Columbus: Abnormal uterine bleeding Flashcards
Normal menstrual volume?
Normal frequency?
Normal duration?
5 to 80 mL
24 to 35 days
4.5 to 7 days
Define AUB
Any uterine bleeding outside the parameters of normal menstruation in the reproductive years.
What is the differential diagnosis for AUB?
P: polyp A: adenomyosis L: leiomyoma M: malignancy and hyperplasia C: coagulopathy O: ovulatory dysfunction including thyroid disease E: endometrial I: iatrogenic including IUD N: not yet classified
What history would you want for AUB?
Cycle regularity, frequency of menstruation, duration of menstrual flow, volume of bleeding. Intermenstrual or postcoital bleeding.
Symptoms of bleeding disorder or PCOS. Anemia symptoms.
Medications including hormones and herbal supplements.
How would you examine a patient with AUB?
vitals: HR, BP and BMI
Skin: hirsutism, acne and acanthosis nigricans. Petechiae or ecchymoses
Thyroid: nodule
Pelvic: cervicitis, bimanual examination for fibroids or malignancy, rectovaginal exam
What is the differential diagnosis for postcoital bleeding?
Cervical ectropion Endocervical polyps Cervicitis particularly from chlamydia CIN and cervical cancer Vaginal atrophy
What is the differential diagnosis of AUB in an adolescent?
Anovulation Coagulopathy such as von Willebrand disease Mullerian anomalies AV malformation Infection Chemotherapy
What percentage of women with menorrhagia since menarche will have a bleeding disorder?
65%
What is the role of von Willebrand factor?
- major adhesion molecule for platelets to the exposed subendothelium
- binding protein for factor VIII
How is von Willebrand disease treated?
DDAVP Oral contraceptives Levonorgestrel IUD Tranexamic acid Plasma derived concentrates of von Willebrand's factor for type 3
How and when is desmopressin acetate administered?
What is it mechanism of action?
Intranasally during menstruation or IV prior to procedures
Releases stored von Willebrand factor from within the endothelium
When does ACOG recommend testing for von Willebrand disease?
- Adolescents with severe menorrhagia
- Adult women with menorrhagia without apparent cause
- Women undergoing hysterectomy for menorrhagia
What tests should be ordered to screen for coagulopathies?
CBC with platelets, PT, aPTT, PFA – 100 (platelet function analyzer)
How does hypothyroidism cause abnormal uterine bleeding?
Does hyperthyroidism cause AUB?
SHBG is reduced which leads to increased free E2 and TRH increases prolactin, which leads to anovulation
Yes but the mechanism is unknown
What supplements and herbal medications affect menstrual bleeding?
Ginkgo and ginseng have antiplatelet activities
High-dose fish oil and omega-3 supplements can impair platelet activation
What laboratory tests should be considered for AUB?
Pregnancy test
Pap smear and STI cultures
Screen for von Willebrand disease when appropriate
CBC and work up of anemia
Consider endocrine testing for anovulatory bleeding
Consider endometrial biopsy
What imaging should be considered for the evaluation AUB?
Transvaginal ultrasound
Saline infusion sonography
HSG
Hysteroscopy
All women over what age should have endometrial sampling as a first-line test?
What is the rate of failure to detect cancer for this method?
When is hysteroscopic directed biopsy recommended?
45
0.9%
Focal endometrial thickening
In what diseases or conditions should younger women have endometrial sampling for work up of abnormal uterine bleeding?
Chronic anovulation
Diabetes, obesity, hypertension
Tamoxifen use
What ultrasound findings of the endometrium warrant further evaluation?
Heterogeneous endometrium or intrauterine fluid collection
When is MRI indicated to evaluate AUB?
Equivocal ultrasound results
Suspicion of adenomyosis
Assess location for surgical or radiologic treatment
What medications and dosages can be used for management of heavy abnormal uterine bleeding?
Conjugated equine estrogen 2.5 mg PO every six hours for 24 hours
OCP taper
Provera 10 mg twice daily until bleeding stops for 14 days
What are chronic therapies for abnormal uterine bleeding and dosages?
NSAIDs: Cox 1 inhibitors, start with menstrual flow and continue for five days, reduces flow 20 to 50%
OCP’s: reduces blood flow approximately 60%
Tranexamic acid: plasminogen activation inhibitor, 1300 mg every eight hours for 5 days, decreases bloodflow by 50%
Oral progestins: 10 days per month if anovulatory
Levonorgestrel IUS: decreases bloodflow 74% in 3 months and 97% at 1 year.
When was Mirena approved for heavy menstrual bleeding by the FDA?
What is the largest uterine size in which a Mirena IUD can be placed?
2009
Less than or equal to 12 weeks size with no cavitary distortion.
How effective is Mirena for adenomyosis?
Improved hemoglobin and decreased uterine volume and pain scores at 12 months. Some worsening at 36 months but still improved over the baseline.
AJOG 2008
What does ACOG recommend prior to endometrial ablation?
Endometrial sampling
What are contraindications to endometrial ablation?
Future fertility Pregnancy Genital tract infection or malignancy Uterine anomaly Prior uterine surgery such as myomectomy classical cesarean section or more than one low transverse cesarean
What is more effective Mirena or endometrial ablation?
No significant difference in menstrual blood loss reduction or major complications
What symptoms occur with endometrial polyps?
Abnormal uterine bleeding, dysmenorrhea, vaginal discharge, postcoital bleeding
What are contraindications to hysteroscopic resection of a polyp or fibroid?
Acute PID or prodromal HSV infection
Purely transmural fibroid
Poor intraoperative visualization or distention of the uterine cavity
What are the 3 recommended prerequisites for hysteroscopic resection of a uterine fibroid?
Single intracavitary myoma involving less than 50% of the myometrium and less than or equal to 3 cm in diameter
Uterine size less than 12 to 14 weeks
Normal hemoglobin and electrolytes
What are the odds of incomplete removal of a type 2 fibroid?
Approximately 40%
Describe the classification system of submucous uterine fibroids.
Type 0: pedunculated submucous fibroids
Type 1: less than 50% intramural submucous fibroids
Type 2: greater than 50% intramural with submucous component
What are contraindications to uterine fibroid embolization?
Active infection or vasculitis History of pelvic radiation Contrast allergy Poorly controlled diabetes Renal failure or insufficiency Arteriovenous shunting Undiagnosed pelvic mass Submucosal fibroid or pedunculated with stalk less than 2 cm Pregnancy
List complications associated with uterine fibroid embolization.
11% readmission rate Ischemic necrosis causing pain and prolonged vaginal discharge Retained fibroid tissue fragments Premature ovarian failure: < 1% Heavy bleeding Systemic or local infection
What is post embolization syndrome?
How can it be distinguished from infection?
Ischemic pain, nausea, vomiting, malaise, uterine tenderness and low-grade fever occurs in 20%, 15% require readmission.
Occurs within first week
Elevated WBC with left shift in both
MRI can be helpful to distinguish from abscess
How does uterine fibroid embolization compare to medical or surgical therapy?
No significant difference in patient satisfaction at two or five years.
No difference in rate of major complications
No difference in ovarian failure rates
Uterine fibroid embolization is associated with higher rates of minor complications and higher re-intervention rates within five years.
Is uterine fibroid embolization contraindicated for patients who desire future fertility?
ACOG recommends to be cautious when considering use and women who want to retain fertility secondary to possible abnormal placentation and amenorrhea
What are the advantages and disadvantages of laparoscopic versus abdominal myomectomy?
Laparoscopic myomectomy is associated with decreased risk of fever, less hemoglobin drop, shorter length of stay and faster recovery. Only OR time was increased in a laparoscopic group.
Major complications, pregnancy rates and recurrence rates were similar.
