LM 13.2: Anovulatory Cycles and Abnormal Uterine Bleeding Flashcards
why are anovulatory uterine bleeding and irregular periods common during gate first few years after menarche?
immaturity of which renders it incapable of naturally responding to estrogen with a LH surge HPO axis
regulatory which renders it incapable of naturally responding to estrogen with a LH surge
what are some of the common causes of irregular menses in adolescence?
- beginning of menarche; anovulation
- coagulation disorders
- psychosocial stress
- exogenous hormone use
- pregnancy
what are common causes of irregular menses in women of reproductive age?
- pelvic infections from STDs
- endometrial polyps or submucous myxomas
- exogenous hormone use
- pregnancy
- anovulation
- fibroids
- thyroid dysfunction
the cause of abnormal bleeding in women of reproductive age is often benign, malignancy is always a possibility, particularly if the woman is obese or has a history of chronic oligoovulation or anovulation
what are common causes of irregular menses in perimenopausal women?
- increased incidence of anovulatory cycles due to depletion of the store of ovarian oocytes
- endometrial hyperplasia, cancer, polyps, or submucosal fibroids become more prevalent, and pathologic endometrial tissue should be suspected in the perimenopausal woman with abnormal bleeding
what are the risk factors associated with cancer in perimenopausal women?
- obesity
- HTN
- DM
- chronic an ovulation
what are the common causes of vaginal bleeding in menopausal women?
- endometrial hyperplasia
- polyps
- sub mucous fibroids
- exogenous hormone use
- endometrial lesions including cancer
- atrophic vaginitis
any vaginal bleeding in menopausal women should be considered abnorma
what is the difference between abnormal uterine bleeding and anovulatory uterine bleeding?
when AUB cannot be attributed to an anatomic, organic or systemic lesion or disease it is referred to as anovulatory uterine bleeding
it is a diagnosis made by excluding all other possible causes, such as leiomyomas, polyps, malignancy, coagulopathies, etc
anovulatory uterine bleeding is a more descriptive term, reflecting the fact that many of these women suffer from chronic anovulation or oligoovulation
what is ovulatory abnormal uterine bleeding?
abnormal uterine bleeding without any attributable anatomic, organic, or systemic cause but associated with regular ovulation
it occurs when there is loss of local endometrial hemostasis
not common at all…
it is generally observed with regular progesterone-withdrawal menses every 24-35 days but with excessive blood loss
usually retains existing premenstrual symptoms associated with ovulation such as dysmenorrhea, midcycle pain, breast tenderness, bloating, and irritability
what is the hormonal marker of menorrhagia?
PGE2alpha : PGF2alpha and level of PGI2 are increased in women with menorrhagia
menorrhagia = excessive bleeding
what is anovulatory uterine bleeding?
noncyclic menstrual blood flow that may range from spotty to excessive, is derived from the uterine endometrium due to anovulatory production of sex-steroids, specifically excluding an anatomic lesion
typically caused by estrogen-withdrawal or estrogen-breakthrough bleeding and occurs in the absence of the cyclic production of ovarian progesterone
may occur with the sustained levels of unopposed estrogen associated with PCOS, obesity, immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and late anovulation
what is the mechanism of anovulatory uterine bleeding?
in the absence of cyclical progesterone and periodic menstruation, the endometrium hyperplastic without the necessary structural support
the hyperplastic, unstructured endometrium is fragile and prone to localized breakage and bleeding
as one site of breakage heals, a different site may break down and bleed. The resulting bleeding is usually erratic—in both timing and volume of blood loss—with alternating periods of amenorrhea
what are the conditions associated with anovulation and abnormal bleeding?
- anorexia nervosa/bullemia nervosa
- recessive physical exercise
- chronic illness
- ovarian insufficiency/premature ovarian failure
- alcohol and other drug abuse
- stress
- thyroid disease
- DM
- androgen excess syndromes like PCOS
what is the mneuominc for structural vs systemic causes of abnormal uterine bleeding?
PALM COINE
STRUCTURAL Polps Adenomyosis Leiomyoma Malignancy
SYSTEMIC Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic
what are the subcategories of abnormal uterine bleeding?
- heavy menstrual bleeding
2. intermenstrual bleeding
what are the normal characteristics of a menstrual cycle?
normal menstrual flow is 5 days
normal menstrual cycle typically lasts between 21-35 days
what is metrorrhagia?
bleeding between cycles
what is polymenorrhea?
bleeding that occurs more often than every 21 days
what is oligomenorrhea?
bleeding that occurs less frequently than every 35 days
what is the HPO axis?
the hypothalamic-pituitary-ovarian axis is when the neuronal nuclei of the hypothalamus to the pituitary gland, which subsequently stimulates the ovaries to produce sex-steroids that act upon the endometrial lining of the uterus
along the HPO axis there is a complex system of positive and negative feedback signals that allow the end-organs to communicate with the higher centers
what is classified as a positive screening for an underlying disorder or hemostasis with AUB?
- heavy menstrual bleeding since menarche
- one of the following
- postpartum hemorrhage
- surgery-related bleeding
- bleeding associated with dental work - two or more of the following symptoms
- bruising one to two times per month
- epistaxsis one to two times a month
- frequent gum bleeding
- family history of bleeding symptoms
what are the medical treatments for management of AUB?
- iron
- antifibrinolytics
- cyclooxygenase inhibitors
- progestins
estrogens + progestins (OCs) - parenteral estrogens (CEEs)
- androgens
- GnRH agonists and antagonists
- antiprogestational agents
when would you treat AUB with iron?
if they are bleeding more than 60 mL per cycle because they could get iron deficiency anemia
how are antifibrinolytics used to treat AUB?
fibrinolysis is the breakdown of clots so antifibrinolytics would help you not to bleed
ex. tranexamic acid
who benefits from the administration of cyclic progestins?
women with anovulatory uterine bleeding, with absence of the post-ovulatory progestagenic luteal phase, are more likely to benefit from the administration of cyclic progestins
what oral contraceptives are best for AUD?
effective for the treatment of both ovulatory AUB and anovulatory uterine bleeding –> it’s the most commonly prescribed treatment in the US
it may be clinically prudent to choose a pill containing 30-35 mirograms of ethinyl estradio, rather than one containing 20 or 50 g
what is the best treatment for acute, excessive rapid uterine bleeding?
conjugated equine estrogens administered intramuscular or IV
parenteral estrogens may be effective in the treatment of both ovulatory AUB and anovulatory uterine bleeding
which androgen is used for AUG?
danazol
it decreased menstrual volume in about half of the women
it’s more effective than mefenamic acid (NSAID)
however, androgenergic side effects are undesirable
how do GnRH agonists treat AUB?
1they create a reversible hypogonadotropic state by down-regulating GnRH-receptors, dramatically decrease production of gonadotropin by the anterior pituitary
they induce amenorrhea by shrinking total uterine volume by about 40% to 60%
lots of side effects and expensive so they’re a last resort
they have been evaluated primarily for stopping bleeding associated with leiomyomas, but may be effective for bleeding associated with both ovulatory AUB and anovulatory uterine bleeding
what are the 3 surgical treatment for AUB?
- hysterectomy
- hysteroscopic endometrial ablation
- nonhysteroscopic endometrial ablation
D&C is now considered obsolete for the evaluation of AUB, and it is also obsolete as a treatment for AUB
what are the chances a pre-menopausal women has endometrial cancer associated with AUB?
risk of endometrial cancer is low (<1%) in women under 40 years of age
in these women, the most common causes of bleeding will not be endometrial cancer or even endometrial hyperplasia, but intracavitary pathologic conditions, including endometrial polyps or submucosal fibroids
however, all perimenopausal women with persistent abnormal uterine bleeding should be evaluated for endometrial hyperplasia or cancer
what is the mostly likely cause of AUB in reproductive age women?
if the reproductive-age woman is not pregnant and has a normal physical examination, then anovulatory uterine bleeding is the most likely diagnosis
TSH and prolactin levels can help rule out pituitary dysfunction as a cause of the anovulation
what is the most common cause of post-menopausal bleeding?
- endometrial atrophy
- then iatrogenic bleeding often due to hormone replacement therapy
- endometrial cancer
- endometrial or cervical polyps
- endometrial hyperplasia
what are the risk factors for endometrial carcinoma?
- unopposed estrogen
- menopause after 52 years
- obesity
- nulliparity
- diabetes
- feminizing ovarian tumors
- feminizing ovarian tumors
- PCOS
- tamoxifen
- Lynch syndrome
what factors decrease your risk of endometrial carcinoma?
- ovulation
- progestin therapy
- combination oral contraceptives
- menopause priori to 49 years
- normal weight
- multiparty
what are the FDA approved treatments of acute AUB?
- provera
- monphasic OCPs
- tranexamic acid
- IV estrogen
- embolization
what are the indications for clinical screening for coagulopathy?
- long standing history of heavy periods since menarch
- a history of post-surgical bleeding
- bleeding after dental work
- a history of postpartum hemorrhage
which labs are indicated for evaluation of AUB?
- CBC
- TSH
- chlamydia trachomatis
- bleeding time
- pregnancy test
pap smear is NOT indicated
