Abnormal Uterine Bleeding

Question 1

Normal menstruation

Answer 1

Volume: normal 5-80 ml
 Frequency: normal 24-35 (38?) days
 Duration of flow: normal 4.5-7 days

Question 2

Questions for hemostatic problems?

Answer 2

Consider hemostatic problem
› Excessive bleeding since menarche
› Family history of bleeding
› Postpartum or post-op bleeding
› Bleeding with dental work
› Mucosal bleeding
 epistaxis
› History of easy bruising
 Large ecchymoses > 5 cm

Question 3

palm coein

Answer 3

 Polyp
 Adenomyosis
 Leiomyoma
 Malignancy &
hyperplasia
 Coagulopathy
 Ovulatory dysfunction
 Endometrial
 Iatrogenic
 Not yet classified

Question 4

post-coital bleeding

Answer 4

 Women aged 20-40
› 2/3 no underlying pathology
› 25 % cervical eversion
 Endocervical polyps
 Cervicitis (chlamydia)
 CIN/-cancer
 Vaginal atrophy

Question 5

Adolescent AUB

Answer 5

 Anovulatory bleeding-50%
 Mullerian anomaly
 Increased risk of coagulopathy-33%

Question 6

VonWillibrand

Answer 6

 Type 1-most common-80%
› aPTT –normal or increased
› vWF antigen & activity decreased
› Factor VIII decreased
› Mucosal bleeding/epistaxis/AUB
 Type 2 & 3
› Elevated aPTT
› Decreased vWF antigen/activity
› Decreased FVIII activity

txa or contraception

Question 7

DDAVP (Desmopressin Acetate)

Answer 7

 Releases stored vWF from within the
endothelium.
 Reduces bleeding in patients with type 1
vWD and some forms of type 2 vWD and
platelet function disorders.

Question 8

Screening coag profile for AUB

Answer 8

 CBC with platelets
 PT
 aPTT
 VW panel

Question 9

Herbs that cause AUB

Answer 9

 Herbal medication
› Anti-platelet activity-Ginkgo, Ginseng
› Coumarin containing herbs-Motherwort
 Fish oil, concentrated omega 3
› impair platelet activation

Question 10

When does contraception breakthrough bleeding need work-up?

Answer 10

irregular bleeding for >3

If they have had normal periods and now is having breakthrough bleeding

Question 11

work-up for AUB

Answer 11

 Pregnancy test
 Pap, cultures for STIs
 Screen for vWD when appropriate
 CBC and w/u of anemia (ferritin level)
 Endocrine testing when anovulatory
 Endometrial biopsy
› Unsatisfactory if it is a focal lesion
 Imaging
› Is it a focal lesion?

Question 12

EMB

Answer 12

“Endometrial tissue sampling should be performed in
pts with AUB who are older than 45 years of age as
first line test”

or younger with risk factors
chronic anovulation
 diabetes, obesity, hypertension
 tamoxifen use

Question 13

Post-menopause endometrial thickness

Answer 13

› Atrophic: 3.4 +1.2 mm
› Hyperplasia: 9.7 + 2.5
› Endometrial cancer: 18.2 + 6.2

Question 14

vaginal bleeding in ER

Answer 14

 OCP “taper”
› OCP of choice qid x 4 days then,
› OCP of choice tid x 3 days then,
› OCP of choice bid x 2 days then,
› For 3 months
 In patients that will receive chemotherapy
› Consider GnRH agonist with aromatase inhibitor to
prevent initial flare
 Unable to take OCP
› Provera 10 mg bid or
› Megace 80 mg po q 6 hr
› Until bleeding stops; maintain for 14 days

Severe
 Foley catheter with a 30 mL balloon
 Conjugated equine estrogen 25 mg IV q 4-6
hr x 24 hrs

Question 15

NovaSure

Answer 15

radiofrequency energy to the bipolar mesh while simultaneously applying suction, thereby evacuating steam and carbonized debris. This process allows for electrosurgical vaporization and underlying desiccation in a relatively rapid fashion (approximately 80–90 seconds).

The device is approved for use with uterine cavities up to 6–10 cm in length ( 4–6.5 cm from internal os)

Question 16

Roller Ball

Answer 16

Generally, the electrosurgical generator is set at 60–100 W.

With the commonly used 3-mm ball and a drag speed of 1 cm/second, the crater produced is approximately 1 mm in depth with thermal damage extending for 1–2 mm more.

Question 17

Hot water irrigation

Answer 17

Before heated fluid is circulated, the cavity is hysteroscopically inspected using room temperature saline at a flow rate of 300 ml/min for 2 minutes. If this priming is successful, the heating element is activated. Fluid pressure is kept below 55 mmHg. This pressure is below the opening pressure of the fallopian tubes and prevents fluid flow into the abdominal cavity. Once the fluid reached 80°C the 10-minute treatment phase begins. Fluid temperature continues to elevate to a maximum of 90°C. After the treatment cycle, the fluid is cooled to 45°C and circulated for 1 minute during the cool down phase. Preliminary studies indicate that uniform endometrial destruction to a depth of 3–4 mm in the uterine cavity and 2–3 mm in the cornual region is easily obtained.15 This irrigation is performed under constant hysteroscopic monitoring.

Question 18

ideal candidate of Hysteroscopic procedure

Answer 18

Single intracavitary myoma and involving
less than 50 % of the myometrium (Type 0 or
1) and up to 3cm in diameter
 Uterine size less than 12-14 weeks
 Normal hemoglobin and normal electrolytes