Dysfunctional uterine bleeding Flashcards
Define dysfunctional uterine bleeding.
Describes menorrhagia in the absence of underlying pathology
Define abnormal uterine bleeding.
Used to describe any symptomatic variation from normal menstruation in terms of regularity, frequency, volume, or duration. It also includes inter-menstrual bleeding (IMB)
How common is abnormal menstrual bleeding?
AUB and heavy menstrual bleeding affect 14-25% of women of reproductive age
AUB is the 4th most common reason for referral to gynaecology in UK
When is AUB most common?
Variation in menstrual flow and cycle length are common at the extremes of reproductive age (during early teenage years and preceding menopause).
What are the causes of AUB?(!)
PALM-COEIN acronym:
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not otherwise classified
What is the pathophysiology of AUB (briefly)?
For normal menstruation to occur, a series of complex orchestrated interactions between endocrine, paracrine, haemostatic factors on the endometrium must occur.
What is the definition of heavy menstrual bleeding?
Excessive menstrual blood loss that interferes with the physical, social, emotional, and/or material quality of life
No quantification in definition.
Describe the follicular and luteal phases of the menstrual cycle.
Rise in oestrogen –> negative feedback to FSH + surge in LH,–> triggering ovulation.
The remaining corpus luteum produces progesterone –> stimulating a secretory endometrium.
If fertilisation does not occur, progesterone and oestrogen levels fall rapidly, leading to synchronous shedding of the endometrial lining approximately 14 ±1 days after ovulation has occurred.
What hormone triggers menstruation?
Progesterone withdrawal secondary to demise of the corpus luteum.
What are the risk factors for AUB?
- Extremes of reproductive age
- PCOS
- Endocrine disorders e.g. hypothyroidism and hyperprolactinaemia
- Anovulatory disorders e.g. hypothalamic anovulation due to excessive exercise, physical stress or sudden loss/increase in weight
- Obesity due to excessive oestrogen
What should you look for on assessment of a patient with AUB?
Hypovolaemia
Anaemia - fatigue, dyspnoea, pallor
Unstable vital signs
Speculum and bi-manual examination - used to examine the cervix and assess the size and shape of the uterus; ensure patient is not bleeding from areas other than the genital tract and to assess amount and intensity of bleeding
What investigations should be done for AUB?
- Pregnancy test - even if using contraception
- FBC
Consider:
- Coagulation profile to exclude bleeding disorder
- TSH
- Routine TVUS scan - although structural abnormality does not imply causality
- Hysteroscopy - recommended when endometrial cavity pathology (e.g., endometrial polyps, submucous leiomyomas) or endometrial pathology (e.g., endometrial hyperplasia, cancer) is suspected
- Endometrial biopsy - if there is risk of hyperplasia or cancer
How do you detect anovulation?
Measure serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
When should you consider endometrial biopsy in AUB?
Only done during hysteroscopy - blind biopsy should not be done
+ when there are risk factors for endometrial pathology (e.g. cancer, hyperplasia). Risk factors include:
- age >45 years
- nulliparity
- persistent irregular bleeding
- obesity
- polycystic ovary syndrome (PCOS)
- hypertension
- diabetes
- family history of breastcolon, or endometrial cancer (e.g., Lynch syndrome)
- history of tamoxifen use
- failure of medical management.
What is the management of heavy menstrual bleeding based on?
Whether the patient does or does not require contraception
What is the management of HMB in a patient who does not require contraception?
- NSAID Mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or
- TXA 1 g tds.
Both are started on the 1st day of the period
- if no improvement then try other drug whilst awaiting referral
What is the management of HMB in a patient who requires contraception?
- 1st line - IUS (Mirena) - used when no pathology for HMB identified or when fibroids <3cm present.
- COCP
- Long-lasting progestogens
NB: The use or progestogens is useful for AUB but also prevention of development of endometrial hyperplasia which may be caused by anovulation which causes unopposed oestrogen stimulation.
What is a medication used in short-term management of HMB?
Norethisterone 5 mg tds - used to stop HMB
This is not a contraceptive and so barrier contraception is recommended with use.
What lifestyle advice should be given in AUB?
Regular exercise and maintaining healthy BMI - high BMI is often associated with ovulatory AUB
Healthy diet will also help limit Fe deficiency anaemia, raise energy levels and improve QoL
In patients with AUB and failure of, or contraindication to, medical treatment and when not desiring fertility, what is a treatment option?
Endometrial ablation/resection - positive outcomes although retreatment may be required
Hysterectomy - a definitive and permanent cure but has significant morbidity. Although it has superior control of menstrual blood loss compared to other methods.
What are the complications of AUB?
Iron deficiency anaemia - mx includes the use of oral or parenteral iron, and a red blood cell transfusion in selected patients (e.g., symptomatic at rest with dyspnoea, chest pain, or pre-syncope).
Endometrial hyperplasia and possible development of endometrial cancer - when anovulatory AUB lasts for long periods
What laboratory findings suggest iron deficiency anaemia?
- Low serum iron
- Increased total iron-binding capacity
- Less than 16% transferrin saturation
- and low serum ferritin.
What is the prognosis with AUB?
During first few years of menarche and perimenopause - prognosis is excellent once stability is established
If cause of AUB is not addressed then significant impact on QoL
