Abnormal Uterine Bleeding Flashcards
(40 cards)
1
Q
**Abnormal Uterine Bleeding **
Definition
A
- **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)
2
Q
Polymenorrhea
Definition
A
Frequent menstruation w/ bleeding intervals <21 days
3
Q
Menorrhagia
Definition
Clinical Definition
A
- 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
4
Q
Metrorrhagia
Definition
A
Irregular menstrual intervals
5
Q
Menometrorrhagia
Definition
A
Irregular menstruation intervals
Excessive flow and/or duration
6
Q
Oligomenorrhea
Definition
A
Menstruation fewer than 9 times/yr
Avg bleeding intervals >35 days
7
Q
Hypomenorrhea
Definition
A
Very light or short duration menstruation
8
Q
Intermenstrual bleeding
Definition
A
Uterine bleeding in btwn apparently ovulatory menses
9
Q
Amenorrhea
Definition
A
Absence of menses for at least 6 mo or 3 cycles
10
Q
Postmenopausal bleeding
Definition
A
Uterine bleeding > 12 mo after cessation of menses
11
Q
What are the 4 most common uterine conditions that cause abnormal uterine bleeding?
A
- Pregnancy – normal or abnormal
- Infection
- Neoplasms
- Adenomyosis
12
Q
What are the neoplasms responsible for abnormal uterine bleeding?
A
- Leiomyomas
- Endometrial Polyps
- Endocervical Polyps
- Cervical Cancer
- Endometrial Cancer
13
Q
Leiomyomas
Definition
Bleeding
Types
A
- 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
14
Q
**Endometrial Polyps **
Definition
Risk
A
- 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 _
15
Q
**Endocervical Polyps **
Definition
Symptoms
A
- Soft, fleshy growths
- Originate from the mucosal surface of the endocervical canal
- When symptomatic, manifest as _intra-menstrual or post-coital spotting _
16
Q
Adenomyosis
Definition
Exam findings
A
- Benign invasion of endometrium into myometrium
- 2/3 – menorrhagia & dysmenorrhea
- Pelvic exam – diffusely enlarged & tender uterus
17
Q
What are some causes of abnormal uterine bleeding unrelated to uterine pathology?
A
“Dysfunctional Uterine Bleeding”
- Exogenous hormones
- Ovulation defects
- Endometrial atrophy
- Coagulopathy
18
Q
What are the 5 main ovulation defects that cause abnormal uterine bleeding?
A
- Oligo-ovulation & Anovulation
- Polycystic Ovarian Syndrome
- Systemic diseases that can mimic PCOS
- Endometrial atrophy
- Coagulopathy
19
Q
Oligo-ovulation & Anovulation
Definition
Risk
A
- 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
20
Q
What is the mechanism of anovulation & its effect on the endometrium?
A
- 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
21
Q
Endometrial Atrophy
Definition
A
- Spotting
- Indistinguishable from earliest symptoms of endometrial cancer
- Must be carefully evaluated in perimenopausal & postmenopausal women
- Hypoestrogenemia – surgical/natural menopause
22
Q
Coagulopathy
Definition
A
Inborn or acquired conditions that interfere w/ normal hemostatic mechanisms in the case of vascular interruption
23
Q
Clinical Evalulation of Abnormal Uterine Bleeding
History
A
- 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
24
Q
Clinical Evaluation of Abnormal Uterine Bleeding
Lab Testing
A
- 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
25
**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
26
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
27
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
28
**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
29
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
30
**Endometriosis**
Anatomic sites
* Most common: **pelvis near tubal fimbria**
* Ovaries
* Anterior & posterior cul-de-sac
* Broad ligament
* Uterosacral ligaments
* Most common extragenital location: **bowel**
31
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
32
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
33
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
34
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 **
35
What are the **treatment options** for endometriosis?
Oral contraceptives & NSAIDs
GnRH agonists
Progestins
Aromatase Inhibitors
Surgical removal
36
\_\_\_\_\_\_\_\_ & _________ are the first line therapy for chronic pain associated w/ endometriosis.
**Oral contraceptives**
**NSAIDs**
37
**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
38
**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
39
\_\_\_\_\_\_\_\_\_ & __________ are the aromatase inhibitors used to treat endometriosis.
**Letrozole**
**Medroxyprogesterone acetate **
40
In patients with endometriosis, success rates w/ **IVF** appear to be (lower/higher).
**Lower**
