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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

A

8% (dime)

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
Q

Endometria carcinoma,

Type II

A

-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
Q

Coagulopathy

A
  • *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
Q

Ovulatory Dysfunction: Primary hypothalamic-pituitrary dysfunction

A
  • 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
Q

Ovulatory Dysfunction: Other

A
  • 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
Q

Peri-menopause

A

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
Q

Treatment for ovulatory dysfunctions

A
  1. NSAIDS- Start with NSAIDS- block prostaglandins involved with menses
  2. Progestins
  3. Combined oral contraceptives
  4. GnRH agonists
  5. Estrogen
31
Q

Progestins to treat ovulary dysfunction

A
  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
Q

Combined oral contraceptives to treat ovulary dysfunction

A
  • 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
Q

GnRH agonists to treat ovulary dysfunction

A

-Depot leuprolide (not great for controlling abnormal ovulatory cycle, cant use long term)

34
Q

Estrogen to treat ovulatory dysfunction

A

High does intravenous (makes endometrium grow, but at a rate that makes it stop bleeding)

35
Q

Endometrial

“E” of COEIN

A
  • 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
Q

Iatrogenic

A
  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
Q

Drugs that cause hyperprolactinemia

A
  • 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
Q

N of “COEIN” stands for

A

Not yet classified (diagnosis of exclusion)

39
Q

What to check for during physical exam

A
  • Excessive weight
  • Signs of PCOS, thyroid disease or insulin resistance
  • Pelvic exam: Cervical, vulvar or vaginal lesion, Uterine size, Adnexal masses, Pain
40
Q

Labs to run during premenopausal workup

A
  1. PREGNANCY TEST
  2. CBC
  3. Thyroid function
  4. Cervical cytology +/- culture
  5. +/- coagulation studies (depends on s/s)
41
Q

Imaging for premenopausal workup

A
  • *Transvaginal ULTRASOUND** BEST IMAGING
  • Saline Infusion
  • Sonohysterography (SIS)
  • Hysteroscopy
  • +/- MRI
42
Q

Who gets tissue sampling as part of work up?

A

45 yo: ANY abnormal bleeding

-Dilation and Curettage, endometrial biopsy, +/- cervical biopsy

43
Q

Differential for postmenopausal bleeding plus 1 major rule

A

**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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