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ACOG Pub Review > PB#136: Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction > Flashcards

PB#136: Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction Flashcards

1
Q

Physiologic reason behind AUB occurring 2/2 ovulatory dysfunction

A

Effects of chronic unopposed estrogen on endometrium

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2
Q

PALM (structural causes) classification of AUB

A

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

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3
Q

Subclassification of AUB-L

A

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

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4
Q

COEIN (nonstructural causes) classification of AUB

A

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

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5
Q

Duration of most ovulatory menstrual cycles; normal duration of flow

A

21-35 days; 5 days (w/ most blood loss occurring within first 3 days)

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6
Q

Median age of menarche; typical range of cycle duration and duration of flow for such pts

A

12.43 y/o; 21-45 days and <7 days

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7
Q

Is it normal for cycle length to vary if cycles are ovulatory?

A

Yes, by a few days per month

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8
Q

At what point in reproductive lifespan does menstrual cycle vary more?

A

Approaching menopause

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9
Q

How are ovary and endometrium coordinated during an ovulatory cycle?

A

Selection/Ovulation of mature oocyte coordinated w/ process that results in growth/differentiation of endometrium

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10
Q

General steps of normal ovulatory cycle (4)

A

Follicle develops > ovulation > corpus luteum develops > luteolysis

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11
Q

Effect of normal ovulatory cycle on endometrium

A

Endometrium sequentially exposed to ovarian production of estrogen alone, followed by combo of estrogen and progesterone, then withdrawal of estrogen and progesterone at end of cycle

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12
Q

Steps of endometrial progression during normal ovulatory cycle (4)

A

Proliferation > secretory change > shedding > repair

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13
Q

Meds that could potentially impair coagulation process during repair of blood vessels at time of menstruation (3)

A

Warfarin, ASA, clopidogrel

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14
Q

Effect of absence of ovulation on endometrium

A

Corpus luteum does not develop and ovary fails to secrete progesterone, resulting in continual endometrial proliferation w/o progesterone-withdrawal-induced shedding and bleeding

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15
Q

Clinical result of absence of regular ovulation

A

Noncyclic, unpredictable bleeding of inconsistent volume

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16
Q

Description of endometrium that develops in milieu of unopposed estrogen

A

Fragile, vascular, lacking sufficient stromal support; as a result, one area of bleeding begins to heal while another area begins to slough, resulting in erratic bleeding patterns

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17
Q

Phases of reproductive lifespan associated w/ physiologic AUB-O (2)

A

Puberty, menopause

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18
Q

Why does puberty result in AUB-O?

A

Immature HPO axis does not develop the necessary hormonal feedback to result in ovulation and subsequent stable endometrium

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19
Q

Why does perimenopause result in AUB-O?

A

Progressive oocyte depletion and abnormal follicular development lead to anovulatory cycles

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20
Q

Physiologic causes of anovulation (4)

A

Adolescence, perimenopause, lactation, pregnancy

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21
Q

Pathologic causes of anovulation (8)

A

Hyperandrogenic anovulation (ie PCOS, CAH, androgen-producing tumors), hypothalamic dysfunction (ie 2/2 anorexia), hyperprolactinemia, thyroid disease, primary pituitary disease, POI, iatrogenic (ie 2/2 radiation/chemotx), meds

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22
Q

Menstrual sxs that pts w/ AUB-O typically do NOT experience (3)

A

Breast discomfort, increased mucoid vaginal discharge, premenstrual cramping

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23
Q

If cycles vary by more than this many days, they are likely anovulatory

A

> 10 days

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24
Q

What should be considered if medical tx fails to resolve bleeding though to be resulting from anovulation (2)?

A

Anatomic causes (including malignancy/hyperplasia), coagulopathy

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25
Q

Recommended assessment for AUB, thought to be AUB-O (6)

A

hCG for sexually active pts (even s/p TL); sensitive hCG testing (to exclude trophoblastic disease in pts who were recently pregnant); TSH (to exclude hypothyroidism/hyperthyroidism); PRL (and, if elevated, repeated in fasting state); EMB (in pts w/ risk factors for hyperplasia/malignancy); SIS/hysteroscopy/TVUS (to r/o anatomic abnormality)

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26
Q

Most frequent cause of AUB-O in pts during first 12-18 months after menarche

A

Immaturity of HPO axis

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27
Q

Time s/p menarche at which cycles typically normalize

A

Third year s/p menarche (60-80% of cycle are 21-34 days long, regardless of age at menarche)

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28
Q

Which adolescent pts achieve regular ovulation sooner?

A

Pts w/ earlier menarche (since time after menarche to normalization of cycles is the same regardless of age at menarche)

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29
Q

Increasing contributor to anovulatory cycles among teens

A

Adolescent obesity

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30
Q

General risk for endometrial hyperplasia/malignancy among adolescent pts w/ AUB

A

Extremely low

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31
Q

Most common bleeding disorder in women

A

vWD

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32
Q

Percent risk of coagulopathy in adolescent pts who require hospitalization (w/ Hgb <10) or transfusion

A

20-30%

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33
Q

Conditions to r/o in initial workup of adolescent pt w/ AUB (3)

A

Pregnancy, sexual trauma, STIs

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34
Q

Physical signs/sxs to inquire about to r/o PCOS/hyperandrogenism (2)

A

Acne, hirsutism

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35
Q

Initial lab testing for adolescent pts w/ AUB (2)

A

hCG, CBC (and if plts are normal, consider further testing for coagulopathy when significant bleeding/anemia present)

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36
Q

Goals of tx for AUB in adolescent pts (4)

A

Halt AUB, prevent recurrence, avert morbidity, improve QoL

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37
Q

Adjuvant tx for pts w/ AUB and w/ evidence of IDA

A

PO iron tx (and if refractory, referred to heme for poss IV iron tx)

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38
Q

Signs/Sxs of PCOS (3)

A

Noncyclic bleeding, hyperandrogenic signs, characteristic ovarian appearance of US

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39
Q

Important comorbid condition for many pts w/ PCOS

A

Obesity

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40
Q

Condition to consider in high-risk pts aged 19-39 y/o w/ AUB-O (especially w/ inadequate response to medical tx)

A

Hyperplasia/malignancy

41
Q

Condition that must be ruled out in pts aged 40+ y/o w/ AUB

A

Hyperplasia/malignancy

42
Q

Definition of perimenopause; mean age of menopause

A

Onset of cycle irregularity to 1 year s/p LMP; 51.4 y/o

43
Q

Factor that lowers age of menopause, and by how much

A

Smoking, by 1.74 years

44
Q

Average duration of menopausal transition (menstrual irregularity)

A

4 years

45
Q

Are cycles always unpredictable during perimenopause?

A

No, they can fluctuate between predictable ovulatory bleeding and erratic AUB-O

46
Q

Condition that must be excluded in all perimenopausal pts (until 1 full year s/p LMP)

A

Pregnancy

47
Q

First-line tx for perimenopausal pts w/ AUB w/o contraindications, and why

A

CHCs (rather than HRT), as it provides pregnancy prevention + menstrual control + alleviation of perimenopausal sxs

48
Q

Does premenopausal HRT provide menstrual regularity; does premenopausal HRT provide contraception?

A

No; no

49
Q

Incidence of endometrial cancer in pts <20 y/o

A

0.2/100,000

50
Q

Clinical hx typically seen in adolescent pts w/ endometrial cancer

A

2-3 years of AUB and obesity

51
Q

Incidence of endometrial cancer for pts 20-34 y/o; incidence of endometrial cancer for pts 35-44 y/o

A

1.6%; 6.2%

52
Q

Risk factors for endometrial cancer in pts <40 y/o (5)

A

Nulliparity, HTN, BMI >30, irregular menstruation, fam hx

53
Q

Incidence of endometrial cancer in pts 40-50 y/o; incidence of endometrial cancer in pts 70-74 y/o

A

13.6-24 cases per 100,000 pt-years; 87.3 cases per 100,000 pt-years

54
Q

Features of endometrial cancer seen more frequently in pts <45 y/o (3)

A

Lower rate of advanced-stage disease, higher degree of tumor differentiation, better prognosis

55
Q

Recommended testing for all pts >45 y/o w/ suspected AUB-O

A

EMB (after pregnancy is excluded)

56
Q

Is management for pts w/ AUB-O medical or surgical?

A

Medical, as underlying issue is endocrinologic (unless medical tx fails, is contraindicated, is not tolerated, or pt has concomitant intracavitary lesions)

57
Q

Classes of first-line medical tx options for AUB-O

A

CHCs, progestin-only therapies

58
Q

Progestin-only therapies for pts w/ AUB-O (5)

A

LNG-IUD, Provera, Megace, norethindrone, depo

59
Q

Benefits of both CHCs and progestin-only therapies re AUB-O (2)

A

Thinning endometrium, endometrial protection)

60
Q

Benefit of cyclic CHC use

A

Induction of regular withdrawal bleeding, improving abnormal menstruation patterns and physiologic functioning

61
Q

Preferred CHCs for pts w/ AUB-O

A

CHCs w/ 20-35micrograms ethinyl estradiol

62
Q

When is hospitalization (+/- high-dose estrogen) indicated for pts w/ AUB (3)?

A

Hemodynamic instability, intolerance of outpt regimen, clinically symptomatic

63
Q

Benefits of extended-cycle oral contraceptive regimens (3)

A

Permits resolution of anemia, emotional recovery from acute bleeding, additional imaging/consultations if needed

64
Q

Is cyclic or continuous dosing preferred for adolescent pts following resolution of anemia?

A

Either is appropriate, as per pt preference

65
Q

What clotting factors have CHCs been shown to increase (2)?

A

Factor VIII, vWF

66
Q

Physiologic benefit of CHCs for pts w/ hyperandrogenic sxs associated w/ PCOS

A

Suppress ovarian/adrenal androgen production and increase SHBG, further reducing bioavailable androgens, ultimately improving sxs (ie hirsutism, acne)

67
Q

Lifestyle changes strongly advised in overweight anovulatory pts (2)

A

Weight loss, increased exercise (w/ evidence showing return to ovulatory cycles w/ sustained weight reduction)

68
Q

Theory for why weight loss improves anovulatory cycles

A

Thought to decrease serum testosterone concentration and resumption of ovulation

69
Q

Tx options for late perimenopausal pt w/ AUB (4)

A

Cyclic progestin tx, low-dose OCPs, LNG-IUD, cyclic hormonal tx

70
Q

Benefits of hormonal tx for late perimenopausal pts w/ AUB (2)

A

Menstrual control, endometrial protection

71
Q

Does cyclic progestin tx or cyclic hormonal tx provide contraception?

A

No (though they do provide relief from perimenopausal sxs)

72
Q

Percentage of pts receiving combined continuous estrogen + cyclic progesterone therapy who experience cyclic menstrual bleeding as well as reduction in vasomotor sxs

A

86%

73
Q

Satisfaction rate at 48 month f/u among obese perimenopausal pts w/ AUB w/ LNG-IUD in place

A

75%

74
Q

Positive features seen w/ longer use of LNG-IUD (2)

A

Decreased menstrual bleeding, amenorrhea

75
Q

Surgical tx options for AUB-O (2)

A

Endometrial ablation, hyst

76
Q

Disadvantages of endometrial ablation (2)

A

Reduces ability to detect/dx future endometrial cancer, does not serve as contraception

77
Q

Long-term complications of endometrial ablation (7)

A

Post-ablation Asherman syndrome, synechiae, cervical stenosis, contracture of endometrium, strictures, endometrial distortion, delay in detection of endometrial cancer

78
Q

Effect of endometrial ablation on endometrial surveillance methods (ie EMB, hysteroscopy, TVUS, SIS)

A

May be compromised

79
Q

Percentage of cases of endometrial cancer found after endometrial ablation that were stage I at dx; interval range from endometrial ablation to endometrial cancer

A

76.5%; 2 weeks to 10 years

80
Q

What should be done if satisfactory endometrial evaluation cannot be collected s/p ablation?

A

Hyst

81
Q

Which AUB pts reported better improvement in QoL between those undergoing hyst and those treated w/ LNG-IUD

A

Equivalent

82
Q

Which endometrial surveillance method is preferred for pts w/ AUB-O; why (3)?

A

Office EMB; less invasive, safer, less expensive

83
Q

Factors that influence sensitivity of office EMB (7)

A

Type of lesion present (focal vs diffuse), pathologic dx (intracavitary fibroid/polyp), size of lesion, presence of uterine malformation, volume of path, surface area of endometrial cavity, number of lesions

84
Q

Additional info that EMB can provide

A

Hormonal status of endometrium

85
Q

Rate of sampling failure of EMB

A

0-54%

86
Q

Percent of endometrium that EMB typically samples (and range reported)

A

4% (0-12%)

87
Q

Percentage of postmenopausal pts w/ insufficient office EMB result that had uterine pathology; percentage of postmenopausal pts w/ insufficient office EMB result that had malignancy

A

20%; 3%

88
Q

Sensitivity of office EMB for detecting polyps/fibroids; sensitivity of office EMB for diagnosing hyperplasia

A

0.1; 0.33

89
Q

Features of lesions more likely to be missed w/ office EMB (2)

A

Focal, encompass small surface area

90
Q

Benefits of hysteroscopy over other methods of endometrial surveillance (3)

A

Affords full visualization of endometrial cavity and endocervix, allows for targeted bx, more accurate dx of atrophy/ hyperplasia/polyps/fibroids/cancer

91
Q

Likelihood of endometrial cancer dx after neg hysteroscopy

A

0.4-0.5%

92
Q

Pts for whom TVUS generally not recommended

A

Non-sexually active pts

93
Q

Between TAUS and TVUS, which is more sensitive in evaluation of endometrium?

A

TVUS (though TAUS can still be used to evaluate other structural abnormalities)

94
Q

Ideal timing of TVUS, and why

A

Day 4-6 of cycle, when endometrium is thinnest

95
Q

Is endometrial thickness useful for determining management in anovulatory pts w/o a cycle?

A

No

96
Q

Typical endometrial thickness range during proliferative phase; typical endometrial thickness range during secretory phase

A

4-8mm; 8-14mm

97
Q

Should endometrial thickness alone be used to exclude benign endometrial path in premenopausal pts; why?

A

No; this would miss 1 in 6 intracavitary lesions

98
Q

Sensitivity of SIS in evaluating uterus/endometrium for pathology; NPV of SIS in evaluating uterus/endometrium for pathology

A

96-100%; 94-100%

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