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OB GYN > AUB + Fibroids in Pre-menopausal women > Flashcards

AUB + Fibroids in Pre-menopausal women Flashcards

1
Q

follicular phase events

A
  • FSH rises + follicles recruited
  • follicles secrete E2, increases granulosa cells
  • granulosa cells aromatize androgens (from theca cells)
  • rising FSH and E2 inhibit pituitary E2, stops all follicles except dominant /w most E2/GCs/FSH receptors
  • FSH induces LH receptors on GC
  • endometrium proliferates
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2
Q

ovulation events

A
  • LH and FSH surge
  • ovulation occurs 12 hours after LH surge
  • P secretion begins, causes proteolytic enzymes and prostaglandins to rupture follicle
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3
Q

luteal phase events

A
  • follicle –> corpus luteum
  • CL secretes P
  • more LH receptors, P increases
  • FSH receptors suppressed, E declines
  • after 14 days CL detriorates (unless fertilization)
  • P drops and menstruation occurs (/w decline of P and E)
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4
Q

progesterone effect on menstrual flow

A

progesterone thins endometrium

need withdrawal of E2 and P to trigger menstruation (take OCP continuously, no period)

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5
Q

Normal Menses

A

24-38 day cycle
period 4.5-8 days
blood loss: 5-80cc
normal variation: +/-2 to 20 days in cycle length

no breakthrough bleed

large pad q1h for 4-5days will cause anemia in 3-4 months

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6
Q

heavy menstrual bleeding definition

A
  • interferes /w life
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7
Q

precocious menstruation

A

before age 9

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8
Q

acute AUB

A

bleed in non-preg woman of reproductive age requiring immediate medical intervention

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9
Q

causes of AUB

A

P- polyps
A- adenomysosis
L - leiomyoma
M - malignancy

C - coag disorder
O - ovulatory disorder
E - endometrial
I - iatrogenic
N - not otherwise classified
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10
Q

causes of AUB in menarche

A

Ovulatory = 1, hypothalamic pituiatyr axis. R/O

  • coagulopathies
  • endocrine
  • pregnancy - SA, molar, ectopic
  • incorrect use of OCP
  • sexual trauma
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11
Q

Coagulopathies in menarche + tests

A

1) VWD - bruising, epistaxis, gums, post surgical

2) platelet abnormality
- thrombasthenia - pt >400, malfunction
- ITP - Plts <150

3) leukemia

Tests: PTT, CBC, factor 8, VWF antigen, VWF functional assay (repeat if needed)

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12
Q

endocrine/ovulatory causes of AUB

A

PCOS

adrenal cause: CAH, cushings

Hypothalamic - eating disorder, exercise, stress, idiopathic, immature HPO axis

thryoid - hypo

prolactinoma

Ovarian: hormone secreting tumour (granulosa cell, sertoli-leydig = rare)

tests: BhCG, TSH, Prolactin, free testosterone, 17-hyrdoxy progesterone and DHEA (for adrenal), glucose/A1C

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13
Q

management of acute AUB in adolescent

A
  • stabilize (ABC) – if very unstable, tamponade –> D+C
  • meds - estrogen: premarin 25 mg IV q6hx24 hrs + gravol, or OCP 1 tab PO tid x 3 days, then bid x3 days, then daily x21 days

maintain OCP for several months to regulate until HPO axis matures

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14
Q

Mature women differential diagnosis for AUB

A

same as in younger

  • structural more common
  • VWB can present later but less common
  • HPO axis mature but can have prolactinoma, stress, weightloss
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15
Q

who to do endometrial biopsy on

A 
women over 40 /w AUB
or RF for endo CA:
- nullip /w infertility
- new onset heavy bleeding
- obesity, PCOS 
- Fam Hx of endo or colon CA
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16
Q

iatrogenic causes of AUB

A

forgotten IUD
OCH/HRT incorrectly used / breakthrough
neuroleptics: interfere /w dopamine + prolactin

17
Q

N in PALM COIEN

A

pregnancy (ectopic?)

other premalignant/malignant (cervix)

18
Q

when to work-up for missed cycle / anovulation

A

after 2-3 occurrences, 1 isolated time is ok (keep diary)

19
Q

workup for AUB/HMB in older pre-menopausal women

A

Hx
VS, signs of anemia
biopsy if needed
labs: CBC, ferritin, TSH, PRL, BhCG, coags if think VWB
sonohysterogram (endo polyps or submucosal fibroids)
US - endo can be up to 14mm before menstruation
Hysteroscopy - if all else neg and HMB persists

20
Q

Tx of Acute AUB in older pre-menopausal women

A

hormones = 1st line

options:

  • NSAID
  • tranexamic acid
  • progestin
  • OCP
  • Mirena IUD - works best
21
Q

Surgical tx of AUB

A

hysteroscopic resection - submucosal fibroids + polyps

hysteroscopic endometrial ablation - 80% improvement but can return

hysterectomy - definitive tx (most morbidity though)

22
Q

types of lyeimyoma

A

submucous
intramural
subserosal

can grow into cervix + vagina too

23
Q

mechanisms of fibroid growth

A

1) monoclonal
2) 40% chromosomal abnormalities
3) GFs: many, includes angiogenesis GF
4) hormonal stimulation: E and P receptors, P causes most growth
5) apoptosis inhibition

24
Q

clinical features of fibroids

A
  • asymptomatic - most
  • bleeding - esp sub mucosal
  • pressure symptoms
  • GI (constipation, bloat)
  • Urinary - freq + urg, rare: acute retention due to compression of cervix into urethra (emergency)
  • infertility if submucous
  • pain NOT associated, if pain and enlarging –> suspect leiomyosarcoma
25
Q

effect of fibroids on fertility

A
  • little evidence to guide
  • submucosal - remove
  • intramural > 5cm - prob should remove
  • myomectomy if uterus > 12wks
26
Q

work-up for fibroids

A
  • exam for size, symphsis fibroid height if out of pelvis
  • US
  • sonohysterogram to differentiate from endo polyp
  • endo bx + labs as needed for AUB
27
Q

non surg tx of fibroids

A
  • OCP
  • tranexamic acid
  • GnRH agonist - shrinks 25-50% in 3 mo, can’t use long term b/c of osteoporosis, grow back
  • SPERM - Ulipristal 5m PO OD, reduces same amnt in 3 months, may not re-grow, monitor liver enzymes, ? long term use
  • Uterine artery embolization (IR): bilat, fibroids necrose + degenerate + normal myometrium stays, not sure effect on preg, improves menorrhagia 90%, may need more tx in 3 years
28
Q

surgical tx of fibroids

A
  • hysteroscopic resection (submucous) - outpatient, quick, effective
  • myomectomy - preserve childbearing, laparascopy if <8cm, risks: blood loss, adhesions new myoma
  • hysterectomy - definitive, more complications
29
Q

issues with fibroids in preg

A
  • pain (15%), from degeneration
  • abnormal placentation
  • premature labour, PPROM
  • dystocia if lower segment
  • fetal malpresentation
  • increase CS
  • increase in PPH
  • follow /w US in 3rd trimester, usually TOL even if in lower seg

OB GYN (22 decks)

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