Dysfunctional Uterine Bleeding Flashcards
Normal uterine bleeding
- cycle is 21-35 days, average is 28 days
- bleeding lasts 2-7 days
- 40 mL blood loss
Menorrhagia
-HEAVY bleeding
> 7 days
> 80 mL blood loss (double normal)
Metorrhagia
- ABNORMAL bleeding
- Polymenorrhea: 35 days
Menometorrhagia
Both heavy and abnormal bleeding
PALM-COEIN reasons for premenopausal uterine bleeding
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
Polyp
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
Risk Factors to getting a uterine polyp
- tamoxifen (breast cancer)
- obesity (have extra estrogen)
- postmenopausal hormones
To better view a polyp can use
Saline infused sonohistogram (used to
expand uterus to see structures you wont see
when uterus is collapsed)
Adeonmyosis
- *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
Best imaging for uterus (especially to see adenomyosis)
Transvaginal ultrasound
Treatment for Adenomyosis
medical/surgical
-may need hysterectomy
Leiomyoma
- AKA: fibroids
- Benign monoclonal tumors arising from smooth muscle of myometrium
- Heavy menstrual bleeding plus pressure symptoms
- 2-3x great risk in african americans
Types of Leiomyomas
- Submucosal fibroid (causes most bleeding, most associated with infertility and miscarriages)
- Intramural fibroid
- Subserosal fibroid
- Pedunculated fibroid
Leiomyoma vs Polyp
- 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)
Treatment for Leiomyoma
- 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
Malignancy
Cervical vs uterine (both present with vaginal bleeding)
Uterine- Hyperplasia vs adenocarcinoma vs sarcoma
Cervical cancer, you can see _________
squamous cell carcinoma
Endometrial hyperplasia
Proliferation of endometrial glands of irregular size and shape
-Hyperplasia is BIG risk factor for endometrial cancer
Simple without atypia, % of people with endometrial hyperplasia that have it
1% (penny)
Complex without atypia, % of people with endometrial hyperplasia that have it
3% (nickel)
Simple with atypia, % of people with endometrial hyperplasia that have it
8% (dime)
Complex with atypia, % of people with endometrial hyperplasia that have it
*29% (quarter)
Risk factors for endometrial hyperplasia
unopposed estrogen!, increasing age, unopposed E2 therapy, tamoxifen, early menarche, late menopause, nulliparity, PCOS, obesity, diabetes, E2 tumor, lynch syndrome, cowden syndrome, family history
Endometrial carcinoma,
Type I
- 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)
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
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
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
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
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
Treatment for ovulatory dysfunctions
- NSAIDS- Start with NSAIDS- block prostaglandins involved with menses
- Progestins
- Combined oral contraceptives
- GnRH agonists
- Estrogen
Progestins to treat ovulary dysfunction
- Medroxyprogesterone acetate (Depo-provera; giving yourself exogenous progesterine lets you control your cycle, make it noormal)
- Norethindrone acetate
- Levonorgestrel-releasing IUD (good for everything, used a ton)
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)
GnRH agonists to treat ovulary dysfunction
-Depot leuprolide (not great for controlling abnormal ovulatory cycle, cant use long term)
Estrogen to treat ovulatory dysfunction
High does intravenous (makes endometrium grow, but at a rate that makes it stop bleeding)
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
Iatrogenic
- 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) - Menopausal hormone therapy
- Steroids
- Drugs that can cause
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
N of “COEIN” stands for
Not yet classified (diagnosis of exclusion)
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
Labs to run during premenopausal workup
- PREGNANCY TEST
- CBC
- Thyroid function
- Cervical cytology +/- culture
- +/- coagulation studies (depends on s/s)
Imaging for premenopausal workup
- *Transvaginal ULTRASOUND** BEST IMAGING
- Saline Infusion
- Sonohysterography (SIS)
- Hysteroscopy
- +/- MRI
Who gets tissue sampling as part of work up?
45 yo: ANY abnormal bleeding
-Dilation and Curettage, endometrial biopsy, +/- cervical biopsy
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
