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CSI- Winter > Dysfunctional Uterine Bleeding > Flashcards

Dysfunctional Uterine Bleeding Flashcards

1
Q

Normal uterine bleeding

A
  • cycle is 21-35 days, average is 28 days
  • bleeding lasts 2-7 days
  • 40 mL blood loss
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2
Q

Menorrhagia

A

-HEAVY bleeding
> 7 days
> 80 mL blood loss (double normal)

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3
Q

Metorrhagia

A
  • ABNORMAL bleeding

- Polymenorrhea: 35 days

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4
Q

Menometorrhagia

A

Both heavy and abnormal bleeding

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5
Q

PALM-COEIN reasons for premenopausal uterine bleeding

A 
PALM: Structural 
P: poly 
A: adenomyosis 
L: leiomyoma
M: malignancy 
COEIN: non-structural 
C: coagulopathy 
O: ovulatory dysfunction
E: endometrial 
I: iatrogenic 
N: not yet classified
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6
Q

Polyp

A

Can cause very heavy bleeding (menorrhagia) or intramenstrual bleeding (bleeding between cycles)

  • Localized hyperplastic overgrowths of endometrial glands and stroma around a vascular core
  • Looks like a finger-like projection into uterus
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7
Q

Risk Factors to getting a uterine polyp

A
  • tamoxifen (breast cancer)
  • obesity (have extra estrogen)
  • postmenopausal hormones
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8
Q

To better view a polyp can use

A

Saline infused sonohistogram (used to
expand uterus to see structures you wont see
when uterus is collapsed)

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9
Q

Adeonmyosis

A
  • *Heavy menstrual bleeding and pelvic pain
  • *Trying to bleed but trapped in muscular tissue (painful)
  • Endometrial glands and stroma within uterine musculature= hypertrophy and hyperplasia= globular uterus
  • can be diffuse or nodular

-WIKI: presence of ectopic glandular tissue found in muscle

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10
Q

Best imaging for uterus (especially to see adenomyosis)

A

Transvaginal ultrasound

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11
Q

Treatment for Adenomyosis

A

medical/surgical

-may need hysterectomy

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12
Q

Leiomyoma

A
  • AKA: fibroids
  • Benign monoclonal tumors arising from smooth muscle of myometrium
  • Heavy menstrual bleeding plus pressure symptoms
  • 2-3x great risk in african americans
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13
Q

Types of Leiomyomas

A
  1. Submucosal fibroid (causes most bleeding, most associated with infertility and miscarriages)
  2. Intramural fibroid
  3. Subserosal fibroid
  4. Pedunculated fibroid
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14
Q

Leiomyoma vs Polyp

A
  • Fibroids are more solid and harder to remove
  • Polyps are softer and easier to remove because they are endometrial glands
  • These two are easily confused
  • Can use use saline infused sonohistogram to see both (submucosal fibroid only)
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15
Q

Treatment for Leiomyoma

A
  • medical:
    1. OCPs
    2. Progestins (IUD or Depo- stops ovulation, no growth of endometrium, may decrease bleeding)
    3. Luprolide (LOTS of people use this- shuts off all estrogen that you’re secreting, can maybe even shrink the fibroid)- 6 months max, puts you in false menopausal state- causes bone loss, NOT reversible (osteoporosis/osteopenia)
  • Once in menopause, no estrogen, fibroids may even shrink

-Surgery: removal

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16
Q

Malignancy

A

Cervical vs uterine (both present with vaginal bleeding)

Uterine- Hyperplasia vs adenocarcinoma vs sarcoma

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17
Q

Cervical cancer, you can see _________

A

squamous cell carcinoma

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18
Q

Endometrial hyperplasia

A

Proliferation of endometrial glands of irregular size and shape

-Hyperplasia is BIG risk factor for endometrial cancer

19
Q

Simple without atypia, % of people with endometrial hyperplasia that have it

A

1% (penny)

20
Q

Complex without atypia, % of people with endometrial hyperplasia that have it

A

3% (nickel)

21
Q

Simple with atypia, % of people with endometrial hyperplasia that have it

22
Q

Complex with atypia, % of people with endometrial hyperplasia that have it

A

*29% (quarter)

23
Q

Risk factors for endometrial hyperplasia

A

unopposed estrogen!, increasing age, unopposed E2 therapy, tamoxifen, early menarche, late menopause, nulliparity, PCOS, obesity, diabetes, E2 tumor, lynch syndrome, cowden syndrome, family history

24
Q

Endometrial carcinoma,

Type I

A
  • endometrioid histology, grade 1,2**

- good prognosis, usually can find this early and low grade (pt comes in when they are bleeding- know this is abnormal)

25
Endometria carcinoma, | Type II
-non-endometrioid histology, or grade 3 endometrioid (Serous, Clear cell, Mucinous, Squamous, Transitional Cell, Mesonephric, Undifferentiated) -NOT associated with endometrial hypoplasia, poor prognosis, aggressive, usually familial inheritance
26
Coagulopathy
* *Von Willebrand disease**= most common - ITP - Platelet function defect CLINICAL: Patients who come in young- really, really heavy periods, mom has really heavy period, gums bleed when they brush their teeth
27
Ovulatory Dysfunction: Primary hypothalamic-pituitrary dysfunction
- Sheehan’s syndrome - Pituitary adenoma/other tumor - Lactation - Stress - Eating disorders - Exercise - Peri-Menopause** (happens 2-6 yrs before menopause) - Autoimmune diseases - Empty sella syndrome - Kallman’s syndrome - Idiopathic hypogonadotropic hypogonadism - Hypothalamic/pituitary tumor, trauma or radiation
28
Ovulatory Dysfunction: Other
- Polycystic ovarian syndrome (PCOS- ABNORMAL CYCLES- heavy bleeding, have follicles but nothing is ovulating, no dominant follicle, doesn’t happen every month- lots of androgens= obese, baldness, etc) - Hyperthyroidism/hypothyroidism - Adrenal or ovarian tumors - Liver or renal disease - Cushings disease - Congenital adrenal hyperplasia - Premature ovarian failure - Turner syndrome - Androgen Insensitivity syndrome
29
Peri-menopause
not having functional ovulation every cycle, in between you have abnormal growth of endometrium and you’re not having a period, when you DO get a period everything comes out at once
30
Treatment for ovulatory dysfunctions
1. NSAIDS- Start with NSAIDS- block prostaglandins involved with menses 2. Progestins 3. Combined oral contraceptives 4. GnRH agonists 5. Estrogen
31
Progestins to treat ovulary dysfunction
1. Medroxyprogesterone acetate (Depo-provera; giving yourself exogenous progesterine lets you control your cycle, make it noormal) 2. Norethindrone acetate 3. Levonorgestrel-releasing IUD (good for everything, used a ton)
32
Combined oral contraceptives to treat ovulary dysfunction
- Normal - High dose (bleeding heavily, 3 pills for 3 days, stabilizes lining quickly, but patient that can’t go to surgery/borderline for surgery)
33
GnRH agonists to treat ovulary dysfunction
-Depot leuprolide (not great for controlling abnormal ovulatory cycle, cant use long term)
34
Estrogen to treat ovulatory dysfunction
High does intravenous (makes endometrium grow, but at a rate that makes it stop bleeding)
35
Endometrial | "E" of COEIN
- confusing term (when you rule everything out, maybe something local is going on) - Endometritis (ascending bacterial flora from vaginal canal) - PID - Local endometrial hemostasis disorders
36
Iatrogenic
1. Birth control: - Copper IUD (no hormone, no control over cycle, can make periods heavier and more painful, if pt comes with this complaint, tx is to take out copper IUD) - OCPs - Progestin (only contraceptive, pills, shots, IUD, can cause light abnormal spotting, metorrhagia) 2. Menopausal hormone therapy 3. Steroids 4. Drugs that can cause
37
Drugs that cause hyperprolactinemia
- Antipsycotics, antidepressants, antiemetics, antihypertensive - Metoclopramide, prochlorperazine, methyldopa, verapamil, amitriptyline, haloperidol, risperidone CLINICAL: Pt on weird meds with abnormal vaginal bleeding- think of meds causing the problem
38
N of "COEIN" stands for
Not yet classified (diagnosis of exclusion)
39
What to check for during physical exam
- Excessive weight - Signs of PCOS, thyroid disease or insulin resistance - Pelvic exam: Cervical, vulvar or vaginal lesion, Uterine size, Adnexal masses, Pain
40
Labs to run during premenopausal workup
1. PREGNANCY TEST 2. CBC 3. Thyroid function 4. Cervical cytology +/- culture 5. +/- coagulation studies (depends on s/s)
41
Imaging for premenopausal workup
* *Transvaginal ULTRASOUND** BEST IMAGING - Saline Infusion - Sonohysterography (SIS) - Hysteroscopy - +/- MRI
42
Who gets tissue sampling as part of work up?
45 yo: ANY abnormal bleeding -Dilation and Curettage, endometrial biopsy, +/- cervical biopsy
43
Differential for postmenopausal bleeding plus 1 major rule
**ALWAYS INVESTIGATE (ALWAYS get a biopsy) - Atrophy** (most common cause) - Hyperplasia - Carcinoma - Hormonal therapy - Atrophic vaginitis - Trauma - Polyps - Uterine prolapse and friction ulcers - Blood dyscrasias

CSI- Winter (44 decks)

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