Menstruation/Bleeding

Question 1

What is the PALM-COEIN classification of abnormal uterine bleeding approved by the Federation of Gynecology and Obstetrics (FIGO)?

Answer 1

P - Polyp
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
C - Coagulopathy
O - Ovulatory disfunction
E - Endometrial
I - Iatrogenic
N - Not yet classified

Question 2

Iatrogenic causes of AUB

Answer 2

Exogenous gonadal steroids
Intrauterine systems or devices
Other systemic or local agents

Question 3

Polyps

Answer 3

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

Question 4

Adenomyosis

Answer 4

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.

Question 5

Leiomyoma

Answer 5

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)

Question 6

AUB Management

Answer 6

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

Question 7

What defines heavy menstrual bleeding?

Answer 7

> 80 mL total in a period

Question 8

Common causes of teenage pelvic pain?

Answer 8

Primary dysmenorrhea (benign)
Trauma
Ovarian Cyst
Musculoskeletal injury

Question 9

Common causes of young adult pelvic pain?

Answer 9

Pregnancy
Secondary dysmenorrhea
* Endometriosis/adhesions

Question 10

Common cause of mid-adult/perimenopause pelvic pain?

Answer 10

Fibroids

Question 11

Common cause of post-menopausal pelvic pain?

Answer 11

Cancer

Question 12

Common cause of teenage AUB?

Answer 12

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

Question 13

Common cause of young adult AUB?

Answer 13

Pregnancy
Weight gain or loss
Eating disorder
Thyroid/endocrine disorders

Question 14

Common cause of mid adult AUB?

Answer 14

Pregnancy
Thyroid (draw TSH)
Pituitary adenoma (draw prolactin)
Opiate abuse

Question 15

Common cause of peri/menopausal AUB?

Answer 15

Menopause (see increased FSH)

Question 16

Common cause of post-menopausal bleeding

Answer 16

Endometrial atrophy

do endometrial biopsy, US, MRI

Question 17

Common cause of teenage pelvic masses?

Answer 17

Ovarian cyst
STI
Bartholins gland cyst

Question 18

Common cause of young adult pelvic masses?

Answer 18

Dermoid cysts (teratoma). High incidence bilateral and family hx. 2% malignant. Chronic worsening discomfort, often painful sex.

Question 19

Common cause of mid adult pelvic masses?

Answer 19

Fibroids

Question 20

Common cause of peri/menopausal pelvic masses?

Answer 20

Ovarian cancer - do ultrasound. ROMA system (risk of ovarian malignancy)

Question 21

What is Lysteda?

Answer 21

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.

Question 22

What is the provera challenge for amenorrhea?

Answer 22

• **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

Question 23

What size ovarian cysts do you follow up on and how often?

Answer 23

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