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ACOG Pub Review > PB#128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women > Flashcards

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

1
Q

Duration of normal menstrual flow

A

~5 days

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2
Q

Range of normal menstrual cycle length

A

21-35 days

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3
Q

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

A

PALM-COEIN

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4
Q

Two broad categories into which AUB can be further divided

A

HMB, IMB

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5
Q

Structural causes of AUB (4)

A

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

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6
Q

Two ways to further subdivide AUB-L

A

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

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7
Q

Nonstructural causes of AUB (5)

A

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

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8
Q

Pathophysiologic mechanism behind AUB-O

A

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

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9
Q

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

A

Ovulatory AUB

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10
Q

Pathophysiologic mechanisms for ovulatory AUB (3)

A

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

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11
Q

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

A

20%

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12
Q

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

A

All pts w/ excessive menstrual bleeding

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13
Q

Positive screen for disorder of hemostasis (3)

A

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

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14
Q

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

A

Heme consult, vWF factor/ristocetin cofactor testing

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15
Q

Initial lab testing for HMB (3)

A

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

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16
Q

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

A

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

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17
Q

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

A

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

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18
Q

Important components of medical hx for AUB (8)

A

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

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19
Q

Important components of physical exam for AUB (4)

A

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

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20
Q

Important labs when evaluating AUB (5)

A

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

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21
Q

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

A

SIS, TVUS, MRI, hysteroscopy

22
Q

Tissue sampling methods when evaluating for AUB (2)

A

EMB, hysteroscopy-directed sampling

23
Q

Common causes of AUB in adolescent pts (2)

A

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

24
Q

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

A

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

25
Q

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

A

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

26
Q

Indication for TVUS when pt presenting w/ AUB

A

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

27
Q

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

A

No

28
Q

Is SIS superior to TVUS in detection of intracavitary lesions?

A

Yes

29
Q

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

A

46.6%

30
Q

When is MRI indicated in pts w/ AUB?

A

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

31
Q

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

A

TVUS

32
Q

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

A

Presumptive AUB-E or AUB-O

33
Q

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

A

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

34
Q

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)

A

AUB-Lsm > AUB-P, AUB-A

35
Q

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)

A

Presumptive AUB-E or AUB-O

36
Q

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

A

Consider MRI

37
Q

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

A

EMB

38
Q

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)

A

Presumptive AUB-E or AUB-O

39
Q

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

A

Management of AUB-M

40
Q

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

A

Proceed to hysteroscopy +/- bx

41
Q

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

A

Presumptive AUB-E or AUB-O

42
Q

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

A

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

43
Q

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

A

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

44
Q

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

A

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

45
Q

Is PPV or NPV higher for EMB?

A

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

46
Q

Posttest probability of endometrial cancer for positive EMB result

A

81.7%

47
Q

Posttest probability of endometrial cancer for negative EMB result

A

0.9%

48
Q

US findings that support dx of adeno (4)

A

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

49
Q

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

A

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

50
Q

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

A

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)

51
Q

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

A

If persistent bleeding despite therapy

ACOG Pub Review (6 decks)

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