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