?
Medroxyprogesterone acetate (MPA) 10 mg once daily for 7-10 days.
What is an alternative to sequential high-dose estrogen-progestin therapy for acute bleeding?
Combination oral contraceptives (OCs) containing both estrogen and progestin.
What is the typical dosing regimen of combination OCs for acute bleeding?
Four tablets per day in divided doses until bleeding stops, then continued for at least 1 week.
Why might high-dose estrogen therapy be contraindicated in some women?
Prior thrombosis, certain rheumatologic diseases, or estrogen-responsive cancers.
When is estrogen therapy more logical for prolonged heavy bleeding?
If ultrasound shows a thin endometrial stripe (<5 mm).
When should curettage be considered in cases of heavy bleeding?
If the endometrium is thick (>10-12 mm) or if an anatomic finding is suspected.
What is the role of progestogens in the management of acute bleeding?
They stop endometrial growth and promote an organized slough of the endometrium.
What is the typical dosing regimen for high-dose progestogens in acute bleeding?
MPA 60 mg/day (20 mg three times daily) for 7 days, then 20 mg/day for 3 weeks.
Which progestogen regimen has shown similar efficacy to combination OCs in stopping acute bleeding?
MPA 60 mg/day for 7 days, then 20 mg/day for 3 weeks.
What is the mechanism of action of progestogens in stopping acute bleeding?
They stabilize the endometrium and increase the PGF2α/PGE ratio, promoting vasoconstriction.
What synthetic androgen has been used for the treatment of heavy menstrual bleeding?
Danazol
What are the main limitations of danazol for treating heavy menstrual bleeding?
Significant side effects such as weight gain and skin problems.
What is the quickest surgical method to stop acute bleeding in hypovolemic women?
Dilation and curettage (D&C).
When is D&C indicated for acute bleeding?
For hypovolemic women and older women at high risk for endometrial neoplasia.
Is D&C curative for anovulatory bleeding?
Rarely, as it does not address the underlying pathophysiology.
What is an alternative surgical treatment for abnormal bleeding when medical therapy fails?
Endometrial ablation (EA).
What are contraindications to endometrial ablation?
Very large uteri, endometrial hyperplasia, or cancer.
Why is pretreatment with danazol or a GnRH agonist beneficial before endometrial ablation?
It thins the endometrium, improving success rates.
Which women have a higher risk of requiring hysterectomy after endometrial ablation?
Those with dysmenorrhea, prior cesarean section, or structural abnormalities.
What is the leading cause of hysterectomy in the U.S.?
Abnormal uterine bleeding (AUB).
What are the indications for hysterectomy in AUB?
Failure of medical therapy, contraindications to medical therapy, or excessive menstrual blood loss.
Which surgical option is preferred when fibroids are causing excessive bleeding?
Uterine artery embolization (UAE).
What is the recommended treatment for adolescents with heavy menstrual bleeding?
MPA 10 mg/day for 10 days each month for at least 3 months.
What is the best long-term treatment for anovulatory abnormal bleeding?
Oral contraceptives (OCs) or cyclic progestogens.
Which treatment is most effective for chronic ovulatory heavy menstrual bleeding if no anatomic abnormalities are present?
Low-dose OCs.
