Lecture 9: Abnormal uterine bleeding

Question 1

Define abnormal uterine bleeding:

Answer 1

Any variation from the normal menstural cycle, and include changes in

• Regularity and Hz of menses
• Duration of flow, or,
• Amount of blood

Ask/ascertain the impact on quality of life.

Question 2

What are the causes of AUB?

Answer 2

PALM-COEIN

Structural abnormalities:

• Polyps
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia

Non-structural abnormalities

• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not yet classified

Question 3

How is the diagnosis of AUB made?

Answer 3

History
Exam
Investigations

Question 4

What exams are made in AUB?

Answer 4

• General (anemia etc)
• Abdominal/pelvic i.e polyp
• Speculum, bimanual

Question 5

What is AUB treatment dependent on?

Answer 5

The cause lol

PALM-COEIN

Question 6

What can endometrial thickening be a sign of:

Answer 6

US finding:

• Could be polyp
• Need to exclude endometrial hyperplasia/cancer
• > Endometrial biopsy

Question 7

Why is endometrial hyperplasia (EH) a concern?

Answer 7

• EH is a concern as it is a precursor for endometrial cancer
• Classified as with or without atypia
• > Up to 25% will progress to cancer
• > up to 25% will have concurrent cancer

Question 8

What are the risk factors for endometrial hyperplasia / cancer?

Answer 8

• Obesity
• Nulliparity
• Anaemia
• Non-european ethnicity
• Thickened endometrium on US scan
• Family history

Question 9

What is the treatment/role of progesterones in endometrial hyperplasia:

Answer 9

• > Either 3 months (oligio-ovulation) follicular phase or 0 ovulation.
• > But w/o hormones i.e progesterone. Then endo thickness and doesnt stop.
• > Need progesterone and its withdrawl i.e mimic this (luteal phase) -> oral contraception [progesterone and estrogen] -> 3 weeks then 1 week of controlled bleeding

Question 10

What is the definition of PCOS:

Answer 10

2 out of the 3 following features:

• Oligio-ovulation and/or anovulation
• Clinical and/or biochemical evidence of hyperandrogenism
• Polycystic ovaries on ultrasound

Question 11

What are the presenting of PCOS:

Answer 11

Reproductive

• Irregular menses
• Hirsutisum
• Infertility
• Pregnancy complications

Metabolic

• Insulin resistance
• Metabolic syndrome
• Impaired glucose tolerance / diabetes
• CV risk factors

Psychological

• Anxiety
• Depression
• Body image

Question 12

What is the hormone profile to investigate for PCOS:

Answer 12

• LH
• FSH
• Estradiol
• Progesterone
• Testosterone (Sex hormone binding globulin) and (Free testosterone)
• Prolactin
• TSH

Question 13

What are some other diagnosis to consider in place of PCOS?

Answer 13

Hyperprolactinaemia
Androgen tumor of the ovary or the adrenal gland
Late onset congenital adrenal hyperplasia
Hypogonadotrophic hypopituitarism (low BMI, ruled out by LH and FSH)

Question 14

How can PCOS be managed?

Answer 14

Lifestyle changes can restore ovulation and improve fertility

• Weight loss
• Moderate exercise

Medication

• Induce ovulation
• Reduce insulin resistance
• Regulate hormones and menses

Surgery to induce ovulation

Question 15

How does surgery for ovulation induction work?

Answer 15

• Removes androgen producing tissue (stroma or theca cells)
• LH and androgen levels fall

(theca produce LH?, this influences androgen levels)