Menses/Abnormal Uterine Bleeding Flashcards
what is the normal range for cycle length
21-35 days
what is the average blood loss during menstrual cycle
30ml; normal variation spotting to 80ml
what is the first menstrual period
menarche
what is the hypothalamus’s effect on the menstrual cycle
GnRH is secreted in pulsatile manner beginning several days before onset of menstruation
what is the anterior pituitary’s effect on menstrual cycle
GnRH stimulates production and release, also in pulsatile fashion, of FSH and LH
production of FSH and LH down-regulates release of GnRH from hypothalamus
What days of menses is the follicular phase
days 6-14
what day of menses us ovulation
day 14
what days of menses is the luteal phase
day 15-28
What is amenorrhea
lack of menses/period
what is dysmenorrhea
pain with menses
what is primary amenorrhea
absence of menses by age 16 or age 14 without onset of puberty - usually anatomical or hormonal, genetic
what is secondary amenorrhea
absence of menses for 3 menstrual cycles or total of 6 months in women who have had normal menstruation
what are some causes of primary amenorrhea if normal secondary sexual characteristics
imperforate hymen
transverse vaginal septum
cervical or mullerian agenesis (absence of vagina and or uterus)
what are some causes of primary amenorrhea if incomplete development of secondary sexual characteristics
hypothalamus or pituitary tumor
hypothyroidism
premature ovarian failure
hyperprolactinemia
what are some of the causes of primary amenorrhea if secondary sexual characteristics are ABSENT
physiological delay of puberty (not common in girls)
gonadal agenesis or dysgenesis (Turners)
Ovarian resistance syndrome
GnRH-deficiency (rare)
hyperprolactinemia
CNS mass lesion
what is the most common cause of secondary amenorrhea
pregnancy
what are other causes of secondary amenorrhea
drug use
stress
significant weight changes
excessive exercise
what is menorrhagia
heavy, prolonged menstrual flow (>7 days or > 80mL)
what is metrorrhagia
uterine bleeding at irregulat intervals, esp. between expected mnestrual periods
what is menometrorrhagia
excessive uterine bleeding both at expected time of menses and at irregular intervals
what is mid-cycle spotting
spotting that occurs just before ovulation, usually due to decline in estrogen
what is considered AUB
any bleeding prior to menarche is abnormal
any post-menopausal bleeding is abnormal
what are concerns with bleeding prior to menarche
concern for malignancy, trauma, sexual abuse, urinary tract issues
what is the concern with bleeding post-menopausal
primary concern is malignancy
when is AUB most common
beginning and end of reproductive years
what is acute AUB
EMERGENCY
excessive bleeding requiring immediate intervention to prevent further blood loss
what is chronic AUB
menstrual bleeding irregularities for most of the previous 6 months
What is the treatment of acute AUB
volume replacement with bleeding cessation
stabilize hemodynamically (IV fluids, blood products)
hormonal control of bleeding
may consider, bladder cath inserted into uterus and inflated to tamponade bleeding
what is the primary concern with AUB
Endometrial cancer
what are the risk factors of endometrial cancer
obesity, nulliparity, DM, infertility/unopposed estrogen/chronic anovulatory cycles, ages >35yo, tamoxifen
what has protective effects of endometrial cancer
OCPs
what is the most common presenting symptom of endometrial cancer
AUB
what is the treatment for endometrial cancer
total hysterectomy (TAH/TVH) and bilateral salpingo-oophorectomy
recurrence treated with high dose progestins or anti-estrogens
what can be associated symptoms/systemic symptoms of AUB
weight loss, fever, chills
pain (pelvic)
vaginal discharge
bowel/bladder symptoms
anemia signs/symptoms
what occurs with anovulatory cycle
corpus luteum dose not form
estrogen stimulates endometrium unopposed which continues to proliferate
endometrium outgrows blood supply and sloughs incompletely; bleeds irregularly and maybe profusely or for a long time
what occurs with ovulatory AUB
progesterone secretion is prolonged
irregular shedding of endometrium results because estrogen levels remain low, near threshold for bleeding (as occurs during menses)
what is the most common cause of anovulatory AUB
PCOS (polycystic ovarian syndrome)
endometriosis
anorexia
what is the clinical presentation of ovulatory AUB
excessive bleeding during regular menstrual cycles
may have other symptoms of ovulation (premenstrual symptoms, breast tenderness, mid-cycle cramping.. etc)
what is the clinical presentation of anovulatory AUB
occurs at unpredictable times and in unpredictable patterns
not accompanied by cyclic changes in basal body temp
what are diagnostics/work up test for AUB
signs of pallor, endocrine disorders, coagulopathies, abdominal exam, pelvic exam (visual, speculum, bimanual)
what needs to be considered with AUB
pregnancy
iatrogenic (meds/herbals)
systemic disorders (thyroid, hematologic, hepatic, HPA-axis)
Genital tract pathology
when is TVUS used for AUB workup
risk factors for endometrial cancer
age >35
bleeding that continues despite use of empiric hormone therapy
pelvic organs that cannot be examined adequately during PE
clinical evidence that suggests abnormalities in ovaries or uterus
What is uterine Leiomyoma
fibroids
benign tumor that originates from smooth muscle layer and surrounding connective tissue of the uterus
what do women with fibroids have an increased risk for
endometrial cancer
what can be the clinical manifestations of uterine leiomyomas
often asymptomatic
-depends on number, size and location
heave/prolonged bleeding
pelvic pain or pressure
reproductive dysfunction
what is the diagnostic imagine of choice for uterine leiomyomas
TVUS
what is the treatment for fibroids
depends on pre vs post menopausal or if women desire fertility
observation
hormonal therapies
hysterectomy - only real ‘cure’
what is adenomyosis
extension of endometrial glands into uterine musculature
what is the classic patient presentation of adenomyosis
middle age, parous, severe dysmenorrhea and menorrhagia. diffusely enlarged globular uterus
what is the definitive therapy for adenomyosis
hysterectomy
how is adenomyosis diagnosed
r/o pregnancy
US
endometrial biopsy (r/o endometrial cancer)
MRI - most accurate imaging tool
what are signs and symptoms of endometriosis
dysmenorrhea, dyspareunia, spotting, pelvic pain
infertility common
what are the diagnostic tests for endometriosis
TVUS, laparoscopy, and biopsy of lesions
what is the treatment for endometriosis
NSAIDs and OCP - first line
GnRH agnoists
Danazol: suppress LH and FSH
surgery
what is DUB
(dysfunctional uterine bleeding)
absence of organic disease or anatomic lesion
usually a problem with the hypothalamic-pituitary-ovarian hormonal axis
what is the most common cause of DUB
ovulation failure shortly after menarche or during perimenopause
what is the treatment of endometrial hyperplasia in postmenopausal women
D&C with strong consideration for hysterectomy
what is the treatment of endometrial hyperplasia in premenopausal women
medroxyprogesterone acetate or levonorgesterel-releasing IUD
treat for 3-6 months and repeat endometrial sampling
what is the treatment for AUB
hormone therapy : OCP, progestogen, IUD
what is the mechanism of hormone therapy for the treatment of AUB
suppresses endometrial development
re-establishes predictable bleeding patterns
decreases menstrual flow
what are the benefits of OCP with AUB
decrease menstrual blood loss by 40-50%
decrease breast tenderness and dysmenorrhea
decreased risk of uterine and ovarian cancer
what is the benefit of using Clomiphene
if pregnancy desired and bleeding not heavy, can induce ovulation
what are non-hormonal treatments of AUB
NSAIDs: reduces bleeding, relieves dysmenorrhea
Tranexamic acid : inhibits plasminogen activator, reduces blood loss
what is the most common cause of AUB
ovulatory dysfunction
what are the tests for treatable causes of bleeding
pregnancy test
CBC and ferritin
hormone levels
TVUS or hysteroscopy and endometrial sampling
what is dysmenorrhea
painful menses that interferes with normal activities
what is secondary dysmenorrhea
painful menses due to pelvic pathology
incidence increases iwth age
what are common causes of new onset/episodic dysmenorrhea
ruptured corpus luteum or ovarian cyst
ectopic pregnancy
PID
ovarian torsion
spontaneous abortion
what are causes of chronic secondary dysmeorrhea
endometriosis
adenomyosis
leiomyoma (fibroids)
what is PMS
wide range of physical or emotional symptoms usually occurring 5-11 days before monthly menstrual cycle (during luteal phase)
what are PMS symptoms
HA
swelling of ankles, feet and hands
bachache
abd cramps/heaviness
moodiness, sadness
abdominal fullness/gaseous
breast tenderness
weight gain
irritability, hostility or aggressive behavior
what is treatment for PMS
exercise and diet change
nutritional supplements: Vit B6, calcium, magnesium
NSAIDs
OCPs
What is PMDD
(premenstrual dysphoric disorder)
condition marked by sadness, inability of function normally at work or in personal relationships, irritability and anger but which occurs only in the premenstrual period and then abates with the onset of menses or shortly after
what is the treatment of PMDD
balanced diet
adequate rest
regular exercises 3-5 times per week
SSRI therapy
nutritional supplements
