Dysfunctional Uterine Bleeding

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Define: Amenorrhea

Absence of menses for 6 months or longer

What is a common cause of DUB in adolescents and Premenopausal women? MOA?

Anovulatory Cycles MOA: 1.) LH surge and ovulation is immature 2.) Rising estrogen levels from developing follicle leads to endometrium proliferation and decreased FSH 3.) Corpus Luteum does not form in an anovulatory cycle resulting in a failure to secrete progesterone 4.) Unopposed estrogen stimulates overgrowth of the endometrium 5.) Endometrium outgrows blood supply resulting in necrosis and irregular sloughing of the endometrium 6.) Estrogen promotes healing of endometrium so some parts are always healing as others slough 7. Resulting in Menometrorrhagia (Excessive, Irregular bleeding)

What is the last resort but viable option for a women who does not desire child bearing?

Hysterectomy

In perimenopausal / postmenopausal women, what should always be first considered?

Malignancy until proven otherwise

What are examples of DUB caused by a Systemic Illness?

Menometrorrhagia - Hypothyroidism - Cushing's Disease - Adrenal Hyperplasia (21 OH- Deficiency) - Prolactinoma - Liver or Renal Disease - Leukemia - Infections: PID - Pregnancy: Spontaneous abortion/ectopic pregnancy

What are examples of DUB caused by Iatrogenic bleeding?

Menometrorrhagia - Oral Contraceptives - Depot Medroxyprogesterone Acetate - Postmenopausal Hormone Therapy - Anticoagulants - Herbal Supplements

Ovulatory DUB presents as what? MOA

Menorrhagia MOA: Unknown 1.) Prostaglandin E2 leads to increased fibrinolytic activity 2.) Ovulating women have prolonged progesterone secretion (lowering estrogen levels) 3.) Causes Irregular Shedding of the uterine lining and break-through bleeding

DUB in perimenopausal women is related to what?

Ovarian Function: There is an increase variability of the menstrual pattern in women approaching menopause

Define: Menometrorrhagia

Prolonged or Excessive uterine bleeding occurs at irregular and more frequent than normal intervals

Define: Menorrhaga

Prolonged or excessive uterine bleeding occurring at regular intervals

What procedure is most commonly used to treat heavy bleeding from fibroids, gyne malignancies or post partum hemorrhage?

Uterine Artery Embolization

Define: Polymenorrhea

Uterine Bleeding occuring at regular intervals of less than 21 days (cycle length <21 days)

Differentiate a Uterine Polyp from Uterine Fibroids

Uterine Polyp: Relatively small, made of endometrial tissue, soft and malleable, may regress at some point Uterine Fibroids (Leiomyoma or Myoma): May grow up to the size of watermelon, is a benign tumor, made up of hard muscle tissue of uterus, Does not regress

Define: Oligomenorrhea

Uterine bleeding at intervals > 35 days to six months (Cycle length > 35 days)

Define: Metrorrhaga

Uterine bleeding occurring at irregular and more frequent than normal interval

What does a Uterine Sarcoma arise from?

Uterine cancer arising from the stroma or myometrium of the uterus

What Pertinent PE findings would be found in a patient with DUB?

- Vitals: Access for Orthostatic hypotension due to excessive blood loss - BMI - Visual Field Testing: Evaluate visual field loss due to a pituitary tumor (Prolactinoma) - Thyroid Exam: Evaluate for Hashimoto's - Look for signs of PCOS: Hirsutism, Acne, Obesity - Look for Signs of Coagulopathy: Bruising, Gum, or nose bleeding - Look for signs of Systemic Illness: Hepatomegally, Splenomegally, Fever - Evaluate Abdomen for masses: Enlarged Liver, palpable mass: gravid, ovarian tumor

When is a Myomectomy performed?

Fibroid Resection for female patients who wish to retain fertility

What can a Diverticulitis Rupture cause?

Fistulization to the uterus

What is Dysfunctional Uterine Bleeding?

- Abnormal Endometrial bleeding in the absence of pelvic or systemic disease - Can be characterized clinically by amount, duration, and frequency

What are you looking for during a Bimanual exam in a patient with suspected DUB?

- Adenexal or ovarian mass - Cervical motion Tenderness - Is the uterus enlarged, pain on papation

When should an endometrial ablation be performed?

- Alternative to hysterectomy - Used to cauterize the lining of the uterus with electricity - Used to ablate the lining of the uterus - minimally invasive - pts have much lighter periods following procedure

What Medications can cause DUB?

- Anticoagulants - Antipsychotics - Corticosteroids - Contraceptives - Hormone Replacement Therapy - SSRIs - Tamoxifen - Herbal Supplements: Black Cohash, Soy (Contain Plant estrogens)

What are the causes of DUB?

- Bleeding Associated with uterine pathology - Dysfunctional uterine bleeding (DUB) without anatomic abnormalities - Bleeding with a systemic illness - Iatrogenic Bleeding

What pertinent information should be obtained in a patient's work up with suspected DUB?

- Bleeding Patterns (Duration, Quantity, Associated with intercourse) - Associated Symptoms (fever, pain, alterations in bowel or bladder function) - Current Medications - Herbal Supplements - Family history of bleeding disorders/coagulopathies - Sexual history: Evaluate possibility of pregnancy, history of STD's

What is Abnormal Uterine Bleeding?

- Bleeding excessively or occurs outside the normal cycle - More than 7 Days of Bleeding

What are the risk factors for endometrial cancer?

- Chronic Anovulation (prolonged exposure to unopposed E2) - Nulliparity - Tamoxifen Use - Personal or FHx of Breast/Ovarian Cancer - Unopposed estrogen use (Estrogen therapy alone in menopause)

What should be used to treat postmenopausal women?

- Cyclic HRT - Continuous Combined HRT: Daily Prempro

What should be performed if a patient's endometrial biopsy is non-diagnostic or inconclusive?

- Dilation and Curettage * Allows more extensive sampling of uterus * Imperative for the gynecologist to know the locations of the polyp to adequately remove them using dilation and curettage

What procedures should be performed on a patient suspected of PUD? Why?

- Endometrial Biopsy: indicated in all women with DUB who are 40 years of age or older, since their risk of developing malignancy is much higher * Sample taken from Uterus Lining - Hysteroscopy: used to view lining of the uterus (endometrium) when the endometrial biopsy is inconclusive or non-diagnostic * Can detect abnormalities such as polyps, fibroids, and uterine septae * Biopsies from uterine lining can be easily taken through the hysteroscope

What is the purpose of a Pap Smear when evaluating a patient for DUB? What additionally should be done during the PAP smear?

- Evaluate Cervical Cytology - to r/o cervicitis/ cervical dysplasia - Swab for N. Gonorrhea/Chlamydia - Should Biopsy any visible lesions - Check for previously inserted intrauterine device (IUD) used for contraception

What Labs Tests should be performed when performing an initial work up for DUB? What does each result mean?

- HCG: r/o pregnancy - CBC: r/o anemia/infection/iron deficiency - FSH: Value great than or equal to 23 IU/ml is consistent with menopause - TSH/ FT4: r/o Hypothydroidsim - Testosterone Level: r/o PCOS, Adrenal Dysfunction (21 OH Deficiency) - Prolactin level: Rule out Prolactinoma - Progesterone Level: r/o 21 Hydroxylase Deficiency, Ovarian tumors, or Adrenal tumors - LFTs: if alcoholism or hepatitis is suspected, any condition affecting liver metabolism of estrogen can be associated with abnormal uterine bleeding

What should be used to treat Perimenopausal women?

- Medroxyprogesterone to regulate bleeding - Oral Contraceptives (Contraindicated in women older than 35 y/o who smoke)

What should be given to a patient in attempts to slow uterine bleeding by constricting the uterine vasculature, reducing prostaglandins, and improving platelet aggregation?

- NSAIDs - Mefanamic Acid (Ponstel) 500 mg TID po during menses

What should be used to treat Anovulatory Bleeding?

- Oral Contraceptives: Regulates cycles while providing contraception * Medroxyprogesterone regulates cycle and can protect against endometrial hyperplasia due to withdrawal bleed * Clomiphene can induce ovulation in women who desires pregnancy

What should be included in the External Pelvic Exam when having a patient with suspected DUB?

- Tanner Stage - Hymen Characteristics - Clitoral Size - Signs of Infection or Trauma

What imaging should be performed for a patient with suspected PUD? Why?

- Transvaginal Ultrasound - This allows visualization of the endometrial cavity for polyps or fibroids and endometrial thickness

What can cause Premenarchal Children?

- Trauma - Sexual Abuse - Foreign Bodies - Precocious Puberty - Infection

What are examples of DUB caused by Uterine pathology?

"Heavy bleeding, regular cycle (Menorrhagia) - Endometrial polyps - Adenomyosis: Endometrial tissue within uterine muscle - Endometrial Hyperplasia - Uterine Cancer - Cervical Cancer

Define: Intermentrual bleeding

"Spotting" - uterine bleeding between regular menstrual periods

Define Adenomyosis

Benign condition where endometrial glands invade the myometrium

What can bladder cancer cause?

Bleeding

What can urethritis cause?

Bleeding that may be difficult to differentiate from vaginal bleeding

What can hemorrhoids cause?

Bleeding that may be difficult to distinguish from uterine bleeding

What are examples of - Dysfunctional uterine bleeding (DUB) without anatomic abnormalities

Heavy Bleeding, Irregular Cycle (Menometrorrhagia) - Polycystic Ovarian Syndrome (PCOS): Hypothalamic dysfunction due to hyperandrogenism -Anorexia (Causing Hypothalamic Dysfunction): BMI of 17% is needed to start menses - Excessive Exercising - Menarche or Perimenopausee

What may an Endometrial Infection be caused by?

Cervical Stenosis

When treating a patient for DUB, what should be r/o early?

Cervical and Uterine Cancers

Normal Menstruation Cycle

Day 1-5: Menstrual Flow (Cessation of Progesterone Production) Day 6-14: Menstrual flow ceases due to rising estrogen produced by developing ovarian follicle, causing endometrial proliferation Day 15-28: Endometrium increases in thickness

What is the purpose of a Speculum Exam in a patient with suspected PUD?

Direct visualization of cervix and vaginal vault, identify source of bleeding (vaginal/rectal/urethral)

Define Adenocarcinoma

Endometrial Cancer

Women older than 40 or younger women with a history of anovulation need a(n) ____________

Endometrial Evaluation


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