Columbus: Abnormal uterine bleeding

Question 0

Normal menstrual volume?
Normal frequency?
Normal duration?

Answer 0

5 to 80 mL
24 to 35 days
4.5 to 7 days

Question 1

Define AUB

Answer 1

Any uterine bleeding outside the parameters of normal menstruation in the reproductive years.

Question 2

What is the differential diagnosis for AUB?

Answer 2

P: polyp
A: adenomyosis
L: leiomyoma
M: malignancy and hyperplasia
C: coagulopathy
O: ovulatory dysfunction including thyroid disease
E: endometrial
I: iatrogenic including IUD
N: not yet classified

Question 3

What history would you want for AUB?

Answer 3

Cycle regularity, frequency of menstruation, duration of menstrual flow, volume of bleeding. Intermenstrual or postcoital bleeding.
Symptoms of bleeding disorder or PCOS. Anemia symptoms.
Medications including hormones and herbal supplements.

Question 4

How would you examine a patient with AUB?

Answer 4

vitals: HR, BP and BMI
Skin: hirsutism, acne and acanthosis nigricans. Petechiae or ecchymoses
Thyroid: nodule
Pelvic: cervicitis, bimanual examination for fibroids or malignancy, rectovaginal exam

Question 5

What is the differential diagnosis for postcoital bleeding?

Answer 5

Cervical ectropion
Endocervical polyps
Cervicitis particularly from chlamydia
CIN and cervical cancer
Vaginal atrophy

Question 6

What is the differential diagnosis of AUB in an adolescent?

Answer 6

Anovulation
Coagulopathy such as von Willebrand disease
Mullerian anomalies
AV malformation
Infection
Chemotherapy

Question 7

What percentage of women with menorrhagia since menarche will have a bleeding disorder?

Answer 7

65%

Question 8

What is the role of von Willebrand factor?

Answer 8

1. major adhesion molecule for platelets to the exposed subendothelium
2. binding protein for factor VIII

Question 9

How is von Willebrand disease treated?

Answer 9

DDAVP
Oral contraceptives
Levonorgestrel IUD
Tranexamic acid
Plasma derived concentrates of von Willebrand's factor for type 3

Question 10

How and when is desmopressin acetate administered?

What is it mechanism of action?

Answer 10

Intranasally during menstruation or IV prior to procedures

Releases stored von Willebrand factor from within the endothelium

Question 11

When does ACOG recommend testing for von Willebrand disease?

Answer 11

1. Adolescents with severe menorrhagia
2. Adult women with menorrhagia without apparent cause
3. Women undergoing hysterectomy for menorrhagia

Question 12

What tests should be ordered to screen for coagulopathies?

Answer 12

CBC with platelets, PT, aPTT, PFA – 100 (platelet function analyzer)

Question 13

How does hypothyroidism cause abnormal uterine bleeding?

Does hyperthyroidism cause AUB?

Answer 13

SHBG is reduced which leads to increased free E2 and TRH increases prolactin, which leads to anovulation

Yes but the mechanism is unknown

Question 14

What supplements and herbal medications affect menstrual bleeding?

Answer 14

Ginkgo and ginseng have antiplatelet activities

High-dose fish oil and omega-3 supplements can impair platelet activation

Question 15

What laboratory tests should be considered for AUB?

Answer 15

Pregnancy test
Pap smear and STI cultures
Screen for von Willebrand disease when appropriate
CBC and work up of anemia
Consider endocrine testing for anovulatory bleeding
Consider endometrial biopsy

Question 16

What imaging should be considered for the evaluation AUB?

Answer 16

Transvaginal ultrasound
Saline infusion sonography
HSG
Hysteroscopy

Question 17

All women over what age should have endometrial sampling as a first-line test?

What is the rate of failure to detect cancer for this method?

When is hysteroscopic directed biopsy recommended?

Answer 17

45

0.9%

Focal endometrial thickening

Question 18

In what diseases or conditions should younger women have endometrial sampling for work up of abnormal uterine bleeding?

Answer 18

Chronic anovulation
Diabetes, obesity, hypertension
Tamoxifen use

Question 19

What ultrasound findings of the endometrium warrant further evaluation?

Answer 19

Heterogeneous endometrium or intrauterine fluid collection

Question 20

When is MRI indicated to evaluate AUB?

Answer 20

Equivocal ultrasound results
Suspicion of adenomyosis
Assess location for surgical or radiologic treatment

Question 21

What medications and dosages can be used for management of heavy abnormal uterine bleeding?

Answer 21

Conjugated equine estrogen 2.5 mg PO every six hours for 24 hours
OCP taper
Provera 10 mg twice daily until bleeding stops for 14 days

Question 22

What are chronic therapies for abnormal uterine bleeding and dosages?

Answer 22

NSAIDs: Cox 1 inhibitors, start with menstrual flow and continue for five days, reduces flow 20 to 50%
OCP’s: reduces blood flow approximately 60%
Tranexamic acid: plasminogen activation inhibitor, 1300 mg every eight hours for 5 days, decreases bloodflow by 50%
Oral progestins: 10 days per month if anovulatory
Levonorgestrel IUS: decreases bloodflow 74% in 3 months and 97% at 1 year.

Question 23

When was Mirena approved for heavy menstrual bleeding by the FDA?

What is the largest uterine size in which a Mirena IUD can be placed?

Answer 23

2009

Less than or equal to 12 weeks size with no cavitary distortion.

Question 24

How effective is Mirena for adenomyosis?

Answer 24

Improved hemoglobin and decreased uterine volume and pain scores at 12 months. Some worsening at 36 months but still improved over the baseline. AJOG 2008

Question 25

What does ACOG recommend prior to endometrial ablation?

Answer 25

Endometrial sampling

Question 26

What are contraindications to endometrial ablation?

Answer 26

``` Future fertility Pregnancy Genital tract infection or malignancy Uterine anomaly Prior uterine surgery such as myomectomy classical cesarean section or more than one low transverse cesarean ```

Question 27

What is more effective Mirena or endometrial ablation?

Answer 27

No significant difference in menstrual blood loss reduction or major complications

Question 28

What symptoms occur with endometrial polyps?

Answer 28

Abnormal uterine bleeding, dysmenorrhea, vaginal discharge, postcoital bleeding

Question 29

What are contraindications to hysteroscopic resection of a polyp or fibroid?

Answer 29

Acute PID or prodromal HSV infection Purely transmural fibroid Poor intraoperative visualization or distention of the uterine cavity

Question 30

What are the 3 recommended prerequisites for hysteroscopic resection of a uterine fibroid?

Answer 30

Single intracavitary myoma involving less than 50% of the myometrium and less than or equal to 3 cm in diameter Uterine size less than 12 to 14 weeks Normal hemoglobin and electrolytes

Question 31

What are the odds of incomplete removal of a type 2 fibroid?

Answer 31

Approximately 40%

Question 32

Describe the classification system of submucous uterine fibroids.

Answer 32

Type 0: pedunculated submucous fibroids Type 1: less than 50% intramural submucous fibroids Type 2: greater than 50% intramural with submucous component

Question 33

What are contraindications to uterine fibroid embolization?

Answer 33

``` Active infection or vasculitis History of pelvic radiation Contrast allergy Poorly controlled diabetes Renal failure or insufficiency Arteriovenous shunting Undiagnosed pelvic mass Submucosal fibroid or pedunculated with stalk less than 2 cm Pregnancy ```

Question 34

List complications associated with uterine fibroid embolization.

Answer 34

``` 11% readmission rate Ischemic necrosis causing pain and prolonged vaginal discharge Retained fibroid tissue fragments Premature ovarian failure: < 1% Heavy bleeding Systemic or local infection ```

Question 35

What is post embolization syndrome? How can it be distinguished from infection?

Answer 35

Ischemic pain, nausea, vomiting, malaise, uterine tenderness and low-grade fever occurs in 20%, 15% require readmission. Occurs within first week Elevated WBC with left shift in both MRI can be helpful to distinguish from abscess

Question 36

How does uterine fibroid embolization compare to medical or surgical therapy?

Answer 36

No significant difference in patient satisfaction at two or five years. No difference in rate of major complications No difference in ovarian failure rates Uterine fibroid embolization is associated with higher rates of minor complications and higher re-intervention rates within five years.

Question 37

Is uterine fibroid embolization contraindicated for patients who desire future fertility?

Answer 37

ACOG recommends to be cautious when considering use and women who want to retain fertility secondary to possible abnormal placentation and amenorrhea

Question 38

What are the advantages and disadvantages of laparoscopic versus abdominal myomectomy?

Answer 38

Laparoscopic myomectomy is associated with decreased risk of fever, less hemoglobin drop, shorter length of stay and faster recovery. Only OR time was increased in a laparoscopic group. Major complications, pregnancy rates and recurrence rates were similar.