Menstrual Disorders and Dysfunctional Uterine Bleeding Flashcards
1
Q
Menorrhagia, hypomenorrhea, metrorrhagia, menometrorrhagia, polymenorrhea, oligomenorrhea, amenorrhea
A
- Menorrhagia (hypermenorrhea): prolonged duration of menses (>7 days) and/or increased amount of bleeding (>80mL) occurring at regular intervals
- Hypomenorrhea: unusually scanty menstrual bleeding lasting for less than 2 days; menses occur at regular intervals
- Metrorrhagia: uterine bleeding at irregular intervals, particularly between expected menstrual periods
- Menometrorrhagia: uterine bleeding that is prolonged and completely irregular
- Polymenorrhea: frequent but regular menstrual cycles (<21 days)
- Oligomenorhea: regular but prolonged menstrual cycles (>35 days)
- Amenorrhea: no menstrual bleeding for at least 3 cycles or 6 months
2
Q
Postmenopausal bleeding, postcoital bleeding, dysmenorrhea, anovulatory bleeding, dysfunctional uterine bleeding
A
- Postmenopausal bleeding (PMB): uterine bleeding that occurs more than 12 months after the last menstrual period
- Postcoital bleeding: vaginal bleeding during or after intercourse
- Dysmenorrhea: painful menses
- Anovulatory bleeding: uterine bleeding that is not associated with ovulation
- Dysfunctional uterine bleeding (DUB): abnormal uterine bleeding with no demonstrable organic cause; a diagnosis of exclusion
- Abnormal vaginal bleeding may be from the genital tract (vulva, vagina, cervix, uterus) or extragenital (skin, urethra, bladder, anus/GI tract)
3
Q
differential diagnosis: abnormal vaginal bleeding
A
- VulvoVaginal
- Trauma
- Cancer
- Atrophy
- Infection
- Benign growths
- Cervical
- Ectropion
- Infection (Cervicitis) – particularly HSV – can cause a LOT of inflammation and bleeding
- Polyps
- Organ prolapse
- Cancer
- Ovarian/Adnexal
- Salpingitis (PID)
- Ovarian cancer (unusual) – very rare cause of bleeding – most ovarian pathologies are going to cause intraabdominal bleeding
- Uterine
- DUB
- Leiomyoma; structural abnormalities
- Ectopic or intrauterine pregnancy
- Ovulatory dysfunction*
- Bleeding disorders
- Infection (PID, endometritis)
- Endometrial cancer
- *Ovulatory dysfunction can occur due to normal life transitions (perimenarche, perimenopause), stress and poor nutrition (obesity, anorexia), exogenous hormones (HRT, OCP, IUD, etc), pregnancy or lactation, PCOS, other endocrinopathies (eg, thyroid disease)
- Once girls hit around 100 lbs, girls start getting their period and because of the obsesity epidemic, girls are getting their periods younger and younger
- If you have a patient who is bleeding and pregnant, your differential is ENTIRELY different than your differential for hormone, structural, etc.
- You may want to get liver and kidney tests as well
4
Q
evaluation: history
A
- Age, parity, contraception, sexual hx, medications
- Onset, frequency, duration of bleeding – cyclic or random? Change from baseline?
- Associated molimenol sx (breast tenderness, cramping, moody, etc) – ovulatory
- Associated pregnancy sx or positive pregnancy test?
- Pain – dysmenorrhea, dyschezia, dysuria, dyspareunia, abdominal/pelvic pain
- Vaginal discharge, fever, galactorrhea, hot flashes, heat/cold intolerance, etc to further narrow ddx
- Personal/family h/o bleeding d/o, endocrinopathy, reproductive tract dz, cancer
- Recent trauma/infection
- Recent illness, stress, excessive exercise or weight change
5
Q
evaluation: PE
A
- VS – hemodynamically stable? LMP
- General – BMI, acne, hirsutism, pallor
- Neck – lymph nodes, thyroid
- Breasts – galactorrhea
- Abdomen – distention, pain, masses; lymph nodes
- Pelvic – bimanual and speculum exams
- Rectal/Rectovaginal exams may be warranted
6
Q
evaluation: labs
A
- Vaginal swab for GC/Chlamydia, Affirm
- Pap smear
- Pregnancy test (UPT ok but quantitative serum HCG best)
- CBC, CMP
- Coagulation studies (esp adolescents/young adults)
- TSH, prolactin, DHEA-S, testosterone if indicated
- Serum FSH, LH, estradiol, progesterone levels not typically helpful
- Endometrial sampling if indicated
- Imaging studies: TVUS first line when indicated
- May be combined with SIS or hysteroscopy in some cases
- CMP to evaluate liver/kidney function – can cause anemia, coagulopathy
7
Q
uterine leiomyomas
A
- Fibroids or myomas
- Most common pelvic tumor, from smooth muscle cells of myometrium
- Most commonly present with heavy or prolonged menstrual bleeding, less commonly cause pelvic pain/pressure
- May affect fertility or pregnancy outcome
- Parallels estrogen/progesterone changes in life cycle of women
- PE will indicate enlarged, nontender, mobile uterus with irregular contour
- Remainder of PE should be normal
- Imaging studies (TVUS) to diagnose and r/o other pathology
- Sagittal transvaginal sonogram shows hypoechoic endometrial thickening (arrowheads) (A).
- Sagittal sonohysterogram shows submucosal fibroid with thin overlying endometrium (cursors) (B).
- Management depends on symptoms, age, desire for fertility
- Medical therapy
- OCP or Levonorgestrel IUD
- GnRH agonists most effective
- Surgical therapy
- Myomectomy
- Hysterectomy
- Endometrial ablation (some types)
- Interventional radiology
- Uterine artery embolization
- Fibroids generally shrink perimenopause and postmenopause as estrogen levels decline; can get worse during pregnancy
- GnRH agonists/antagonists not commonly used but GnRH agonists are most effective; Other hormonal/medical therapies are available off-label or in other countries
8
Q
dysfunctional uterine bleeding
A
- Diagnosis of exclusion
- Evaluation dictated by H&P, risk factors
- Can be ovulatory or anovulatory bleeding
- Management is that of underlying disorder
- 1st line therapy medical – OCP, Levonorgesterel IUD preferred
- Surgical therapy includes endometrial ablation, dilatation & curettage (D&C), hysterectomy
9
Q
treatment of DUB: acute bleeding
A
- Substitute a pharmacologic luteal phase for missed physiologic luteal phase
- Minimal bleeding a few days duration
- Provera (MPA)10 mg PO QD x10 days or Prometrium 200 mg x 14 days
- Moderate bleeding >3 days:
- monophasic oral contraceptive BID-TID x 5-7 days
- Extremely heavy bleeding: Conjugated Estrogen (Premarin) 25 mg IV Q6H x 4 doses, then progesterone or surgical curettage
10
Q
treatment of DUB: recurrent
A
- Combination OCP’s
- one tablet per day for 21 days
- Intermittent progestin therapy
- Medroxyprogesterone acetate 10mg BID, Day1-10 of each month/cycle
- Prolonged use of high doses associated with fatigue, mood swings, weight gain, lipid changes
- Levonorgeterel IUD
- 80% reduction of blood loss at 3 months; 100% reduction in 1 year
- Found to be superior to antifibrinolytic agents and prostaglandin synthetase inhibitors
- Reinsert q 5 years
- Recurrent episodes can be managed medically with the judicious use of hormones.
- Combination OCP’s for 21 days can manage this type of bleeding in reproductive age women unless conception is the goal, then use clomiphene
- Progestins alone usually not very effective to stop ACUTE bleeding, but are indicated for long term treatment.
- Progestins alone are considered by many to be the treatment of choice for most women with chronic anovulatory DUB. Progestins stop endometrial growth, and support and organize an estrogen primed endometrium. When discontinued an organized slough of the endometrium occurs, which allows for rapid cessation of bleeding.
- Fraser et al. Reported the administration of 5-10 mg of medroxyprogesterone acetate or norethindrone (3x per day for 2-3 wks) significantly decreased blood loss by as much as 50% in both ovulatory and anovulatory bleeding
- Women with anovulatory bleeding received progestins from days 12-25 of each cycle, and women with ovulatory bleeding to the progestins on days 5-25. So these regimens were successful for women with both types of DUB.
- The progesterone IUD has been used successfully to treat women with ovulatory DUB.
- Bergqvist et al. Reported a decrease in MBL from an average of 138ml to 49 ml in 12 women with one year of IUD usage.
- Milson et al. used the levonorgestral IUD to treat DUB and reported an 80% reduction in the MBL at 3 months and 100% reduction at the end of the first year of use. It has a duration of action of 7 years or more.
11
Q
treatment of DUB: immature HPO axis
A
- Anovulatory Cycles
- Most common cause of DUB in adolescents (maturing hypothalamic-pituitary axis)
- Responses to anovulation
- amenorrhea
- estrogen withdrawal bleeding
- estrogen breakthrough bleeding: stromal crowding
- heavy (menorrhagia) or irregular (metrorrhagia) bleeding
- Therapy
- Progestin therapy 10 days every month or every other until full maturity of the axis provides effective therapy
- Low dose OCP’s
- Some adolescents have anovulatory DUB because of an immature hypothalamic-pituitary axis. These patients respond ideally to progestins. Regular cyclic withdrawal bleeding can be induced until maturity of the positive feedback mechanism occurs.
- Progestin therapy does not interfere with the normal progression to spontaneous ovulatory cycles.
12
Q
treatment of DUB: perimenopausal women
A
- Evaluate endometrium
- Endometrial biopsy (EMB)
- Endovaginal ultrasound (endometrial stripe < 5mm)
- Saline ultrasound (SIS)
- Treatment based on site/etiology of bleeding
- Atrophic vaginitis: Topical estrogen
- Endometrial atrophy: due to hypoestrogenism resulting in thinning of surface that is prone to bleeding
- Endometrial hyperplasia: continuous bleeding
- Progesterone x 3-6 months, then re-biopsy
- Tri-cyclic or continuous HRT
13
Q
postcoital bleeding
A
- Differential Diagnosis:
- Endocervical infection (GC,Chlamydia)
- Cervical or vaginal warts
- Friable ectropion
- Neoplasia (invasive): Vaginal, cervical, endocervical, or endometrial
- Endometritis (acute or chronic)
- Polyp: Endocervical or endometrial
- Vaginal foreign body
- Urethral lesion
14
Q
endometrial ablation
A
- Requires normal EMB
- Not effective if submucosal fibroids
- Subsequent pregnancy contraindicated
- ACOG Technical Bulletin 81 (2007)
- … endometrial ablation is indicated for the treatment of menorrhagia or patient perceived heavy menstrual bleeding in premenopausal women with normal endometrial cavities who have no desire for future fertility…
- Surgical destruction of the endometrium for the treatment of abnormal uterine bleeding; some anesthesia required
- Resectoscopic ablation is performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometrium
- Non-resectoscopic ablation is performed with a disposable device which is inserted into the uterine cavity and delivers energy to uniformly destroy the uterine lining
- Pregnancy is contraindicated following endometrial ablation, but ablation does not prevent pregnancy. Contraception is still necessary after ablation in sexually active women. Endometrial ablation is not appropriate in women with endometrial hyperplasia or cancer. Endometrial sampling should be performed in all women prior to ablation. Resectoscopic ablation is usually performed with regional or general anesthesia. Non-resectoscopic endometrial ablation can be performed using local, regional, or general anesthesia.
15
Q
rectoscope and loops
A
- First generation techniques
- 20 years ago
- Rollerball/Resectoscope
- Highly dependent on operator skill
- Risk
- Uterine perforation
- Cervical laceration
- Intraoperative fluid overload
- 2 hours operating time
