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m4 obgyn > Abnormal uterine bleeding > Flashcards

Abnormal uterine bleeding Flashcards

(45 cards)

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1
Q

Normal menstrual cycle

A

Length: ~21-35 days
Duration: ~3-7 days
Amount of bleeding: ~4 pads/day, no flooding
Pain (discomfort/cramps) - should not interfere with day to day activities
No intermenstrual bleed

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2
Q

Terminology: Hypomenorrhoea

A

Periods < 3 days (30ml) with scanty bleeding per menstrual cycle

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3
Q

Terminology: Hypermenorrhoea

A

Periods > 80ml (>4 soaked pads/days) per menstrual cycle
*frequent, excessive bleeds

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4
Q

Terminology: Menorrhagia

A

Periods > 7 days &/or > 80ml blood loss
*prolonged, heavy bleeds

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5
Q

Terminology: Amenorrhea

A

Absence of menstruation

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6
Q

Terminology: Oligomenorrhoea

A

Infrequent menstruation > 35 days apart

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7
Q

Terminology: Polymenorrhea

A

Frequent menstruation, cycle length < 21 days apart

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8
Q

Terminology: Metrorrhagia

A

Bleeding of normal amounts but at irregular intervals

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9
Q

Terminology: Menometrorrhagia

A

Bleeding that is excessive in amount, prolonged in duration and may occur at regular or irregular intervals

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10
Q

Acute AUB

A

Excessive uterine bleeding requiring immediate intervention to prevent further blood loss

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11
Q

Chronic AUB

A

AUB present for the majority of the past 6 months

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12
Q

Causes of heavy menstrual bleeding

A

TRO red flags first
- Pregnancy
- Ectopic pregnancy
- GTD
- Miscarriages

Structural: PALM
Polyps/Pregnancy (miscarriage/ectopic)
Adenomyosis
Leiomyomas (fibroids)
- Submucosal fibroids
Malignancies (cervical/endometrial) & Hyperplasia

Functional: COEIN
Coagulopathy
Ovulatory dysfunction (DUB)
Endometrial (Hyperplasia/ Polyp/ Cancer)
Iatrogenic (IUCD/ Anti-platelets/ Anti-coagulants)
Not yet classified
- Thyroid disorders
- Infection (Cervicitis/ Endometritis/ PID)
- Trauma
- Sexual abuse
- FB

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13
Q

Endometrial polyps

A

Overgrowth of endometrial lining
- Majority are benign

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14
Q

Symptoms of endometrial polyps

A
  • Intermenstrual bleeding
  • Heavy bleeding
  • Prolonged bleeding
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15
Q

Diagnosis of endometrial polyps

A

TV Ultrasound
GOLD: Hysteroscopy

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16
Q

Treatment of endometrial polyps

A

Conservative
Surgical: Hysteroscopic removal of polyp

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17
Q

Adenomyosis

A

Endometrial tissue grows into myometrium and leads to diffusely enlarged uterus with increased surface area and vascularity
- Benign

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18
Q

Symptoms of adenomyosis

A
  • Heavy menstrual bleeding with dysmenorrhea
  • Deep-thrust dyspareunia (during pre-menstrual period)
  • Chronic pelvic pain
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19
Q

PE in adenomyosis

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A

Mobile, diffusely enlarged, soft globular uterus

20
Q

Investigations for adenomyosis

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A

TV Ultrasound
- thickening of myometrium
- subendometrial linear striations

Dilatation & curettage hysteroscopy TRO endometrial Ca IVO heavy menstrual bleeding

21
Q

Diagnosis of adenomyosis

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A

Histological dx after hysterectomy

22
Q

Treatment of adenomyosis

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A

Medical
Non-hormonal -> If patient wishes to conceive:
- Tranexamic acid (anti-fibrinolytic)

Hormonal:
- COCP
- Progestogens (Depo, *Mirena [best tx option], POP)
- GnRH agonist (temporary)

Surgical
- Endometrial ablation
- Hysterectomy (if not fertility sparing)
- Alternative: Uterine artery embolisation

23
Q

What is the best treatment option for heavy menstrual bleeding (non-fertility sparing)?

24
Q

Leiomyoma/fibroids

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A

Benign proliferation of smooth muscle cells in myometrium of uterus

25
Progression of fibroids/leiomyoma
Arise during reproductive years -> enlarge during pregnancy -> regress after menopause
26
Risk factors of fibroids
Influenced by endogenous > exogenous oestrogen - Nulliparity - Family hx - HTN, obesity
27
What is known to reduce risk of fibroids?
OCP
28
Classifications of fibroids/leiomyoma
1. Submucosal - Below endometrial surface, bulging into uterine cavity - Endometrium is distorted - Increased endometrial surface area for more bleeding 2. Intra-mural - Centrally within myometrium - May cause bleeding in a big fibroma that involves submucosal component 3. Pedunculated sub-serosal - Attached to uterus by narrow pedicle containing vessels 4. Cervical - Arising from cervix
29
Symptoms of leiomyoma/fibroid
If p/w regular, heavy menstrual bleeding (due to increase SA of endometrium) -> submucosa or intra-mural with submucosa component If p/w pressure symptoms - Urinary urgency/ frequency if pressing on bladder - Posterior cervical fibroid can push uterus forward, compressing mid-urethra and cause urinary retention - Back pain -> Increased VTE risk: Very large fibroids can compress on vena cava -> Sub-serosal P/w infertility
30
Investigation for fibroid
TV Ultrasound to know position of fibroids as it determines the sx
31
Treatment of fibroids
Conservative if symptomatic and/or small Medical (same as above) Surgery - Fertility sparing: Myomectomy to just remove fibroids - No need for fertility sparing, definitive: Hysterectomy (eliminates current sx and chance of recurrence) Other alternatives: Endometrial ablation, uterine artery embolisation
32
Complications of fibroids
- Distortion of uterine wall can lead to difficulty implanting (Subfertility) - Early pregnancy loss/ malpresentation
33
Endometrial hyperplasia/malignancy
Overabundant growth and proliferation of endometrium resulting from prolonged unopposed estrogen stimulation
34
Risk factors of endometrial hyperplasia
Extremes of reproductive age with anovulation Nulliparity, early menarche PCOS Obesity (Increased extra-ovarian aromatization of adrenal androgen to estrogen) Granulosa-Theca cell Tumors (Estrogen Producing) Prolonged use of estrogen-only hormonal therapy Chronic Tamoxifen Use FHx Genetic syndrome (HNPCC)
35
How can endometrium hyperplasia present?
1. AUB: HMB/IMB/PMB 2. Incidental finding of endometrial thickness on US For postmenopausal - If Less than 5mm -> Observe -> If persistent bleed -> D&C - If 5mm or more -> Endometrial sampling with pipelle -> If insufficient/inadequate -> D&C For premenopausal >15mm at anytime of the menstrual cycle 3. Abnormal PAP smear
36
Investigations for endometrium hyperplasia
- TV ultrasound to assess endometrium thickness - Endometrial sampling via pipelle - Hysteroscopy + D&C (GOLD)
37
Histological results and its risk of malignancy
Simple Hyperplasia (with or w/o atypia) / Complex hyperplasia without atypia: risk of malignancy <5% in 25 years = Benign -1% in 19 years???? Complex Hyperplasia with atypia: risk of malignancy ~20% = Pre cancerous -> Need to do D&C TRO endometrial Ca!!!
38
Treatment for Simple Hyperplasia (with or w/o atypia) / Complex hyperplasia without atypia
Uterus conserving: 1st line: Mirena IUCD Progestogens: Norethisterone or Medroxyprogesterone daily
39
Treatment for Complex Hyperplasia with atypia
Do D&C TRO endometrial ca!!! 1st line: Hysterectomy 2nd line: Mirena IUCD
40
Dysfunctional uterine bleeding
Excessive bleeding (amt, freq or duration) from female genital tract, for which no cause can be found after physical examination or investigations - Dx of EXCLUSION
41
Types of DUB
1. Anovulatory DUB a. Adolescence (<20yo) - Immature HPO but full of follicles b. Perimenopausal woman (>40yo) - Depleted follicles but mature HPO c. Childbearing age (20-40yo) - PCOS - Stress, weight gain - Thyroid dysfunction 2. Ovulatory DUB - early degeneration or prolonged function of corpus luteum - pre-menstrual spotting or prolonged spotting after menstrual flow
42
Treatment for anovulatory DUB
Non-hormonal tx - Tranexemic acid - NSAIDs Desire fertility: Ovulation induction (Clomiphene Citrate/ IVF/ GnRH) Desire contraception: Follow above
43
Treatment of ovulatory DUB
Non-hormonal tx - Tranexemic acid - NSAIDs Desire fertility: Luteal phase progesterone (corpus luteum is deficient -> inadequate progesterone -> endometrial lining cannot be maintained -> sheds immediately -> cycles are irregular/ frequent, hence by giving progesterone it helps to regulate the cycle) Desire infertility - Follow above
44
Physical examination for heavy menstrual bleeding
1. General (BMI/ Acne/ Hirsutism/ Thyroid lump/ VFs/ Pallor) 2. Breast (Galactorrhea) 3. Abdo PE (Mass/ Size/ Mobility/ Tenderness) 4. Pelvic PE - Inspection - Speculum: Cervical lesion/ polyp/ Fibroid at vulva/ Vagina, Discharge - VE: Pelvic/ Adnexal mass and tenderness
45
Investigations for heavy menstrual bleeding
1. UPT TRO pregnancy 2. Bloods - FBC TRO anemia - PT/ PTT TRO coagulopathy   - TFT TRO thyroid dysfunction   - Hormonal profile (FSH, LH, estradiol, prolactin, testosterone) if anovulation is suspected   3. Imaging - Transvaginal ultrasound -> structural abnormalities (polyps, fibroids, adenomyosis) -> thickening of uterine lining -> malignancy 4. Biopsy - Endometrial sampling biopsy With pipelle or D&C (Dilatation & Curettage)

m4 obgyn (41 decks)

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