From Iusmicm

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Revision as of 01:03, 15 December 2011

Contents 1 Abnormal Uterine Bleeding 2 =Objectives 2.1 The Lawn (An analogy to remember) 2.2 Menstrual cycle 2.2.1 Terminology 2.2.2 Post-Menopausal Endometrium 2.2.3 DepoProvera Endometrium 2.2.4 Menstrual cycle 2.2.5 Anovulation 2.2.6 Endometrial Hyperplasia 2.2.7 Fibroids 2.2.8 Endometrial Polyp 2.2.9 Coagulopathy 2.2.10 Estrogen 2.2.11 Progesterone 2.2.12 How to distinguish between hormonal and anatomical abnormal bleeding? 2.2.12.1 History 2.2.12.2 Physical Exam 2.2.12.3 Comprehensive Differential 2.2.13 Medical Therapy 2.2.14 Surgical Therapy 2.2.14.1 Polypectomy: Weed Killer 2.2.14.2 Endometrial Curetting: Sod Cutting 2.3 Questions

Abnormal Uterine Bleeding

• Or "Mary, Mary, How does your lawn grow?"

=Objectives

• Understand Menstrual cycle
• Understand common causes of abnormal uterine bleeding
• Simplify abnormal uterine bleeding

The Lawn (An analogy to remember)

Menstrual cycle

• There are two major phases to the menstrual cycle: proliferative, secretory

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Terminology

• Dysfunctional uterine bleeding:
  • has classically been used to describe excessive noncyclic endometrial bleeding unrelated to anatomical lesions of the uterus or to systemic disease
  • it is a diagnosis of exclusion
• Think of dysfunctional uterine bleeding as anovulatory bleeding
  • Anovulatory bleeding is usually the primary cause.
• Anovulation may be related to a systemic medical disease or may be due to a variety of factors which affect the hypothalamic pituitary axis.

• Menorrhagia:
  • Excessive or prolonged menstrual bleeding.
  • Technically defined as blood loss greater than 80 mL per cycle and / or menstrual periods lasting longer than seven days.
• However, both patients and clinicians are unreliable in their ability to predict the amount of blood loss and measurement of actual blood loss is not practical in a clinical setting.
• In ovulatory women, menorrhagia is typically due to an anatomic lesion (eg, fibroid) or systemic disease (eg, hemostatic defect).
• Anovulation is also a common cause of menorrhagia.

• Metrorrhagia: light bleeding from the uterus at irregular intervals.
• Menometrorrhagia: heavy bleeding from the uterus at irregular intervals.

• Amenorrhea: absence of bleeding for at least three usual cycle lengths.
• Oligomenorrhea: bleeding that occurs at an interval greater than 35 days.
• Polymenorrhea: regular bleeding that occurs at an interval less than 24 days.
• Intermenstrual bleeding: bleeding that occurs between menses or between expected hormone withdrawal bleeds in women using some forms of hormonal contraception or hormone replacement therapy.

• Premenstrual spotting: light bleeding preceding regular menses.
• Post coital spotting: vaginal bleeding that is noted within 24 hours of vaginal intercourse.

Post-Menopausal Endometrium

DepoProvera Endometrium

Menstrual cycle

• The proliferative phase of the uterine cycle is concurrent with the follicular phase of the ovarian cycle.
  • Recall that estrogen dominates in the proliferative phase.
  • Recall that estrogen is trying to make the uterus an acceptable place for implantation.
• The secretory phase of the uterine cycle is concurrent with the luteal phase of the ovarian cycle.
  • Recall that progesterone (from the corpus luteum) dominates in the secretory phase.
  • Recall that progesterone is trying to make the uterus an acceptable place for the embryo to grow.

Anovulation

• Without ovulation, a corpus luteum is not made and progesterone levels are not elevated.
• Without progesterone, the "grass isn't cut"; that is, the endometrial secretory layer doesn't stop proliferating.

Endometrial Hyperplasia

Fibroids

Endometrial Polyp

Coagulopathy

Estrogen

Progesterone

How to distinguish between hormonal and anatomical abnormal bleeding?

• Hormonal:
  • Anovulation
  • Hyperplasia / Cancer
  • Postmenopausal
  • Thyroid dysfunction

• Anatomical
  • Polyps
  • Fibroids
  • Coagulopathy

• By the results of the workup!!
• By the response to treatment!!

History

• Intermenstrual Spotting
  • Think uterus: polyp, cervical cancer, IUD, infection
  • Think ovulation: drop in estrogen just before ovulation
• Regular, Heavy Bleeding
  • Think ovulatory with an anatomical issue (fibroids, polyps most common but don’t forget vWd)
• Irregular, Heavy Bleeding
  • Think anovulation (PCOS, thyroid most common)

Physical Exam

• Check Bowel / Bladder
• Check Vulva
• Check Vagina
• Check Cervix
• Feel Uterus
• Check Skin (Hair, Hump and Hirsutism)

Comprehensive Differential

• Uterus: fibroids, polyps, hyperplasia, cancer, adenomyosis, endometritis, anovulation
• Cervix: polyps, ectropion, endometriosis, cancer, cervicitis
• Vulva: skin tags, infections, cancer, trauma
• Vagina: atrophy, polyps, infection, trauma, cancer
• Systemic: thyroid, pituitary, PCOS, stress, smoking, coagulopathy, renal / liver disease, hormone secreting tumors, leukemia, platelet dysfunction.
• Drugs: Contraceptives, anticoagulants, steroids, chemotherapy, antipsychotics, dilantin

Medical Therapy

• Acute, Profuse Hemorrhage:
  • High Dose IV estrogen
• Chronic, Stable Hemorrhage:
  • High Dose Oral Estrogen
  • High Dose Contraceptives (Speroff)
  • High Dose Progesterone
  • NSAIDs
  • Mirena IUD
  • Lupron

Surgical Therapy

• Acute, Profuse Hemorrhage
  • D & C
• Chronic, Stable Hemorrhage
  • D & C
  • Hysteroscopy
    • Polypectomy
    • Resection
  • Ablation
  • Hysterectomy

Polypectomy: Weed Killer

Endometrial Curetting: Sod Cutting

Questions

• 67 yo AA female presents to you with postmenopausal bleeding.
• The most likely cause of her bleeding is?
  • Atrophic vaginitis
  • Atrophic endometrium
  • Anovulatory bleeding
  • Trauma
  • Endometrial cancer

• 27 yo AA female presents to you with postcoital bleeding.
• The most likely cause of her bleeding is?
  • Atrophic vaginitis
  • Cervical Bleeding
  • Anovulatory bleeding
  • Trauma
  • Endometrial cancer

• 27 yo AA female presents to you with irregular, heavy bleeding. She weighs over 300 lbs.
• The most likely cause of her bleeding is?
  • Atrophic vaginitis
  • Cervical Bleeding
  • Anovulatory bleeding
  • Trauma
  • Endometrial cancer

• 47 yo AA female presents to you with frequent, irregular, heavy bleeding. She weighs over 300 lbs.
• The second step of her evaluation is?
  • Ultrasound
  • CT scan
  • FSH and LH
  • TSH
  • Endometrial biopsy

• 47 yo AA female presents to you with frequent, irregular, heavy bleeding. She weighs over 300 lbs.
• The most likely cause of her bleeding is?
  • Atrophic vaginitis
  • Fibroids
  • Anovulatory bleeding
  • Endometrial Polyp
  • Endometrial cancer

• 47 yo AA female presents to you with regular, heavy bleeding. She weighs over 300 lbs.
• The most likely cause of her bleeding is?
  • Atrophic vaginitis
  • Fibroids
  • Anovulatory bleeding
  • Endometrial Polyp
  • Endometrial cancer

• Label the hormones.
  • Estradiol
  • Progesterone
  • Luteinizing Hormone
  • Follicle Stimulating Hormone

• Label the hormones.
  • Estradiol
  • Progesterone
  • Luteinizing Hormone
  • Follicle Stimulating Hormone

• Label the hormones.
  • Estradiol
  • Progesterone
  • Luteinizing Hormone
  • Follicle Stimulating Hormone

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• Label the hormones.
  • Estradiol
  • Progesterone
  • Luteinizing Hormone
  • Follicle Stimulating Hormone

• 25 yo Asian woman with new onset heavy, irregular menses presents to your office. Your history reveals almost daily bleeding that interferes with her ADL.
• Physical exam reveals a slightly overweight (BMI=29) woman with no abnormal physical findings.
• The most likely diagnosis is:
  • Fibroids
  • Anovulatory cycles
  • Polyp
  • Pemature ovarian failure
  • Endometrial Cancer

• A 70 yo white woman presents to your office from a nursing home with no complaints. No nursing home staff accompanied her to the office. You call the nursing home and speak with her PCA who tells you she noticed a small amount of blood in her diaper for

a few days last week.

• The most likely diagnosis is:
  • Urinary tract infection
  • Rectal cancer
  • Cervical cancer
  • Atrophic endometrium
  • Atrophic vaginitis