PB#128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women Flashcards
Duration of normal menstrual flow
~5 days
Range of normal menstrual cycle length
21-35 days
Classification system used to help organize etiology of AUB in nonpregnant pts of reproductive age
PALM-COEIN
Two broad categories into which AUB can be further divided
HMB, IMB
Structural causes of AUB (4)
AUB-P (polyp), AUB-A (adeno), AUB-L (leiomyoma), AUB-M (malignancy/hyperplasia)
Two ways to further subdivide AUB-L
AUB-Lsm (submucosal myoma), AUB-Lo (other myoma)
Nonstructural causes of AUB (5)
AUB-C (coagulopathy), AUB-O (ovulatory dysfunction), AUB-E (endometrial), AUB-I (iatrogenic), AUB-N (not yet classified)
Pathophysiologic mechanism behind AUB-O
Unopposed E2 (since AUB-O is typically the result of an endocrinopathy, ie PCOS)
Does ovulatory or anovulatory AUB account for most cases of AUB in post-adolescent pts?
Ovulatory AUB
Pathophysiologic mechanisms for ovulatory AUB (3)
Abnormal prostaglandin synthesis and receptor upregulation, increased local fibrinolytic activity, increased tPA activity
Percentage of pts (at any age) presenting w/ HMB that have an underlying bleeding disorder
20%
Which pts should be screened for an underlying disorder of hemostasis?
All pts w/ excessive menstrual bleeding
Positive screen for disorder of hemostasis (3)
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
Next steps for pts w/ positive screen for underlying disorder of hemostasis (2)
Heme consult, vWF factor/ristocetin cofactor testing
Initial lab testing for HMB (3)
CBC, coags (though bleeding time not indicated), TSH
Common meds/herbal remedies that may cause AUB (7)
Warfarin, heparin, NSAIDs, hormonal contraceptives, ginkgo, ginseng, motherwort
Categories needed for full diagnostic eval of pts w/ AUB (5)
Hx, physical exam, labs, imaging (when indicated), tissue sampling (when indicated)
Important components of medical hx for AUB (8)
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
Important components of physical exam for AUB (4)
General physical, external pelvic exam, spec exam w/ Pap (if needed/indicated), bimanual exam
Important labs when evaluating AUB (5)
Pregnant test (urine or blood), CBC, targeted screening for bleeding disorders (when indicated), TSH, GC/CT
Common diagnostic tests/imaging options for evaluating AUB (4)
SIS, TVUS, MRI, hysteroscopy
Tissue sampling methods when evaluating for AUB (2)
EMB, hysteroscopy-directed sampling
Common causes of AUB in adolescent pts (2)
Persistent anovulation 2/2 immaturity/dysregulation of HPO axis, normal physiology
Common causes of AUB in 19-39 y/o pts (5)
Pregnancy, structural lesions (ie fibroids, polyps), anovulatory cycles (PCOS), use of hormonal contraception, endometrial hyperplasia
Common causes of AUB in pts 40+ y/o (4)
Anovulatory bleeding (which may represent normal physiology in response to declining ovarian function), endometrial hyperplasia/carcinoma, endometrial atrophy, fibroids
Indication for TVUS when pt presenting w/ AUB
Any pt w/ abnormal physical exam (enlarged and/or globular uterus)
Is measurement of endometrial thickness helpful in eval of AUB in premenopausal pts?
No
Is SIS superior to TVUS in detection of intracavitary lesions?
Yes
Percentage of pts w/ intrauterine anomalies in pts w; AUB
46.6%
When is MRI indicated in pts w/ AUB?
To guide tx of fibroids (particularly when uterus is enlarged, contains multiple fibroids, or precise fibroid mapping is of clinical importance)
Next step if: increased risk for structural abnormality, no increased risk for hyperplasia/malignancy
TVUS
AUB categories if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > normal cavity on TVUS (2)
Presumptive AUB-E or AUB-O
Next step if: increased risk for structural abnormality, no increased risk for hyperplasia malignancy > abnormal cavity on TVUS
SIS vs hysteroscopy +/- bx to attempt to identify a target lesion
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)
AUB-Lsm > AUB-P, AUB-A
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)
Presumptive AUB-E or AUB-O
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
Consider MRI
Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality
EMB
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)
Presumptive AUB-E or AUB-O
Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality > adequate EMB specimen w/ evidence of atypical hyperplasia/malignancy
Management of AUB-M
Next step if: increased risk for hyperplasia/malignancy, no increased risk for structural abnormality > inadequate EMB specimen
Proceed to hysteroscopy +/- bx
AUB categories if: no increased risk for hyperplasia/malignancy, no increased risk for structural abnormality (2)
Presumptive AUB-E or AUB-O
Why isn’t there diagnostic value for endometrial thickness in premenopausal pts?
Because endometrial thickness varies throughout menstrual cycle in response to hormonal changes
Situations in which endometrial sampling is indicated in premenopausal pts w/ AUB (4)
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
In what situation may cancer be missed by blind bx (EMB)?
If cancer occupies <50% of surface area of endometrial cavity
Is PPV or NPV higher for EMB?
PPV (positive EMB more accurate for ruling in disease than negative EMB is for ruling out disease)
Posttest probability of endometrial cancer for positive EMB result
81.7%
Posttest probability of endometrial cancer for negative EMB result
0.9%
US findings that support dx of adeno (4)
Heterogeneous myometrium, myometrial cysts, asymmetric myometrial thickness, subendometrial echogenic linear striations
Point in evaluation at which point therapy is appropriate for most pts
If no increased risk of endometrial hyperplasia/neoplasia/structural abnormalities is determined
For which pts is complete diagnostic evaluation warranted before initiation of therapy? (3)
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)
When would further eval be warranted on a pt who is taking tx for AUB?
If persistent bleeding despite therapy
