Lecture 9: Abnormal uterine bleeding

Question 1

Define Abnormal Uterine bleeding and what is the severity based on

Answer 1

Any variation from the normal menstrual cycle including changes in regularity and frequency of menses, duration of flow or amount of blood loss.

The severity is based on the woman’s subjective experience and impression of the level of blood loss- the impact on their daily life

Question 2

Define Heavy Menstrual bleeding

Answer 2

Excessive menstrual blood loss which interferes with physical, emotional, social and material quality of life which may occur alone or in combination with other symptoms

Question 3

What are causes of abnormal uterine bleeding/

heavy menstrual bleeding

Answer 3

Structural: interferes with the cramping of spiral arteries leading to excessive bleeding
- Polyps, Adenomyosis, Leiomyoma, Malignancy and hyperplasia (Cancer)

Nonstructural:
Coagulopathy, Endometrial,
Iatrogenic,
Not yet classified

Ovulatory dysfunction- mainly

Question 4

How is a structural cause of AUB diagnosed - what exams, and what are the treatments

Answer 4

1. History
2. General exam- anemia, abdo exam for mass
3. Investigations:

• transvaginal USS scan for Endometrial thickness- checked against day in the cycle (16mm in luteal phase- otherwise may be hyperplasia.
• Endometrial biopsy
• speculum exam
• smear and swab

Treatment differs with cause - generally surgical removal

Question 5

What is Endometrial Hyperplasia possible underlying cause, risk factors in pre menopausal women

Answer 5

It is the precursor to endometrial cancer- 25% will progress/have concurrent cancer. It presents as crowding of glands, +/- cellular atypia.

Underlying cause is anovulation or oligo-ovulation *which may be affected by higher hormones.
Thickening of the endometrium is promoted by E2. Without ovulation there is no Progesterone (P2) to cause lining to shed so it continues to thicken to a point where it will keep shedding off- leading to excessive bleeding.

Risk factors:
- mainly obesity, nulliparity, anaemia, pasifika, thickened endometrium, family history

Question 6

What are the treatments for Endometrial hyperplasia and the heavy bleeding it causes and how does it work

Answer 6

Treatment is giving Progesterone everyday like depo provera, minipill, jadelle, mirena or in the combined pill. When there is a break in the treatment there will be a withdrawal bleed- shedding of the endometrial lining.
This will be heavy at first but will reach the point where it is starting from scratch again and will stop heavy bleeding.

Late stage can be hysterectomy which may be sad for younger women

Question 7

What is the diagnostic criteria/presentation for polycystic ovary syndrome

Answer 7

2 out of 3 of following features

• Oligo ovulation and or anovulation : ammenorrhoea
• Clinical and or biochemical evidence of hyper androgenism: high serum androgens, hirsuitism, male pattern baldness, chin acne
• Polycystic ovaries on USS: enlarged ovaries, _>20 follicles on one ovary or ovarian volume _>10 ml

Question 8

What is the main mechanism behind PCOS - maybe dnk

Answer 8

Higher ratio of LH to FSH release in the early part of the cycle even if both values are within the normal range (usually should be 1:1).

Increased LH increases androgen production

• less aromatase for conversion to E2 available and
• decreases Sex hormone binding globulin= more free testosterone
• in obesity there is increased peripheral aromatase conversion which increases negative feedback on FSH more
• Hyperinsulinemia increases GnRH pulses which favours LH over FSH

Question 9

What health problems are people with PCOS more at risk of

Answer 9

Can also have higher risk of:

• Insulin resistance, diabetes,
• CVS disease, metabolic syndrome: - Obesity
• Pregnancy complications
• Infertility
• Anxiety, depression, body image: therefore don’t diagnose in women in their 20s bc it might just need time while their HPO axis is developing

Question 10

What is the epidemiology of PCOS and the aetiology

Answer 10

10% of women at reproductive age.
There is genetic predisposition with ethnic variation

Aetiology: follicles mature to antral stage but not further so it is not ovulated

Question 11

What is the treatment, management of PCOS

Answer 11

1. Weight loss 5-10% over 6 mo via diet and moderate exercise can restore ovulation, improve fertility, SHBG, insulin sensitivity
2. Medication:
   a) meds to reduce insulin resistance eg. Metformin

b) Don’t want pregnancy:
Long acting Hormonal contraceptives - have P2

c) Want pregnancy: induce ovulation with letrozole (aromatase inhibitor)

Or

3. surgery for ovulation induction
   - removes stroma or theca cells to drop LH levels