Menstruation/Bleeding Flashcards
What is the PALM-COEIN classification of abnormal uterine bleeding approved by the Federation of Gynecology and Obstetrics (FIGO)?
P - Polyp A - Adenomyosis L - Leiomyoma M - Malignancy and hyperplasia C - Coagulopathy O - Ovulatory disfunction E - Endometrial I - Iatrogenic N - Not yet classified
Iatrogenic causes of AUB
Exogenous gonadal steroids
Intrauterine systems or devices
Other systemic or local agents
Polyps
Epithelial proliferations (variable vascular, glandular, fibromuscular and connective tissue)
Often asymmptomatic, some cause AUB
Classification: present or absent as defined by 1 or combo of US and hysteroscopic imagine with or without histopathology
Adenomyosis
When endometrial cells grow into uterine wall
Diagnosed by US or MRI. Hard to dx.
Maybe tender or a little larger.
Hysteroscope, endometrial bx, ablation/d&c.
o Hard to tx – can use CHCs.
Leiomyoma
Benign fibromuscular tumors (aka fibroid)
Vary in spectrum, size, rates of growth, and location (subendometrial, subserosal, intramural, or a combo)
Submucosal (in the endometrial cavity) most likely to cause AUB
o Left alone unless causing problem or person wants to get pregnant
o Lupron – GnRH agonist → induces hypoestrogenic state (menopausal sx, risk of osteoporosis)
o Ulipristal acetate (Ella)
AUB Management
CHC
Progestins: cyclic (Provera, Prometrium) or
continuous (DMPA, Mirena IUD)= 80-90% blood loss
GnRH agonists (create hypoestrogenic state)
NSAIDs
Tranexamic Acid (Lysteda)
Fe supplement, if anemic
Refer to surgeon as needed:
Endometrial resection and ablation
Hysterectomy
What defines heavy menstrual bleeding?
> 80 mL total in a period
Common causes of teenage pelvic pain?
Primary dysmenorrhea (benign)
Trauma
Ovarian Cyst
Musculoskeletal injury
Common causes of young adult pelvic pain?
Pregnancy
Secondary dysmenorrhea
* Endometriosis/adhesions
Common cause of mid-adult/perimenopause pelvic pain?
Fibroids
Common cause of post-menopausal pelvic pain?
Cancer
Common cause of teenage AUB?
Primary amenorrhea (no prior menses, draw FSH/LH) BMI (must be at least 100 lbs) Thyroid Anatomy Trauma/Concussion Fragile X Nutrition Clotting disorder? Ask about family hx
Common cause of young adult AUB?
Pregnancy
Weight gain or loss
Eating disorder
Thyroid/endocrine disorders
Common cause of mid adult AUB?
Pregnancy
Thyroid (draw TSH)
Pituitary adenoma (draw prolactin)
Opiate abuse
Common cause of peri/menopausal AUB?
Menopause (see increased FSH)
Common cause of post-menopausal bleeding
Endometrial atrophy
do endometrial biopsy, US, MRI
Common cause of teenage pelvic masses?
Ovarian cyst
STI
Bartholins gland cyst
Common cause of young adult pelvic masses?
Dermoid cysts (teratoma). High incidence bilateral and family hx. 2% malignant. Chronic worsening discomfort, often painful sex.
Common cause of mid adult pelvic masses?
Fibroids
Common cause of peri/menopausal pelvic masses?
Ovarian cancer - do ultrasound. ROMA system (risk of ovarian malignancy)
What is Lysteda?
aka Tranexamic acid
Used for HMB
1300 TID x 3-5 during period.
Very expensive, need good insurance coverage. Fibrinolytic. Good for women who are trying to conceive.
What is the provera challenge for amenorrhea?
- **Give 5-10 mg provera x 7-10 days
- Can stop if starts bleeding.
- If no bleed post 10 days, repeat in 1 week → if still no bleed give estrogen too
***Withdrawal bleed during/after provera → suggests anovulation (because she has a lining in her uterus means there must be estrogen)
No withdrawal bleed → suggests low/no estrogen (hypothalamic vs ovarian failure) or problem with outflow tract (adhesions/Asherman’s or cervical stenosis)
**If patient has withdrawal bleed after estrogen → suggests hypoestrogen (hypothalamic vs ovarian failure).
No withdrawal bleed post estrogen → outflow tract issue
What size ovarian cysts do you follow up on and how often?
Ovarian cysts larger than 7-10 cm need further work up (MRI, surgical consult)
• Reassure postmenopausal cyst < 1cm (1cm-7 cm and low risk → yearly reimaging), premenopausal <5 cm (yearly follow ups for 5 – 7 cm)
Do US at beginning of cycle
