Dysfunctional Uterine Bleeding Flashcards Preview

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Flashcards in Dysfunctional Uterine Bleeding Deck (43)
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1
Q
Normal uterine bleeding
A
-cycle is 21-35 days, average is 28 days
-bleeding lasts 2-7 days
-40 mL blood loss
2
Q
Menorrhagia
A
-HEAVY bleeding
> 7 days
> 80 mL blood loss (double normal)
3
Q
Metorrhagia
A
-ABNORMAL bleeding
-Polymenorrhea: 35 days
4
Q
Menometorrhagia
A
Both heavy and abnormal bleeding
5
Q
PALM-COEIN reasons for premenopausal uterine bleeding
A
PALM: Structural
P: poly
A: adenomyosis
L: leiomyoma
M: malignancy

COEIN: non-structural
C: coagulopathy
O: ovulatory dysfunction
E: endometrial
I: iatrogenic
N: not yet classified
6
Q
Polyp
A
**Can cause very heavy bleeding (menorrhagia) or intramenstrual bleeding (bleeding between cycles)**

-Localized hyperplastic overgrowths of endometrial glands and stroma around a vascular core
-Looks like a finger-like projection into uterus
7
Q
Risk Factors to getting a uterine polyp
A
-tamoxifen (breast cancer)
-obesity (have extra estrogen)
-postmenopausal hormones
8
Q
To better view a polyp can use
A
Saline infused sonohistogram (used to
expand uterus to see structures you wont see
when uterus is collapsed)
9
Q
Adeonmyosis
A
**Heavy menstrual bleeding and pelvic pain
**Trying to bleed but trapped in muscular tissue (painful)
-Endometrial glands and stroma within uterine musculature= hypertrophy and hyperplasia= globular uterus
-can be diffuse or nodular

-WIKI: presence of ectopic glandular tissue found in muscle
10
Q
Best imaging for uterus (especially to see adenomyosis)
A
Transvaginal ultrasound
11
Q
Treatment for Adenomyosis
A
medical/surgical
-may need hysterectomy
12
Q
Leiomyoma
A
-AKA: fibroids
-Benign monoclonal tumors arising from smooth muscle of myometrium
-Heavy menstrual bleeding plus pressure symptoms
-2-3x great risk in african americans
13
Q
Types of Leiomyomas
A
1. Submucosal fibroid (causes most bleeding, most associated with infertility and miscarriages)
2. Intramural fibroid
3. Subserosal fibroid
4. Pedunculated fibroid
14
Q
Leiomyoma vs Polyp
A
-Fibroids are more solid and harder to remove
-Polyps are softer and easier to remove because they are endometrial glands
-These two are easily confused
-Can use use saline infused sonohistogram to see both (submucosal fibroid only)
15
Q
Treatment for Leiomyoma
A
-medical:
1. OCPs
2. Progestins (IUD or Depo- stops ovulation, no growth of endometrium, may decrease bleeding)
3. Luprolide (LOTS of people use this- shuts off all estrogen that you’re secreting, can maybe even shrink the fibroid)- 6 months max, puts you in false menopausal state- causes bone loss, NOT reversible (osteoporosis/osteopenia)
-Once in menopause, no estrogen, fibroids may even shrink

-Surgery: removal
16
Q
Malignancy
A
Cervical vs uterine (both present with vaginal bleeding)

Uterine- Hyperplasia vs adenocarcinoma vs sarcoma
17
Q
Cervical cancer, you can see _________
A
squamous cell carcinoma
18
Q
Endometrial hyperplasia
A
Proliferation of endometrial glands of irregular size and shape

-Hyperplasia is BIG risk factor for endometrial cancer
19
Q
Simple without atypia, % of people with endometrial hyperplasia that have it
A
1% (penny)
20
Q
Complex without atypia, % of people with endometrial hyperplasia that have it
A
3% (nickel)
21
Q
Simple with atypia, % of people with endometrial hyperplasia that have it
A
8% (dime)
22
Q
Complex with atypia, % of people with endometrial hyperplasia that have it
A
*29% (quarter)
23
Q
Risk factors for endometrial hyperplasia
A
unopposed estrogen!, increasing age, unopposed E2 therapy, tamoxifen, early menarche, late menopause, nulliparity, PCOS, obesity, diabetes, E2 tumor, lynch syndrome, cowden syndrome, family history
24
Q
Endometrial carcinoma,
Type I
A
-endometrioid histology, grade 1,2**
-good prognosis, usually can find this early and low grade (pt comes in when they are bleeding- know this is abnormal)
25
Q
Endometria carcinoma,
Type II
A
-non-endometrioid histology, or grade 3 endometrioid
(Serous, Clear cell, Mucinous, Squamous, Transitional Cell, Mesonephric, Undifferentiated)

-NOT associated with endometrial hypoplasia, poor prognosis, aggressive, usually familial inheritance
26
Q
Coagulopathy
A
**Von Willebrand disease**= most common
-ITP
-Platelet function defect

CLINICAL: Patients who come in young- really, really heavy periods, mom has really heavy period, gums bleed when they brush their teeth
27
Q
Ovulatory Dysfunction: Primary hypothalamic-pituitrary dysfunction
A
-Sheehan’s syndrome
-Pituitary adenoma/other tumor
-Lactation
-Stress
-Eating disorders
-Exercise
-Peri-Menopause** (happens 2-6 yrs before menopause)
-Autoimmune diseases
-Empty sella syndrome
-Kallman’s syndrome
-Idiopathic hypogonadotropic hypogonadism
-Hypothalamic/pituitary tumor, trauma or radiation
28
Q
Ovulatory Dysfunction: Other
A
-Polycystic ovarian syndrome (PCOS- ABNORMAL CYCLES- heavy bleeding, have follicles but nothing is ovulating, no dominant follicle, doesn’t happen every month- lots of androgens= obese, baldness, etc)
-Hyperthyroidism/hypothyroidism
-Adrenal or ovarian tumors
-Liver or renal disease
-Cushings disease
-Congenital adrenal hyperplasia
-Premature ovarian failure
-Turner syndrome
-Androgen Insensitivity syndrome
29
Q
Peri-menopause
A
not having functional ovulation every cycle, in between you have abnormal growth of endometrium and you’re not having a period, when you DO get a period everything comes out at once
30
Q
Treatment for ovulatory dysfunctions
A
1. NSAIDS- Start with NSAIDS- block prostaglandins involved with menses
2. Progestins
3. Combined oral contraceptives
4. GnRH agonists
5. Estrogen
31
Q
Progestins to treat ovulary dysfunction
A
1. Medroxyprogesterone acetate (Depo-provera; giving yourself exogenous progesterine lets you control your cycle, make it noormal)
2. Norethindrone acetate
3. Levonorgestrel-releasing IUD (good for everything, used a ton)
32
Q
Combined oral contraceptives to treat ovulary dysfunction
A
-Normal
-High dose (bleeding heavily, 3 pills for 3 days, stabilizes lining quickly, but patient that can’t go to surgery/borderline for surgery)
33
Q
GnRH agonists to treat ovulary dysfunction
A
-Depot leuprolide (not great for controlling abnormal ovulatory cycle, cant use long term)
34
Q
Estrogen to treat ovulatory dysfunction
A
High does intravenous (makes endometrium grow, but at a rate that makes it stop bleeding)
35
Q
Endometrial
("E" of COEIN)
A
-confusing term (when you rule everything out, maybe something local is going on)
-Endometritis (ascending bacterial flora from vaginal canal)
-PID
-Local endometrial hemostasis disorders
36
Q
Iatrogenic
A
1. Birth control:
-Copper IUD (no hormone, no control over cycle, can make periods heavier and more painful, if pt comes with this complaint, tx is to take out copper IUD)
-OCPs
-Progestin (only contraceptive, pills, shots, IUD, can cause light abnormal spotting, metorrhagia)
2. Menopausal hormone therapy
3. Steroids
4. Drugs that can cause
37
Q
Drugs that cause hyperprolactinemia
A
-Antipsycotics, antidepressants, antiemetics, antihypertensive

-Metoclopramide, prochlorperazine, methyldopa, verapamil, amitriptyline, haloperidol, risperidone

CLINICAL: Pt on weird meds with abnormal vaginal bleeding- think of meds causing the problem
38
Q
N of "COEIN" stands for
A
Not yet classified (diagnosis of exclusion)
39
Q
What to check for during physical exam
A
-Excessive weight
-Signs of PCOS, thyroid disease or insulin resistance
-Pelvic exam: Cervical, vulvar or vaginal lesion, Uterine size, Adnexal masses, Pain
40
Q
Labs to run during premenopausal workup
A
1. PREGNANCY TEST
2. CBC
3. Thyroid function
4. Cervical cytology +/- culture
5. +/- coagulation studies (depends on s/s)
41
Q
Imaging for premenopausal workup
A
**Transvaginal ULTRASOUND** BEST IMAGING
-Saline Infusion
-Sonohysterography (SIS)
-Hysteroscopy
-+/- MRI
42
Q
Who gets tissue sampling as part of work up?
A
45 yo: ANY abnormal bleeding

-Dilation and Curettage, endometrial biopsy, +/- cervical biopsy
43
Q
Differential for postmenopausal bleeding plus 1 major rule
A
**ALWAYS INVESTIGATE (ALWAYS get a biopsy)

-Atrophy** (most common cause)
-Hyperplasia
-Carcinoma
-Hormonal therapy
-Atrophic vaginitis
-Trauma
-Polyps
-Uterine prolapse and friction ulcers
-Blood dyscrasias