Vaginal Bleeding

Question 1

In any woman with vaginal bleeding

Answer 1

Rule out pregnancy

Question 2

Don’t forget it bleeding while pregnant in T1

Answer 2

Establish location of pregnancy + bloodwork B-hCG, hemoglobin, WBC,
Rh (ABO) for winrho if needed. In study book give it if 7weeks pregnant or more
STI screen
And don’t forget vital signs to exclude shock due to bleeding or septic abortion

Question 3

Differentials for AUB

Answer 3

Pregnancy (ectopic)
Trauma
Infection
Systemic (HypoT4/hyperprolactemia/cushings/PCOS/adrenal/Hypothalamic suppression/stress)
Iatrogenic/medication eg anticoagulants/hyperprolactinemia - antipsychotic/antidepressants
AUB -PALM —> structural
Polyp
Adenomyosis
Leiomyoma
Malignancy

Question 4

Investigation in AUB

Answer 4

CBC (Hb)
B-hCG (serum + 9 days after conception - urine + 28 days after LMP)
TSH, prolactin
Blood type and screen
Coags: vWF, fibrinogen (history of menorrhagia)
Iron studies
Gono/Chlam (cevicitis)
Cervical cancer screening (as per guidelines)
Endometrial sampling if
>40 yo

Question 5

Risk factor for AUB

Answer 5

Obesity, PCOS, nulliparity, DB
HNPCC (Lynch syndrom 40-60% endometrial CA)

Question 6

Acute Management of AUB in non-pregnant women

Answer 6

Conjugated equine estrogen 25 mg IV q4-6h x 24h (consider antiemetic due to SE of N/V)
Combined OCP TaiD x 7d
medroxyprogesterone acetate 20mg TID x 7d
TXA 1g PO/IV TID x 5d
Procedure: D&C / endometrial ablation/ uterine artery embolization/hysterectomy

Treat underlying pathology
Correct anemia (iron replacement)

Question 7

Treatment of AUB w heavy menstrual bleeding

Answer 7

Mirena
Combined OCP
Progestin
Tranexamic, NSAIDs
Expectant if not anemic or tx not desired

Question 8

AUB treatments for those w ovulatory dysfunction

Answer 8

Mirena
Combined Oscar
Progestin