Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction

Question 1

Causes of anovulation

Answer 1

Physiologic:
- Adolescence
- Pregnancy
- Perimenopause 
- Lactation
Pathologic:
- Hyperandrogenic anovulation (PCOS, congenital adrenal hyperplasia, and androgen secreting tumor)
- Hypothalamic dysfunction (anorexia)
- Hyperprolactinemia
- Thyroid disease
- Primary pituitary disease
- Premature ovarian failure
- Iatrogenic
- Medications

Question 2

Recommended assessments for evaluation of ovulatory AUB

Answer 2

• Pregnancy test (even in tubal ligation pts)
• beta-HCG levels in women who have recently been pregnant to rule out trophoblastic disease
• TSH levels
• Prolactin level (if elevated, repeat in fasting state)
• endometrial biopsy (in at-risk pts)
• Imaging (possibly)

Question 3

Differential diagnosis of ovulatory AUB

Answer 3

13-18 yrs:

• bleeding disorder
• pregnancy
• sexual trauma
• STD
• PCOS

19-39 yrs:

• PCOS
• endometrial hyperplasia/cancer

40 yrs to menopause:

• Perimenopause
• Pregnancy

Question 4

Perimenopause

Answer 4

starts at the onset of cycle irregularity and lasts 1 yr after last menses

Question 5

Duration of menopausal transition

Answer 5

average of 4 yrs

Question 6

Risk factors for endometrial cancer

Answer 6

• BMI over 30
• nulliparity
• hypertension
• irregular menstruation
• family history

Question 7

Treatment options

Answer 7

Medical therapy is highly preferred.
Exogenous steroids: 
Pregestin-only:
- Levonorgestrel IUD 
- Medroxyprogesterone acetate
- Megestrol acetate
- Norethindrone acetate
- Depot shot

Combined hormonal contraceptives

• transdermal patches
• vaginal rings
• oral contraceptives