PB#128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women

Question 1

Duration of normal menstrual flow

Answer 1

~5 days

Question 2

Range of normal menstrual cycle length

Answer 2

21-35 days

Question 3

Classification system used to help organize etiology of AUB in nonpregnant pts of reproductive age

Answer 3

PALM-COEIN

Question 4

Two broad categories into which AUB can be further divided

Answer 4

HMB, IMB

Question 5

Structural causes of AUB (4)

Answer 5

AUB-P (polyp), AUB-A (adeno), AUB-L (leiomyoma), AUB-M (malignancy/hyperplasia)

Question 6

Two ways to further subdivide AUB-L

Answer 6

AUB-Lsm (submucosal myoma), AUB-Lo (other myoma)

Question 7

Nonstructural causes of AUB (5)

Answer 7

AUB-C (coagulopathy), AUB-O (ovulatory dysfunction), AUB-E (endometrial), AUB-I (iatrogenic), AUB-N (not yet classified)

Question 8

Pathophysiologic mechanism behind AUB-O

Answer 8

Unopposed E2 (since AUB-O is typically the result of an endocrinopathy, ie PCOS)

Question 9

Does ovulatory or anovulatory AUB account for most cases of AUB in post-adolescent pts?

Answer 9

Ovulatory AUB

Question 10

Pathophysiologic mechanisms for ovulatory AUB (3)

Answer 10

Abnormal prostaglandin synthesis and receptor upregulation, increased local fibrinolytic activity, increased tPA activity

Question 11

Percentage of pts (at any age) presenting w/ HMB that have an underlying bleeding disorder

Answer 11

20%

Question 12

Which pts should be screened for an underlying disorder of hemostasis?

Answer 12

All pts w/ excessive menstrual bleeding

Question 13

Positive screen for disorder of hemostasis (3)

Answer 13

HMB and one of the following:
1) HMB since menarche
2) 1+ of: hx of PPH, surgery-related bleeding, bleeding associated w/ dental work
3) 2+ of: bruising 1-2x/month, epistaxis 1-2x/month, frequent gum bleeding, family hx of bleeding sxs

Question 14

Next steps for pts w/ positive screen for underlying disorder of hemostasis (2)

Answer 14

Heme consult, vWF factor/ristocetin cofactor testing

Question 15

Initial lab testing for HMB (3)

Answer 15

CBC, coags (though bleeding time not indicated), TSH

Question 16

Common meds/herbal remedies that may cause AUB (7)

Answer 16

Warfarin, heparin, NSAIDs, hormonal contraceptives, ginkgo, ginseng, motherwort

Question 17

Categories needed for full diagnostic eval of pts w/ AUB (5)

Answer 17

Hx, physical exam, labs, imaging (when indicated), tissue sampling (when indicated)

Question 18

Important components of medical hx for AUB (8)

Answer 18

Age of menarche/menopause, menstrual bleeding patterns, severity of bleeding (clots, flooding), pain (severity, tx), medical conditions, surgical hx, use of meds, sxs/signs of poss hemostatic disorder

Question 19

Important components of physical exam for AUB (4)

Answer 19

General physical, external pelvic exam, spec exam w/ Pap (if needed/indicated), bimanual exam

Question 20

Important labs when evaluating AUB (5)

Answer 20

Pregnant test (urine or blood), CBC, targeted screening for bleeding disorders (when indicated), TSH, GC/CT

Question 21

Common diagnostic tests/imaging options for evaluating AUB (4)

Answer 21

SIS, TVUS, MRI, hysteroscopy

Question 22

Tissue sampling methods when evaluating for AUB (2)

Answer 22

EMB, hysteroscopy-directed sampling

Question 23

Common causes of AUB in adolescent pts (2)

Answer 23

Persistent anovulation 2/2 immaturity/dysregulation of HPO axis, normal physiology

Question 24

Common causes of AUB in 19-39 y/o pts (5)

Answer 24

Pregnancy, structural lesions (ie fibroids, polyps), anovulatory cycles (PCOS), use of hormonal contraception, endometrial hyperplasia

Question 25

Common causes of AUB in pts 40+ y/o (4)

Answer 25

Anovulatory bleeding (which may represent normal physiology in response to declining ovarian function), endometrial hyperplasia/carcinoma, endometrial atrophy, fibroids

Question 26

Indication for TVUS when pt presenting w/ AUB

Answer 26

Any pt w/ abnormal physical exam (enlarged and/or globular uterus)

Question 27

Is measurement of endometrial thickness helpful in eval of AUB in premenopausal pts?

Answer 27

No

Question 28

Is SIS superior to TVUS in detection of intracavitary lesions?

Answer 28

Yes

Question 29

Percentage of pts w/ intrauterine anomalies in pts w; AUB

Answer 29

46.6%

Question 30

When is MRI indicated in pts w/ AUB?

Answer 30

To guide tx of fibroids (particularly when uterus is enlarged, contains multiple fibroids, or precise fibroid mapping is of clinical importance)

Question 31

Next step if: increased risk for structural abnormality, no increased risk for hyperplasia/malignancy

Answer 31

TVUS

Question 32

AUB categories if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > normal cavity on TVUS (2)

Answer 32

Presumptive AUB-E or AUB-O

Question 33

Next step if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > abnormal cavity on TVUS

Answer 33

SIS vs hysteroscopy +/- bx to attempt to identify a target lesion

Question 34

AUB categories if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > abnormal cavity on TVUS > target lesion identified on SIS/hysteroscopy (3)

Answer 34

AUB-Lsm > AUB-P, AUB-A

Question 35

AUB categories if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > abnormal cavity on TVUS > no target lesion identified on SIS/hysteroscopy (2)

Answer 35

Presumptive AUB-E or AUB-O

Question 36

Next step if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > abnormal cavity on TVUS > presence of target lesion unable to be assessed

Answer 36

Consider MRI

Question 37

Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality

Answer 37

EMB

Question 38

AUB categories if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality > adequate EMB specimen w/o evidence of atypical hyperplasia/malignancy (2)

Answer 38

Presumptive AUB-E or AUB-O

Question 39

Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality > adequate EMB specimen w/ evidence of atypical hyperplasia/malignancy

Answer 39

Management of AUB-M

Question 40

Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality > inadequate EMB specimen

Answer 40

Proceed to hysteroscopy +/- bx

Question 41

AUB categories if: no increased risk for hyperplasia/malignancy, no increased risk for structural abnormality (2)

Answer 41

Presumptive AUB-E or AUB-O

Question 42

Why isn't there diagnostic value for endometrial thickness in premenopausal pts?

Answer 42

Because endometrial thickness varies throughout menstrual cycle in response to hormonal changes

Question 43

Situations in which endometrial sampling is indicated in premenopausal pts w/ AUB (4)

Answer 43

Pts >45 y/o, pts <45 y/o w/ hx of unopposed estrogen (ie obesity, PCOS), pts <45 y/o w/ hx of failed medical management, pts <45 y/o w/ persistent AUB

Question 44

In what situation may cancer be missed by blind bx (EMB)?

Answer 44

If cancer occupies <50% of surface area of endometrial cavity

Question 45

Is PPV or NPV higher for EMB?

Answer 45

PPV (positive EMB more accurate for ruling in disease than negative EMB is for ruling out disease)

Question 46

Posttest probability of endometrial cancer for positive EMB result

Answer 46

81.7%

Question 47

Posttest probability of endometrial cancer for negative EMB result

Answer 47

0.9%

Question 48

US findings that support dx of adeno (4)

Answer 48

Heterogeneous myometrium, myometrial cysts, asymmetric myometrial thickness, subendometrial echogenic linear striations

Question 49

Point in evaluation at which point therapy is appropriate for most pts

Answer 49

If no increased risk of endometrial hyperplasia/neoplasia/structural abnormalities is determined

Question 50

For which pts is complete diagnostic evaluation warranted before initiation of therapy? (3)

Answer 50

Pts w/ increased risk (pts w/ genetic risk factors for endometrial cancer, pts >45 y/o, pts who prolonged anovulatory cycles are associated w/ unopposed E2)

Question 51

When would further eval be warranted on a pt who is taking tx for AUB?

Answer 51

If persistent bleeding despite therapy