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Flashcards in AUB Deck (24):
1

Abnormal uterine bleeding definition

change in frequency of menses, duration of flow, or amount of blood loss
due to any cause: structural/functional

2

Acute AUB

episode of bleeding requiring immediate attention

3

Chronic AUB

>6 mo and not requiring immediate intervention

4

Menorrhagia

Prolonged (>7 d) or excessive (>80 cc) uterine bleeding occurring at regular intervals (hypermenorrhea)

5

Metrorrhagia

uterine bleeding occurring at irregular but frequent intervals, the amount being variable

6

Age related menstrual cycle changes

first 5-7 y after menarche, cycles are longer
become shorter over the reproductive years (more cycles per year)
8-10 y before menopause, cycles lengthen

7

Normal parameters of menstrual cycles

q 28 +/- 7 d
flow 4 +/- 2 d
average blood loss 40 +/- 20 cc
1-3% in extremes

8

Nonstructural causes of abnormal uterine bleeding

COEIN
Non-structural:
Coagulopathy
Ovulatory dysfunction
Endometrial
iatrogenic
Not yet classified

9

Management of AUB - general principles

exclude serious pathology: pregnancy/cancer
reverse abnormalities of endometrium

10

Management of non-structural causes of AUB

identify with investigations:
Day 3 FSH/LH/Estradiol
Prolactin, TSH
Day 21 progesterone
bHCG

CBC, ferritin, vW factor, coagulation panel
renal/liver panel

11

DDx for anovulatory bleeding/DUB

Physiological: adolescence, perimenopausal, lactation, pregnancy
Pathological:
Hypothalamic - anorexia, stress, Kallman's
Pituitary: hyperPRL, hypothyroid, primary pit disease
Hyperandrogenic: PCOS, androgen-producing tumour, CAH
Ovarian: PCOS, POI

12

Menopause stages

Perimenopause (~5 y to transition to menopause)
early - variable cycle length
late: >=2 skipped cycles & intervals of amenorrhea
Amenorrhea for 12 mos = menopause
Postmenopause

13

Ovulatory bleeding

Endometrial defect
deficiencies in local production of v/cs (endothelin-1, PGF2a)
and/or
accelerated lysis of endometrial clot because of excessive production of plasminogen activator

14

Structural causes of AUB

PALM
Polyp
Adenomyosis
Leiomyoma - submucosal, other
Malignancy/hyperplasia

15

Adenomyosis

thickened wall of uterus, can be mistaken for fibroids

16

Need for investigation for endometrial hyperplasia/CA

Abnormal uterine lining
Cervical cytology abnormalities
Monitoring for women with endometrial pathology (e.g. hyperplasia)
Screening in women at high risk of developing endometrial cancer (e.g. Lynch syndrome)

Endometrial neoplasia should be suspected in premenopausal women who are anovulatory and have prolonged periods of amenorrhea (>=6 mo)

17

Women with abnormal uterine lining - postmenopausal

investigate for endometrial hyperplasia/endometrial cancer
- any bleeding, regardless of vol
- further evaluation of a US finding of an endometrial thickness > 4 mm

18

Women with abnormal uterine lining - 45 y to menopause

investigate for endometrial hyperplasia/endometrial cancer
- any AUB, including intermenstrual bleeding in women who are ovulatory
- AUB in any woman that is: (any one)
- frequent (80 ml
- prolonged >7 d

19

Women with abnormal uterine lining -

investigate for endometrial hyperplasia/endometrial cancer
- AUB that is persistent
- history of unopposed E exposure (obesity, chronic anovulation) or failed medical management of bleeding, women wtih high risk of endometrial cancer (tamoxifen, Lynch, Cowden syndromes)

20

Cervical cytology results indication for investigations for endometrial abnormalities

Presence of atypical glandular cells (AGC)
- endometrial
- all subcategories other than endometrial IF:
- >=35 yo, or at risk for endometrial ca
Presence of benign-appearing endometrial cells in women >= 40 y
who also have AUB or risk factors for endometrial ca

21

Endometritis/cervicitis

most common: gonorrhea, chlamydia
present with
- purulent discharge
- post-coital bleeding
- pelvic tenderness
- fever

22

Approach to AUB

Chronic AUB (>=3 mo)
Structured history for ovulatory function, related medical history

Physical examination - uterine evaluation

Ancillary investigations - CBC, endocrinopathy, inherited coagulopathies if indicated

23

AUB investigations

CBC and ferritin to determine degree of anemia
b-HCG, coags (adolescents), TSH, PRL, liver function tests, renal panel (systemic disease?), VWD, D21 serum progesternoe, D3 FSH/LH
Daily body temps or D21 progesterone

24

Medical tx for AUB

estrogen - acute only
NSAIDs, anti-fibrinolytics - endometrial ovulatory AUB
OCP, cyclical progesternoe - anovulatory AUB
Mirena - anovulatory/ovulatory AUB

Surgical: ablation, resection, hysterectomy