AUB + Fibroids in Pre-menopausal women Flashcards
follicular phase events
- FSH rises + follicles recruited
- follicles secrete E2, increases granulosa cells
- granulosa cells aromatize androgens (from theca cells)
- rising FSH and E2 inhibit pituitary E2, stops all follicles except dominant /w most E2/GCs/FSH receptors
- FSH induces LH receptors on GC
- endometrium proliferates
ovulation events
- LH and FSH surge
- ovulation occurs 12 hours after LH surge
- P secretion begins, causes proteolytic enzymes and prostaglandins to rupture follicle
luteal phase events
- follicle –> corpus luteum
- CL secretes P
- more LH receptors, P increases
- FSH receptors suppressed, E declines
- after 14 days CL detriorates (unless fertilization)
- P drops and menstruation occurs (/w decline of P and E)
progesterone effect on menstrual flow
progesterone thins endometrium
need withdrawal of E2 and P to trigger menstruation (take OCP continuously, no period)
Normal Menses
24-38 day cycle
period 4.5-8 days
blood loss: 5-80cc
normal variation: +/-2 to 20 days in cycle length
no breakthrough bleed
large pad q1h for 4-5days will cause anemia in 3-4 months
heavy menstrual bleeding definition
- interferes /w life
precocious menstruation
before age 9
acute AUB
bleed in non-preg woman of reproductive age requiring immediate medical intervention
causes of AUB
P- polyps
A- adenomysosis
L - leiomyoma
M - malignancy
C - coag disorder O - ovulatory disorder E - endometrial I - iatrogenic N - not otherwise classified
causes of AUB in menarche
Ovulatory = 1, hypothalamic pituiatyr axis. R/O
- coagulopathies
- endocrine
- pregnancy - SA, molar, ectopic
- incorrect use of OCP
- sexual trauma
Coagulopathies in menarche + tests
1) VWD - bruising, epistaxis, gums, post surgical
2) platelet abnormality
- thrombasthenia - pt >400, malfunction
- ITP - Plts <150
3) leukemia
Tests: PTT, CBC, factor 8, VWF antigen, VWF functional assay (repeat if needed)
endocrine/ovulatory causes of AUB
PCOS
adrenal cause: CAH, cushings
Hypothalamic - eating disorder, exercise, stress, idiopathic, immature HPO axis
thryoid - hypo
prolactinoma
Ovarian: hormone secreting tumour (granulosa cell, sertoli-leydig = rare)
tests: BhCG, TSH, Prolactin, free testosterone, 17-hyrdoxy progesterone and DHEA (for adrenal), glucose/A1C
management of acute AUB in adolescent
- stabilize (ABC) – if very unstable, tamponade –> D+C
- meds - estrogen: premarin 25 mg IV q6hx24 hrs + gravol, or OCP 1 tab PO tid x 3 days, then bid x3 days, then daily x21 days
maintain OCP for several months to regulate until HPO axis matures
Mature women differential diagnosis for AUB
same as in younger
- structural more common
- VWB can present later but less common
- HPO axis mature but can have prolactinoma, stress, weightloss
who to do endometrial biopsy on
women over 40 /w AUB or RF for endo CA: - nullip /w infertility - new onset heavy bleeding - obesity, PCOS - Fam Hx of endo or colon CA
iatrogenic causes of AUB
forgotten IUD
OCH/HRT incorrectly used / breakthrough
neuroleptics: interfere /w dopamine + prolactin
N in PALM COIEN
pregnancy (ectopic?)
other premalignant/malignant (cervix)
when to work-up for missed cycle / anovulation
after 2-3 occurrences, 1 isolated time is ok (keep diary)
workup for AUB/HMB in older pre-menopausal women
Hx
VS, signs of anemia
biopsy if needed
labs: CBC, ferritin, TSH, PRL, BhCG, coags if think VWB
sonohysterogram (endo polyps or submucosal fibroids)
US - endo can be up to 14mm before menstruation
Hysteroscopy - if all else neg and HMB persists
Tx of Acute AUB in older pre-menopausal women
hormones = 1st line
options:
- NSAID
- tranexamic acid
- progestin
- OCP
- Mirena IUD - works best
Surgical tx of AUB
hysteroscopic resection - submucosal fibroids + polyps
hysteroscopic endometrial ablation - 80% improvement but can return
hysterectomy - definitive tx (most morbidity though)
types of lyeimyoma
submucous
intramural
subserosal
can grow into cervix + vagina too
mechanisms of fibroid growth
1) monoclonal
2) 40% chromosomal abnormalities
3) GFs: many, includes angiogenesis GF
4) hormonal stimulation: E and P receptors, P causes most growth
5) apoptosis inhibition
clinical features of fibroids
- asymptomatic - most
- bleeding - esp sub mucosal
- pressure symptoms
- GI (constipation, bloat)
- Urinary - freq + urg, rare: acute retention due to compression of cervix into urethra (emergency)
- infertility if submucous
- pain NOT associated, if pain and enlarging –> suspect leiomyosarcoma
effect of fibroids on fertility
- little evidence to guide
- submucosal - remove
- intramural > 5cm - prob should remove
- myomectomy if uterus > 12wks
work-up for fibroids
- exam for size, symphsis fibroid height if out of pelvis
- US
- sonohysterogram to differentiate from endo polyp
- endo bx + labs as needed for AUB
non surg tx of fibroids
- OCP
- tranexamic acid
- GnRH agonist - shrinks 25-50% in 3 mo, can’t use long term b/c of osteoporosis, grow back
- SPERM - Ulipristal 5m PO OD, reduces same amnt in 3 months, may not re-grow, monitor liver enzymes, ? long term use
- Uterine artery embolization (IR): bilat, fibroids necrose + degenerate + normal myometrium stays, not sure effect on preg, improves menorrhagia 90%, may need more tx in 3 years
surgical tx of fibroids
- hysteroscopic resection (submucous) - outpatient, quick, effective
- myomectomy - preserve childbearing, laparascopy if <8cm, risks: blood loss, adhesions new myoma
- hysterectomy - definitive, more complications
issues with fibroids in preg
- pain (15%), from degeneration
- abnormal placentation
- premature labour, PPROM
- dystocia if lower segment
- fetal malpresentation
- increase CS
- increase in PPH
- follow /w US in 3rd trimester, usually TOL even if in lower seg
