Abnormal Uterine Bleeding Flashcards by Victor Redmon

**Abnormal Uterine Bleeding **

Definition

**Describes any uterine bleeding outside the parameters of normal menstruation that occurs during the reproductive years **
Important to differentiate btwn abnormal bleeding associated w/ uterine factors or anovulation (lack of ovulation)

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Polymenorrhea

Definition

Frequent menstruation w/ bleeding intervals <21 days

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Menorrhagia

Definition

Clinical Definition

Excessive menstrual bleeding
Flow (<80 mL) and/or duration (<7 days)
Regulatory ovulatory cycles
Clinical Definition
- Bleeding on the heaviest day requiring changing soaked sanitary pads or tampons more than once every 2 hrs
- Using more than one sanitary pad
- Using a sanitary pad & tampon at a time

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Metrorrhagia

Definition

Irregular menstrual intervals

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Menometrorrhagia

Definition

Irregular menstruation intervals
Excessive flow and/or duration

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Oligomenorrhea

Definition

Menstruation fewer than 9 times/yr
Avg bleeding intervals >35 days

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Hypomenorrhea

Definition

Very light or short duration menstruation

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Intermenstrual bleeding

Definition

Uterine bleeding in btwn apparently ovulatory menses

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Amenorrhea

Definition

Absence of menses for at least 6 mo or 3 cycles

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Postmenopausal bleeding

Definition

Uterine bleeding > 12 mo after cessation of menses

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What are the 4 most common uterine conditions that cause abnormal uterine bleeding?

Pregnancy – normal or abnormal
Infection
Neoplasms
Adenomyosis

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What are the neoplasms responsible for abnormal uterine bleeding?

Leiomyomas
Endometrial Polyps
Endocervical Polyps
Cervical Cancer
Endometrial Cancer

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Leiomyomas

Definition

Bleeding

Types

Benign myometrial tumors
Common but many don’t cause symptoms
Menorrhagia more likely to be related to those lying immediately adjacent to the endometrium
Types
- Intramural
- Pedunculated subserosal
- Subserosal
- Submucosal
- Cervical

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**Endometrial Polyps **

Definition

Risk

Localized overgrowths of the endometrium
Project into the uterine cavity
Usually benign in pre-menopausal women
Risk of associated endometrial malignancy _increases significantly w/ age _

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**Endocervical Polyps **

Definition

Symptoms

Soft, fleshy growths
Originate from the mucosal surface of the endocervical canal
When symptomatic, manifest as _intra-menstrual or post-coital spotting _

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Adenomyosis

Definition

Exam findings

Benign invasion of endometrium into myometrium
2/3 – menorrhagia & dysmenorrhea
Pelvic exam – diffusely enlarged & tender uterus

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What are some causes of abnormal uterine bleeding unrelated to uterine pathology?

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“Dysfunctional Uterine Bleeding”

Exogenous hormones
Ovulation defects
Endometrial atrophy
Coagulopathy

What are the 5 main ovulation defects that cause abnormal uterine bleeding?

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Oligo-ovulation & Anovulation
Polycystic Ovarian Syndrome
Systemic diseases that can mimic PCOS
Endometrial atrophy
Coagulopathy

Oligo-ovulation & Anovulation

Definition

Risk

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Irregularity or absence of ovulation
Common in women of reproductive-age not using hormonal contraception
Episodes of endometrial exposure to unopposed estrogen increase the risk of AUB, endometrial hyperplasia & endometrial cancer

What is the mechanism of anovulation & its effect on the endometrium?

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Chronic exposure of endometrium to estrogen w/o postovulatory progesterone
Endometrium abnormally thickened & structurally incompetent
Asynchronous shedding of portions of the endometrium w/o vasoconstriction
Heavy bleeding
Blood not lysed by endometrial enzymes –> blood clots –> menstrual cramping

Endometrial Atrophy

Definition

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Spotting
Indistinguishable from earliest symptoms of endometrial cancer
Must be carefully evaluated in perimenopausal & postmenopausal women
Hypoestrogenemia – surgical/natural menopause

Coagulopathy

Definition

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Inborn or acquired conditions that interfere w/ normal hemostatic mechanisms in the case of vascular interruption

Clinical Evalulation of Abnormal Uterine Bleeding

History

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Most important factor in determining diagnostic approach
Usual & recent menstrual patterns
Extent of recent bleeding
Sexual activity
Contraception
Personal or FaHx of bleeding disorder
Symptoms of pregnancy, infection, changes in body hair, excessive bleeding, systemic disease
Current medication & information about previous Pap smears
Review of systems
- Weight gain or loss
- Abdominal swelling
- Somnolence
- Nipple discharge

Clinical Evaluation of Abnormal Uterine Bleeding

Lab Testing

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All patients
- Pregnancy test
- CBC (including platelets)
- Pap smear
- Cervical tests for gonorrhea & chlamydia
Appropriate testing for anovulation if applicable
Over age 40: endometrial biopsy
New-onset menorrhagia
- Prothrombin time
- Activation PTT
- Bleeding time
Menorrhagia since menarche
- Above plus: hematology studies

**Clinical Evaluation of Abnromal Uterine Bleeding** Imaging

* **Endometrial Biopsy** * Performed in the office * Flexible catheter placed through cervical canal into the uterus * **Transvaginal Ultrasonography & Sonohysterography** * **Office Hysteroscopy** * Camera & distension media to visualize uterine cavity

How do you **treat** abnormal uterine bleeding unrelated to pregnancy or uterine pathology?

* **Correction of underlying systemic abnormalities** * Returning endometrium to functional status w/ exogenous hormone therapy * ex: hypothyroidism, hyperprolactinemia

What is the **emergency treatment** for anovulatory bleeding?

* **Expedient cessation of bleeding** * **Achieve structural stability of endometrium as quickly as possible** * If don’t desire pregnancy * Promote universal, synchronous endometrial shedding at regular intervals or stop menstruation all together * Combinations of estrogen and/or progestin

**Endometriosis** Definition Primary symptoms Inheritance

* Presence of endometrial glands & stroma _outside_ the endometrial cavity & uterine musculature * Primary symptoms: **pain & infertility ** * Growth is _estrogen dependent _ * Prevalence increased 7X in 1st degree relatives

Classical Theories of Endometriosis (4)

* **Transplantation theory** * Endometrium regurgitated into the peritoneal cavity implants on the peritoneum * **Coelomic metaplasia** * Undifferentiated cells of Müllerian origin in the peritoneal cavity can differentiate into endometrial tissue * **Induction** * Endometrium or another agent induces metaplasia of the mesothelium to endometriotic tissue * **Vascular/lymphatic dissemination** * Explains presence of endometriosis at distant sites

**Endometriosis** Anatomic sites

* Most common: **pelvis near tubal fimbria** * Ovaries * Anterior & posterior cul-de-sac * Broad ligament * Uterosacral ligaments * Most common extragenital location: **bowel**

What types of **adhesions** are formed from endometriosis? What do they cause?

* Adhesion formation btwn different pelvic or abdominal organs * **Peritubal or peri-ovarian adhesions & tubal wall fibrosis** * Decreases tubal motility & access to ovulated oocytes * **Minor adhesions inside the tubal lumen** * May impair transport of the oocyte

With endometriosis, there are: Abnormal levels of \_\_\_\_\_\_\_\_\_\_\_. Negative effects on \_\_\_\_\_\_\_\_\_\_\_\_.

* **Abnormal levels** of cytokines, growth factors, inflammatory cells * **Negatively affects** sperm motility, oocyte maturation, fertilization, embryo survival, tubal function

What type of **pain** is associated w/ endometriosis? What is it caused by?

* **Depth of endometriosis lesions associated w/ pain & dysmenorrhea** * Pain w/ advanced disease caused by: * Extensive adhesions * Ovarian cysts * Deeply infiltrating endometriosis

What are the **symptoms** of endometriosis?

* **Reproductive Tract** * Infertility * Dysmenorrhea * Dyspareunia * Noncyclic pelvic pain * **GI** * Diarrhea and/or constipation * Pain w/ bowel movement * Abdominal cramps * Cyclic rectal bleeding * **Urinary Symptoms** * **Low back pain **

What are the **treatment options** for endometriosis?

Oral contraceptives & NSAIDs GnRH agonists Progestins Aromatase Inhibitors Surgical removal

\_\_\_\_\_\_\_\_ & _________ are the first line therapy for chronic pain associated w/ endometriosis.

**Oral contraceptives** **NSAIDs**

**GnRH agonists for endometriosis** Examples Mechanism

* Empiric treatment w/o laparoscopy * Highly effective in relieving pain associated w/ endometriosis * Intramuscular: **Leuprolide acetate** * SubQ: **Goserelin** * Nasal: **Nafarelin** * _Suppress gonadotropin secretion_ * After initial increase in gonadotropins (first 10 days) --\> decrease in pituitary secretion secondary to GnRH receptor down-regulation * 6 mo course

**Progestins for endometriosis** Examples Mechanism

* **Norethindrone Acetate ** * Most commonly used _add-back regimen_ * Low dose estrogen (**conjugated equine estrogen**) can be added to Norethindrone w/o loss of benefit in symptom control

\_\_\_\_\_\_\_\_\_ & __________ are the aromatase inhibitors used to treat endometriosis.

**Letrozole** **Medroxyprogesterone acetate **

In patients with endometriosis, success rates w/ **IVF** appear to be (lower/higher).

**Lower**

Abnormal Uterine Bleeding Flashcards

(40 cards)