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Flashcards in AUB Deck (68):
1

Classification of abnormal uterine
bleeding

Abnormal rhythm
Abnormal amt
Combination (rhythm and amount)

2

Abnormal rhythm bleeding examples
1
2
3
4

Irregularity of cycle
Intermenstrual bleeding (metrorrhagia)
Postcoital bleeding
Postmenopausal bleeding

3

Abnormal amount example

Increased amount = ______
Decreased amount =_______

menorrhagia

hypomenorrhoea

4

Combination (rhythm and amount)

Irregular and heavy periods = _____
Irregular and light periods =_______

metromenorrhagia

oligomenorrhoea

5

Up to _____ of women in the reproductive age
group complain of increased menstrual loss

20%

6

The mean blood loss in a menstrual cycle is
________

30–40 mL

7

Heavy menstrual bleeding (menorrhagia)—
HMB—is a menstrual loss of more than______

80 mL per
menstruation

8

Two common organic causes of HMB are _____ and ______

fibroids
and adenomyosis (presence of endometrium in the
uterine myometrium

9

Most girls reach menarche by the age of ________

13 (range 10–16 years).

10

Dysfunctional bleeding
is common in the first ______ after menarche due
to many anovulatory cycles resulting in irregular
periods, heavy menses and probably dysmenorrhoea

2–3 years

11

A normal endometrial thickness, as measured by
ultrasound, is between_______

6 and 12 mm

12

The menstrual
cycle is confirmed as being________(biochemically)
if the serum progesterone (produced by the corpus
luteum) is >20 nmol/L during the mid-luteal phase
(5–10 days before menses).

ovulatory

13

The incidence of malignant disease as a cause of bleeding increases with age, being greatest after the age of _________ while endometrial cancer
is predicted to be less than 1 in 100 000 in women
under the age of 3

45,

14

Dysfunctional
uterine bleeding is more common in the extremes of the
reproductive era, while the incidence of cancer as a
cause of bleeding is greatest in the _____ and _____

perimenopausal and
postmenopausal phases.

15

What is HMB

• blood loss >80 mL per menstrual cycle
• bleeding that persists >7 days
• bleeding that is unacceptable to the woman

16

Menorrhagia 4 is essentially caused by excessive local
production of ______in the endometrium
and myometrium and/or excessive _______

prostaglandins

local fibrinolytic activity.

17

By far the most common single ‘cause’ of
menorrhagia is ______

ovulatory dysfunctional uterine
bleeding (DUB).

18

_______ occurs at the
extremes of the reproductive period—around
menarche and perimenopausall

Anovulatory DUB

19

MCC of Anovulatory DUB

fibromyomatas (fibroids),endometriosis, adenomyosis (‘endometriosis’ of the
myometrium), endometrial polyps and PID

20

__________reserved for women who fail
conservative treatment or who are at increased risk
of endometrial cancer

UTZ

21

When to request biopsy in UTZ

If it is >12 mm for premenopausal women
or >5 mm for perimenopausal women, endometrial
biopsy (with or without hysteroscopy) is indicated

22

____ and _______remain the
gold standard for abnormal uterine bleeding.

Hysteroscopy and D&C

23

______excessive bleeding, whether heavy, prolonged or
frequent, of uterine origin, which is not associated
with recognisable pelvic disease, complications of
pregnancy or systemic disease

DUB

24

DUB is MC in what cycle?

It is more common in ovulatory
(regular) rather than anovulatory (irregular)
cycles.

25

Peak incidence of ovulatory DUB in late_____

30s and 40s (35–45 years).

26

_______DUB has two peaks: 12–16
years and 45–55 years. The bleeding is
typically irregular with spotting and variable
menorrhagia

Anovulatory

27

The serum progesterone and the pituitary
hormones___ and ______ will confirm
anovulation

(LH and FSH)

28

DUB Tx

_________ is usually employed
if the uterus is of normal size and there is no
evidence of anaemia

Conservative management

29

Consider surgical management if____ and _____

fertility is
no longer important and symptoms cannot be
controlled by at least 3–4 months of hormone
therapy

30

Mx of acute heavy bleeding

• oral high-dose progestogens (e.g. norethisterone
5–10 mg 4 hourly until bleeding stops then 5 mg bd
or tds for 14 days

31

MX of chronic bleeding

For anovulatory women:

• cyclical oral progestogens for 12 days
• tranexamic acid

32

MX of chronic bleeding

For ovulatory women:

• cyclical prostaglandin inhibitor (e.g. mefenamic acid)
or (one of)
• oral contraceptive
• antifibrinolytic agent (e.g. tranexamic acid 1 g (o) qid,
days 1–4)
• progesterone-releasing IUDs (e.g. Mirena

33

The agent of first choice in DUB is usually
________, which reduces blood loss by 20–25%
as well as helping dysmenorrhoea

mefenamic acid

34

Hormonal agents for DUB include
1
2
3

progestogens, combined
oestrogen–progestogen oral contraceptives and
danazol.

35

The_______constitutes important first-line
therapy in both ovulatory and anovulatory patients,
but at least 20% of patients do not respond

COC

36

In the adolescent with anovulatory DUB, __________ may be required for 6 months
until spontaneous regular ovulation eventuates

cyclical
oral progestogens

37

The most effective agent for both ovulatory and
anovulatory DUB is tranexamic acid, which inhibits
___________

endometrial plasminogen activation

38

Dose of Tranex for DUB

The dose is 1 g
(up to 1.5 g if necessary) orally qid for the first 4 days

39

It is regarded
as the most efficacious of the hormone treatments
with a mean blood loss of 94% of women with
menorrhagia.

The intra-uterine progesterone implant system
(Mirena)

40

Sx Mx

• endometrial ablation or electrodiathermy
excision—to produce _________

amenorrhoea

41

It is preferred to drug
therapy for women with endometrial hyperplasia
with atypia—endometrial ablation is not
appropriate

hysterectomy

42

Emergency menorrhagia (acute flooding) 4
First line

• tranexamic acid 10 mg/kg IV, every 8 hours until
bleeding stops
or
• tranexamic acid 1–1.5 g (o) 6 to 8 hourly until
bleeding stops

43

If above unavailable or not tolerated, other options
are:

• norethisterone 5–10 mg 4 hourly (o) till bleeding
stops, then 5 mg bd or tds (or 10 mg daily) for
14 days
or
• medroxyprogesterone acetate 10 mg (o) 4 hourly
until bleeding stops for 7 days then 20 mg daily
for 21 days
or
• COCP e.g. until bleeding stops then re-evaluate
after 48 hours

44

General guidelines for surgical intervention

• no longer wish to be able to conceive
• are perimenopausal
• have poorly controlled symptoms
• have adverse effects from the drugs
• have significant uterine pathology

45

Patients under 35 years:

Cause of cycle irreg

• the cause is usually hormonal, rarely organic, but
keep malignancy in mind

46

management options for cycle irreg in under 35

— explanation and reassurance (if slight
irregularity)
— COC pill for better cycle control—any pill can
be used
— progestogen-only pill (especially anovulatory
cycles) norethisterone (Primolut N)
5–15 mg/day from day 5–25 of cycle

47

MCC of Intermenstrual bleeding
and postcoital bleeding

factors such as
cervical ectropion (often termed cervical erosion),
cervical polyps, the presence of an IUCD and the oral
contraceptive pill.

48

Cervical ectropion, which is commonly found
in women on the pill and postpartum, can be left
untreated unless _____ and ______

intolerable discharge or moderate
postcoital bleeding (PCB) is present

49

________ are benign tumours of smooth muscle of the
myometrium

Fibroids

50

Pelvic ultrasound (investigation of choice) .
Endometrial thickening >4 mm demands
________ If >7 mm, ________

endometrial sampling.


endometrial cancer should be excluded

51

Med Mx of uterine fibroids

• Consider COCP (30 mcg oestrogen can reduce
bleeding

_________—especially if >42 years can
shrink fibroids (maximum 6 months)—use only
immediately pre-operative

• GnRH analogues

52

Sx Mx of fibroids

— myomectomy (remove fibroids only, esp.
child-bearing years)
— hysteroscopic resection/endometrial
ablation
— hysterectomy

53

This should be the diagnosis until proved otherwise
for postcoital, intermenstrual or postmenopausal
bleeding

Cervical CA

54

MC Sx of cervical CA

• Postcoital bleeding
• Intermenstrual bleeding
• Vaginal discharge—may be offensive

55

PE of cervical CA

• Ulceration or mass on cervix
• Bleeds readily on contact—may be friable

56

This is the diagnosis until proved otherwise in any
woman presenting with postmenopausal bleeding.

Endometrial cancer

57

T or F
Endometrial cancer is not excluded by a
normal cervical smear

T

58

Primary amenorrhoea is the failure of the menses
to start by _______

16 years of age

59

Secondary amenorrhoea is
the absence of menses for over______

6 months in a woman
who has had established menstruation

60

The main approach in the patient with primary
amenorrhoea is to differentiate it from ________ in which there are no signs of sexual
maturation by age

delayed
puberty,

61

Amenorrhea

It is important to keep in mind
the possibility of an ____ and _______, which can suppress hypothalamic
GnRH production.

imperforate hymen and also
excessive exercise

62

Causes of primary amenorrhoea include
1
2
3
4
5

genital
malformations, ovarian disease, pituitary tumours,
hypothalamic disorder and Turner syndrome

63

Diagnostic tests for amenorrhea include

serum FSH, LH, prolactin,
oestradiol and also chromosome analysis.

64

In secondary amenorrhoea, consider a
physiological cause such as
1
2
3

pregnancy or the menopause, failure of some part of the hypothalamic–
pituitary–ovarian–uterine axis (e.g. PCOS) or a
metabolic disturbance

65

_________is the term for infrequent
and usually irregular periods, where the cycles are
between 6 weeks and 6 months

Oligomenorrhoea

66


Premature ovarian failure

Apart from iatrogenic causes this may be caused by
idiopathic early menopause and _______

autoimmune ovarian
failur

67

Remember that ____can obscure the
organic causes of menorrhagia

mental dysfunction

68

_______is more effective than the traditional
curettage. Studies have shown that usually less
than 50% of the uterine cavity is sampled by
curettage.

Hysteroscopy