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Clinical Therapeutics 2 > Premenopausal and Postmenopausal Abnormal Uterine Bleeding > Flashcards

Premenopausal and Postmenopausal Abnormal Uterine Bleeding Flashcards

1
Q

what is the average length of normal menstrual bleeding?

A

5 days (range 2-7)

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2
Q

what is menorrhagia? what does it produce?

A

Blood loss of over 80 mL per cycle and frequently produces anemia

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3
Q

what is normal blood loss during menstruation?

A

40mL per cycle

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4
Q

what is metrorrhagia?

A

bleeding b/w periods

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5
Q

what is polymenorrhea?

A

bleeding that occurs more often than every 21 days

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6
Q

what is oligomenorrhea?

A

bleeding that occurs less frequently thane very 35 days

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7
Q

what is the mnemonic for pre-menopausla abnormal uterine bleeding causes? what’s it based on?

A

PALM-COEIN

based on etiology and bleeding pattern (heavy, light, etc.)

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8
Q

what does PALM-COEIN stand for?

A

mnemonic for pre-menopausla abnormal uterine bleeding causes

  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy and hyperplasia
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified
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9
Q

why does abnormal uterine bleeding occur in adolescents? what does it represent in them?

A

as a result of persistent anovulation due to the immaturity of the hypothalamic-pituitary-ovarian axis

represents normal physiology

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10
Q

abnormal uterine bleeding in women ages 19-39 is often a result of?

A

Pregnancy, structural lesions, anovulatory cycles, use of hormonal contraception, endometrial hyperplasia

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11
Q

what should ALWAYS be r/o as a cause of abnormal uterine bleeding in reproductive age women?

A

Pregnancy

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12
Q

premenopausal pts with AUB include those with what disorders?

A
  • submucosal myomas
  • infection
  • early abortion
  • thrombophilias
  • pelvic neoplasma
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13
Q

what herbal remedies might cause pre-menopausal AUB?

A

Black cohosh, Chamomile, Feverfew, Fish oil, Garlic, Ginger, Gingko, Ginseng

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14
Q

what labs should be run for pts with pre-menopausal AUB?

A

CBC, hCG, thyroid function, coag studies, cervical samples (cytology and culture)

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15
Q

who should coag studies be run on for pre-menopausal AUB?

A

for adolescents with heavy menstrual bleeding and adults with a positive screening history

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16
Q

imaging for dx of pre-menopausal AUB?

A

US, Sonohysterography or hysteroscopy, MRI

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17
Q

how is US useful for pre-menopausal AUB dx?

A

useful to evaluate endometrial thickness or to diagnose intrauterine or ectopic pregnancy or adnexal masses

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18
Q

how is sonohysterography or hysteroscopy useful for pre-menopausal AUB dx?

A

May be able to diagnose endometrial polyps or subserous myomas

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19
Q

how is MRI useful for pre-menopausal AUB dx? is it the primary imaging modality for AUB?

A

NOT PRIMARY IMAGING MODALITY FOR AUB

Can definitively diagnose submucous myomas and adenomyosis

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20
Q

who should endometrial sample be performed in for AUB?

A

in pts with AUB who are older than 45 or in younger pts with h/o unopposed estrogen exposure or failed medical management and persistent AUB

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21
Q

what is the primary role of endometrial sampling?

A

to determine whether carcinoma or premalignant lesions are present

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22
Q

by what diagnostic procedures are polyps, endometrial hyperplasia, and sub mucous myxomas commonly identified?

A

Colposcopy, D&C, Endometrial bx, Endocervical curettage, Hysteroscopy, Saline infusion sonohysterography, Hysterosalpingography, Laparoscopy

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23
Q

what does colposcopy visualize? use with or without? done where?

A

cervical, vaginal, or vulvar epithelium under magnification

used with and w/out dilute acetic acid

done in office

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24
Q

what areas does colposcopy identify?

A

abnormal areas requiring bx

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25
Q

what is D&C?

A

dilation of cervix and curettage of the entire endometrial cavity

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26
Q

what does D&C do?

A

uses metal curette or suction cannula and forceps for removal of endometrial polls

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27
Q

endometrial bx has diagnostic accuracy similar to what other procedure?

A

D&C

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28
Q

what does endocervical curettage do?

A

removal of endocervical epithelium with small curette for dx of cervical dysplasia and cancer

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29
Q

what is hysteroscopy?

A

visual exam of uterine cavity with a small fiberoptic endoscope passed through cervix

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30
Q

what can be performed with hysteroscopy?

A

bx’s and excision of myomas

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31
Q

what does saline infusion sonohysterography visualize? done what by?

A

puts saline into endometrial cavity to visualize sub mucous myxomas or endometrial polyps

done by transvaginal US

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32
Q

what is hysterosalpingography and what does it visualize? mainly used in investigation of what?

A

Injection of radiopaque dye through the cervix to visualize the uterine cavity and oviducts

Mainly used in investigation of infertility

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33
Q

what should be used to identify pts who require definitive therapy for pre-menopausal AUB?

A

hx, PE, labs, imaging, and endometrial sampling

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34
Q

what is AUB-O?

A

abnormal uterine bleeding ovulatory -> HPA axis is mature

vs AUB anovulatory bleeding -> HPA axis is NOT mature

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35
Q

how can AUB-O usually be treated?

A

hormonally - with Progestins

36
Q

what do Progestins do normally and in terms of treating AUB-O?

A

limit and stabilize endometrial growth

37
Q

what is the tx for AUB-O pts with irregular or light bleeding? what occurs with these ex’s?

A

Medroxyprogesterone acetate x 10days

Norethindrone acetate x 10 days

withdrawal bleeding (medical curettage) will occur

38
Q

if Medroxyprogesterone or Norethindrone are successful in tx for AUB-O pts can they be repeated? start meds when? when can they be reinstituted?

A

Yes, they can be repeated if successful for several cycles

starting med on day 15 of subsequent cycles

or can be reinstituted if amenorrhea or dysfunctional bleeding recurs

39
Q

tx of AUB-O pts with heavier bleeding? how often taken? what about after withdrawal bleeding occurs?

A

any of the COC’s -> with 30-35mcg of estrogen estradiol

4x daily for 1 or 2 days followed by 2 pills daily through day 5 and then one pill daily thru day 20

after withdrawal bleeding occurs, pills are taken in the usual doses for 3 cycles

40
Q

tx of AUB-O pts with intractable heavy bleeding?

A

GnRH agonist

  • Depot leuprolide (IM monthly)
  • Nafarelin (intranasally BID) - can be used up to 6 months for ovarian suppression
41
Q

what do the GnRH agonist medications for tx of AUB-O pts with intractable heavy bleeding require?

A

2-4 weeks to down regulate the pituitary and stop bleeding and will not stop bleeding acutely

42
Q

how do you treat AUB-O with heavy bleeding requiring hospitalization? what will these meds do?

A

IV conjugated estrogen - every 4hrs for 3-4 doses

Followed by: ethanol estradiol PO daily for 3 weeks
-give with medroxyprogesterone acetate PO daily for last 10 days of tx or give COC daily for 3 weeks

these will thicken the endometrium and control the bleeding

43
Q

what will NSAIDs do?

A

reduce blood loss menorrhagia

44
Q

if the abnormal uterine bleeding is NOT controlled by hormonal tx what do you do? what structural lesions?

A

hysteroscopy with tissue sampling or saline infusion sonohysterography to evaluate for structural lesions

-polyps, sub mucous myxomas, neoplasms

45
Q

if AUB is not controlled by hormonal tx and thee is no specific pathology, what are tx choices?

A

Endometrial ablation

Levonorgestrel-releasing IUD

Hysterectomy

46
Q

endometrial ablation can be performed through?

A

hysteroscope with laser photocoagulation or electrocautery

47
Q

endometrial ablation non-hysteroscopic techniques (outpatient) can be performed through?

A
  • Balloon thermal ablation
  • Cryoablation
  • Free-fluid thermal ablation
  • Impedence bipolar radiofrequency ablation
  • Microwave ablation
48
Q

what does Levonorgestrel-releasing IUD do?

A

markedly reduces menstrual blood loss

49
Q

how many pts will need endometrial ablation repeat after 5 years?

A

40%

50
Q

is hysterectomy common nowadays?

A

NO!!! UNCOMMON

51
Q

when do you refer a pt with pre-menopausal AUB?

A
  • If bleeding is not controlled with first line therapy

- If expertise is needed for a surgical procedure

52
Q

when do you admit a pt with pre-menopausal AUB?

A
  • If bleeding is uncontrolled with first-line therapy

- Hemodynamically unstable

53
Q

what is post-menopausal abnormal uterine bleeding? this type of bleeding needs to be what?

A

Vaginal bleeding that occurs 6 months or more following cessation of menstrual function

NEEDS TO BE INVESTIGATED!!!

54
Q

most common causes of post-menopausal AUB?

A
  • Atrophic endometrium/vaginal
  • Endometrial proliferation
  • Hyperplasia, endometrial or cervical cancer
  • Administration of estrogens with or without added progestin
  • Endometrial polyps
55
Q

what is the MAIN imaging to dx postmenopausal bleeding?

A

Transvaginal US

56
Q

wha should you inspect and for what to dx postmenopausal bleeding?

A

vulva and vagina for areas of bleeding ulcers, or neoplasms

57
Q

what smear should be done for dx of postmenopausal bleeding?

A

cytologic smear of the cervix and vaginal pool

58
Q

what does transvaginal US measure?

A

endometrial thickness

59
Q

endometrial thickness measurement of 4mm or less indicates what for postmenopausal bleeding?

A

low likelihood of hyperplasia or endometrial cancer

60
Q

endometrial thickness >4mm or heterogeneous appearance to the endometrium means what for post-menopausal bleeding?

A

need to determine if the thickening is global or focal

61
Q

when’d o you need to determine if the thickening of the endometrium is global or focal?

A

when endometrial thickness >4mm or heterogeneous appearance to the endometrium

62
Q

what assists in making distinction of global or focal endometrial thickening?

A

sonohysterography

63
Q

if the thickening of the endometrium is global, then do what?

A

endometrial bx or D&C

64
Q

if the thickening of the endometrium is focal, then dow hat?

A

sampling with hysteroscopy

65
Q

what is the tx for endometrial hyperplasia?

A

cyclic or continuous progestin therapy

-medroxyprogesterone acetate daily PO for 21 or 30 days for 3 months

OR

-norethindrone acetate daily PO for 21 or 30 days for 3 months

66
Q

what is another tx option for endometrial hyperplasia besides cyclic or continuous progestin therapy?

A

levonorgestrel intrauterine system

67
Q

if symptoms of post-menopausal bleeding recur after tx, what should be performed?

A

repeat sampling

68
Q

if endometrial hyperplasia with atypic or if carcinoma of the endometrium is found, what is NECESSARY?

A

HYSTERECTOMY

69
Q

when do you refer pt with post-menopausal bleeding?

A
  • Expertise in performing ultrasonography is required
  • Complex endometrial hyperplasia with atypia is present
  • Hysteroscopy is indicated
70
Q

is neonatal vaginal bleeding normal? does it require tx? is it self-limited?

A

yes, if it lasts <1 week

-it’s self-limited and requires no tx

71
Q

what is neonatal vaginal bleeding caused by?

A

withdrawal of hormones the baby was exposed to in the womb

72
Q

what is the tx for symptomatic endometrial polyps?

A

more likely to be malignant so must be removed

73
Q

what is the tx for endometrial polyps in postmenopausal women?

A

always remove the polyp b/c risk of malignancy is high whether symptoms or asymptomatic

74
Q

what is AUB?

A

bleeding from the uterus that differs in frequency, regularity, duration, or amount from normal uterine bleeding in the absence of pregnancy

75
Q

non-gynecologic etiologic sx’s for AUB?

A

changes in bowel movements or urination

76
Q

infectious etiologic sx’s for AUB?

A

suprapubic/lower abdominal pain, vaginal discharge, fever

77
Q

metabolic etiologies sx’s for AUB?

A

hot flashes, hirsutism, hair loss, acne

78
Q

CNS etiology sx’s for AUB?

A

HA, breast discharge

79
Q

what is important for the workup in 8 year olds? - young age group. what do you inspect? what do you not use for inspection of the vaginal vault?

A

physical exam

-if general exam and inspection of external genitalia don’t elicit a dx, inspect vaginal vault but NOT with a speculum

80
Q

what is mild anovulatory uterine bleeding?

A

longer than normal menses (>7 days) or shortened cycles (<24 days) for at least 2 months with slightly or moderately increased menstrual flow

81
Q

what is moderate anovulatory uterine bleeding?

A

moderately prolonged (>7 days) or frequent menses (every 1-3 weeks) with moderate to heavy menstrual flow and hemoglobin at least 10g/dL

82
Q

what is severe anovulatory uterine bleeding?

A

disruptive menstrual cycles with heavy bleeding with Hgb <10g/dL

may or may not cause hemodynamic instability

83
Q

tx for anovulatory bleeding?

A

menstrual calendar, observation and reassurance vs. hormonal therapy

Iron 60mg PO QD

84
Q

when do you follow-up for anovulatory bleeding?

A

in 3-6 months unless bleeding becomes more severe

85
Q

what is the first thing to rule out if pt is having postcoital bleeding?

A

malignancy

86
Q

what is postmenopausal bleeding?

A

any uterine bleeding in a menopausal woman other than expected cyclic bleeding that occurs in women making cyclical postmenopausal hormone therapy

87
Q

all postmenopausal women with unexpected uterine bleeding, should be evaluated for what?

A

for endometrial carcinoma

Clinical Therapeutics 2 (11 decks)

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