Week 3: Abnormal uterine bleeding

Question 1

Definition of abnormal uterine bleeding

Answer 1

• normal bleeding: cycle 21-35 days, length bleeding < 8days, blood loss 20-80mL
• deviations from these definitions or from individual’s own established patterns of bleeding

Question 2

Differential diagnosis of abnormal bleeding

Answer 2

1. Hormone etiology
   - endogenous or iatrogenic
2. Impaired coagulation
   - Von Willebrand disease
   - other inherited
   - iatrogenic
3. prostaglandin imbalance in endoemterium: low thromboxane or high prostacyclin
   - often underlying cause is unknown
4. Reproductive tract lesions
5. systemic diseases

Question 3

Workup of abnormal uterine bleeding: factors to consider based on age

Answer 3

1. Adolescents
   - inherited coagulopathies
   - STIs, esp. chlamydia (post coital bleeding, light touch causes bleeding)
2. > 35 yo
   - endometrial neoplasia
   - leiomyomata
   - polyps
   - adenomyosis

Question 4

Workup of abnormal uterine bleeding

Answer 4

1. History
   - menstrual history: cyclical bleeding with predictive symptoms (ovulatory bleeding)
   - drugs, STIs
   - other diseases that affect menstrual cycle
2. physical exam
   - signs of endocrine abnormalities
   - bruising
   - pelvic exam
3. Labs
   - CBC, TSH, Prothrombin time, STIs, pregnancy
4. Endometrial biopsy indications
   - new onset of unexplained excessive bleeding
   - spotting/bleeding between menstrual periods
   - low threshold for women with risk factors if over 35, obese, anovulatory, PCOS, family hx of non-polyposis CRC
5. Imaging:
   - transvaginal US for fibroids, masses
   - saline infusion sonography
   - hysteroscopy

Question 5

Medical therapies for abnormal uterine bleeding

Answer 5

1. NSAIDs
   - inhibition of prostaglandins causes vasoconstriction
   - modest efficacy
2. tranexamic acid: inhibits plasminogen to plasmin, preventing clot lysis. Modest efficacy
3. estrogen+progestin: OC, patch, vaginal ring
4. progestin only
   - IUD, oral,
   - injection (depo provera): many women amenorrheic in 1 year
5. GnRH agonist
   - good for pre-op
   - causes hypoestrogenic state: vasomotor symptoms and bone loss
   - not for long term

Question 6

Surgical therapies for abnormal uterine bleeding

Answer 6

1. endometrial ablation
   - but IUD as effective
2. uterine artery embolization
   - effective for fibroid assoc. menorrhagia
   - serious adverse events possible
3. Hysterectomy
   - definitive cure, but eliminates childbearing