Abnormal Uterine bleeding and leiomyomata uteri Flashcards
(29 cards)
A 32 yo G0 LMP 6 weeks ago presents with unrelenting vaginal bleeding x 5 days. The patient has used >30 pads/24 hours. Admits to a history of dizziness, headache, and near syncope. Had subdermal contraceptive implant (Nexplanon®) inserted 6 weeks ago. Has had spotting since insertion.
PE + for tachycardia, hypotension and orthostatic changes
Pelvic exam reveals profuse vaginal bleeding emanating from cervix
Hgb=5 gm/dL; Hct=15%
Transfused 3 units packed RBCs to Hct=24%
Received conjugated equine estrogens (Premarin®) 25 mg IV Q6H x 24 hours
Ultrasound of pelvis reveals 2 cm submucous myoma
Nexplanon was removed
Patient underwent hysteroscopic myomectomy
Bleeding entirely resolved
incidence and definitions
-frequently reason to see gyno, especially in perimenopause
-Menorrhagia- regular, normal intervals (<7 days) but heavier than normal (>80 cc/menstration)
-Menometrorrhagia- bleeding between periods with heavy menstrual periods (as described above)
history
-Careful history of present illness
-How long has bleeding been a problem?
-History of normal periods and abnormal bleeding
-Number of pads, tampons, etc. used in 24 hours
-Is sanitary protection soaked?
-How quickly does the patient soak sanitary protection?
-!A patient who is soaking ≥2 pads per hour for >2 hours needs immediate evaluation
-Symptoms of volume depletion
-Headaches
-Dizziness
-Near syncope or syncope
-Palpitations
-Other symptoms
-Pain
-Easy bruising
-Epistaxis
-Gingival bleeding
-Other concerns
-Past medical history
-Past surgical history
-Past Ob-Gyn history
-Medications
physical exam
-Abnormal vital signs -> obtain orthostatics, if indicated
-Ecchymoses
-Evidence of gingival bleeding or epistaxis
-Pallor
-Petechiae
-On pelvic exam:
-Vulvar or vaginal lesions
-Amount of blood in vault
-Cervical motion tenderness or cervical lesions
-Uterine size, orientation, mobility, tenderness
-Adnexal masses and for tenderness
labs to consider
-CBC
-Urine pregnancy test or serum quantitative beta HCG (unless menopausal or s/p castration)
-TSH with reflex to T4
-Transvaginal US
-Pap smear, if indicated
-Endometrial bx if RF for hyperplasia or malignancy or ≥45yo
-Otherwise, no bx
etiology
-abnormal uterine bleeding (AUB)
-anatomic or structural, OR
-nonstructural
-Structural: LAMP:
-Leiomyomas
-Adenomyosis (endometriosis of myometrium)
-Malignancy
-Polyps
Leiomyomata uteri
-Benign tumors of smooth muscle of the uterus
-80% of patients with uteri
-Only 25% need tx
-If large enough -> palpable on pelvic exam
-Dx via pelvic US
-RF:
-family hx
-increasing age
-HTN
-obesity
-long internal since last delivery
-Sites:
-intramural (MC)
-submucous
-subserosal
-pedunculated
-cervical
sx and conditions associated with leiomyomata uteri
-Abnormal uterine bleeding
-Anemia
-Constipation
-Dysmenorrhea
-Dyspareunia
-Hydronephrosis
-Pelvic pain
-Polyuria
uterine myomas tx
-Pharm:
-GnRH analogues with add-back estrogen therapy
-Levonorgestrel IUD
-Combined oral contraceptives
-Tranexamic acid
-Interventional radiologic management -> Uterine artery embolization
-Surgical management:
-Minimally invasive surgery- Radiofrequency ablation
-Laparoscopic, robotic, hysteroscopic, vaginal or open MYOMectomy
-Laparoscopic, robotic, vaginal, or open HYSTERectomy
interventional radiologic management of leiomyomata uteri
-Uterine artery embolization
-IR procedure
-Inserts material into myomas to cause ischemia and necrosis
-Polyvinyl alcohol particles of trisacryl gelatin microspheres
-May also use metal coils
-Also used for adenomyosis with less good results
-Pregnancy is possible after
-Not best choice for hx of pedunculated myomas
-MRI prior to IR consult
-Assoc with reduction in size of about 60%
-Uterus may decrease in size for up to 1 year after
-No upper limit to uterine size has been identified at this time
hysteroscopy
-Minimally invasive surgery
-Placement of a fiberoptic scope in the uterus through a dilated cervix
-Uses liquid to distend the endometrial cavity
-Mannitol
-Glycine
-Dextran
-D5W
-Sorbitol
-May remove polyps, myomas, septa, etc. through an operating hysteroscope
-May be performed in office with small scope with sedation, or in surgical facility or hospital with deep sedation
adenomyosis
-Presence of endometrial glands and stroma within myometrium
-dysmenorrhea and AUB
-globular uterus may be noted on pelvic exam
-May be suspected based on findings on US or MRI of pelvis
-Best visualized via T2-weighted MRI images
-RF: not yet widely accepted but may include -> increasing age, smoking, multiparity, prior uterine surgery
-non-specific sx: AUB, leiomyoma, endometriosis
-adenomyosis
Adenomyosis in a 48-year-old woman. Sagittal T2-weighted image shows an ill-defined myometrial lesion of low signal intensity in the anterior myometrium. Innumerable hyperintense foci (arrows) are embedded in the lesion
adenomyosis management
-Adenomyomectomy (via laparoscopy, ultraminilaparotomy, or minilaparotomy) with GnRH-a
-Uterine artery embolization
-Hysterectomy
endometrial polyps
-Growths containing glandular tissue, stroma and blood vessels of the endometrium
-up to 50% of pts with AUB and in 35% of pts with infertility
-May be asymptomatic or may cause AUB
-May be sessile or pedunculated
-primarily benign, but may be malignant, particularly in pts with genetic abnormalities (Lynch syndrome, etc.) or postmenopausal
-RF:
-increasing age
-hyperestrogenism
-use of tamoxifen (60%)
-PCOS
-late menopause
-liver disease
endometrial polyps
endometrial polyps management
-In-office hysteroscopic polypectomy: indicated in infertile pts and postmenopausal bleeding
-Consider polypectomy or watchful waiting in asymptomatic postmenopausal
nonstructural etiologies of AUB
-COEIN:
-coagulopathy
-ovulatory disorders
-endometrial disorders
-iatrogenesis
-not yet classified
coagulopathy
-36% of adolescents with AUB have a bleeding disorder
-MC etiology: von Willebrand’s disease
-13% of adolescents with AUB
-34% of all AUB
-Other etiologies -> Platelet disorders - up to 53% of pts with AUB
-Hx:
-Heavy menstrual bleeding since menarche
-Surgical hemorrhage
-Postpartum hemorrhage
-Epistaxis >1-2x/month
-Gingival bleeding
-Bleeding following dental procedures
-Bruising >1-2x/month
-Family hx of bleeding
coagulopathy work up and tx
-Urine pregnancy test (UCG) or serum bHCG
-CBC with review of peripheral smear
-PT
-PTT
-Thrombin or fibrinogen time
-Platelet aggregation
-Von Willebrand panel
-Tx:
-Oral contraceptives, if not CI
-May administer monophasic combined OCs (COCs) 2x daily x 5 days, then continue daily
-Otherwise may use COC taper
-Consider extended cycle OCs
-Progestin-only OCs:
-Norethindrone
-Drospirenone
-Levonorgestrel IUDs Intravenous conjugated equine estrogens if indicated
-Antifibrinolytics:
-Aminocaproic acid (Amicar)
-Tranexamic acid
-In patients with thrombocytopenia:
-Consider GnRH-a
-Desmopressin in patients with a prolonged bleeding time
ovulatory disorders
-While many of these syndromes primarily cause amenorrhea and/or oligomenorrhea, it is possible for AUB to occur as well
-Workup is listed below
-Treat underlying condition
endometrial disorders
-may be numerous conditions of the endometrium that arent well understood
-These may involve disruption of endometrial hemostasis
-May be due to:
-Decreased production of vasoconstrictors
-Prostaglandin F2⍺
-Endothelin-1
-Increased production of substances that increase vasodilation
-Prostaglandin E2
-Prostacyclin
-may also be due to infection, especially with subclinical infection with Chlamydia trachomatis
-However, there are currently no clinical studies available
-These endometrial disorders probably are dx of exclusion in pts with normal ovulatory patterns
-Consider testing for C. trachomatis
-Consider endometrial bx, especially in >45yo, or transvaginal US suspicious for hyperplasia or malignancy
iatrogenesis
-Meds:
-Hormones (including contraceptives):
-Estrogens
-Progestins
-Androgens
-Psychotropic agents (tricyclic antidepressants, SSRIs)
-Affect dopamine metabolism, thus affects prolactin levels and may cause anovulation
-Anticoagulants
