Unit 4 > Topic 45: Normal and Abnormal Uterine Bleeding

A 35-year-old G2P2 comes to the office due to heavy menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow and duration. The periods are now interfering with her daily activities. The patient had two spontaneous vaginal deliveries. She smokes one pack of cigarettes per day. On pelvic examination, the cervix appears normal and the uterus is normal in size, without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, a 2 cm submucosal leiomyoma is noted. An endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. Which of the following would be the best therapeutic option for this patient if she desires to have another child? A. Hysteroscopy with myoma resection B. Laparoscopic myomectomy C. Endometrial ablation D. Oral contraceptives E. Dilation and curettage

Incorrect! Correct answer is A. Hysteroscopic myomectomy preserves the uterus, while removing the pathology causing the patient's symptoms. A laparoscopic approach is not indicated as the myoma is submucosal and not accessible using a laparoscopic approach. Endometrial ablation destroys the endometrium and can create Asherman's syndrome, thus it is reserved for patients who have completed childbearing. Dilation and curettage is unlikely to remove the myoma and is a blind procedure (carried out without direct visualization). Oral contraceptives would typically help with heavy menses, but are contraindicated in this patient, who is over 35 and smokes

A 34-year-old G2P2 presents with inter-menstrual bleeding for one year. The bleeding typically occurs two weeks after her menses and last two to three days. The symptoms began one year ago and the bleeding has not changed recently. She is currently taking oral contraceptives. On pelvic examination, the cervix appears normal and the uterus is normal in size and shape. Her urine pregnancy test is negative; an endometrial biopsy is negative for neoplasia. Which of the following tests or procedures would be indicated for further work-up? A. Prolactin level B. Progesterone level C. Hysterosalpingogram (HSG) D. Pelvic ultrasound E. Colposcopy

Incorrect! Correct answer is D. Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy. An ultrasound would be helpful as the next step in diagnosis. Although an hysterosalpingogram (HSG) might reveal structural abnormalities, it is too invasive for a next step. A colposcopy would not be helpful in the diagnosis, nor would obtaining a Prolactin level, as it would be indicated for the evaluation of anovulatory bleeding. Progesterone levels are not helpful in a patient on oral contraceptives.

A 35-year-old G0 presents with irregular menstrual periods occurring every six to twelve weeks with occasional inter-menstrual bleeding. Currently, she has been bleeding daily for the last four weeks. She reports that her periods have always been irregular, but have become more so with heavier flow and cramping in the last year. She is sexually active with one partner. On physical exam, she is morbidly obese with no abnormalities detected on pelvic exam. Which of the following is the most appropriate next step in the management of this patient? A. Luteinizing hormone level (LH) B. Follicle stimulating hormone level (FSH) C. Testosterone level D. Pelvic CT E. Endometrial biopsy

Incorrect! Correct answer is E. Endometrial biopsy should be performed to rule out endometrial hyperplasia or carcinoma given the history of irregular bleeding, coupled with the increased risk of these diagnoses in morbidly obese patients. While an ultrasound may be helpful, a pelvic CT is not useful in the workup for potential endometrial neoplasia. LH and FSH levels would not aid in the diagnostic workup and testosterone levels would not be useful, unless signs of hirsutism or virilization are present.

n 18-year-old woman comes to the office due to vaginal spotting for the last two weeks. Her menstrual periods were regular until last month, occurring every 28-32 days. Menarche was at age 13. She started oral contraceptives three months ago. On pelvic examination, the uterus is normal in size, slightly tender with a mass palpable in the right adnexal region. No adnexal tenderness is noted. Which of the following tests is the most appropriate next step in the management of this patient? A. Endometrial biopsy B. Pelvic MRI C. Pelvic sonography D. Abdominal CT Scan E. Urine pregnancy test

Incorrect! Correct answer is E. It is vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding. Sonography could be considered as a next step if the pregnancy test is negative in order to evaluate the adnexal finding. Abdominal CT or MRI would not be performed in this patient unless advanced adnexal pathology was found on pelvic sonography. Endometrial biopsy would rarely be indicated in a teen with abnormal bleeding, unless morbidly obese and anovulatory.

A 35-year-old G0 comes to the office because of six months of spotting between her periods and a desire for a pregnancy. She reports using 30 pads/cycle the last two months and has blood clots and cramping pain. Prior menses were light and required 15 pads/cycle. She has been trying to conceive for six months. Her work-up included a transvaginal ultrasound which revealed a 2 cm endometrial polyp. What is the next best step in the management of this patient? A. Hysteroscopic polypectomy B. Observation C. Combination birth control pills D. Endometrial ablation E. Hysterectomy

A Correct! Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice. Hysterectomy is reserved for women with polyps and premalignant or malignant changes.

A 32-year-old G0 presents with irregular menses occurring every six to eight weeks for the past eight months. The bleeding alternates between light and heavy. Her irregular menses were treated successfully with Medroxyprogesterone Acetate (MPA), 10 mg every day, taken for 10 days each month. By which mechanism does the MPA control her periods? A. Stimulates rapid endometrial growth and regeneration of glandular stumps B. Converts endometrium from proliferative to secretory C. Promotes release of Prostaglandin F2α D. Regenerates functional layer of the endometrium E. Decreases luteal phase inhibin production

B Correct! Patients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium. Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium. Inhibin is increased in the luteal phase.

A 36-year-old G0 presents due to increasing facial hair growth and irregular menstrual cycles. She has gained 40 pounds over the last three years. Her symptoms began three years ago and have gradually worsened. She has never been pregnant and is not currently on any medications. On physical exam, she is overweight with dark hair growth at the sideburns and upper lip. The pelvic exam is normal. Which of the following would you expect to find in this patient? A. Decreased luteinizing hormone levels B. Elevated free testosterone C. Decreased prolactin level D. Increased ovarian estrogen production E. Elevated 17-hydroxyprogesterone

B Correct! This patient likely has polycystic ovarian syndrome (PCOS). PCOS patients have testosterone levels at the upper limits of normal or slightly increased. Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production. Insulin resistance and chronic anovulation are hallmarks of PCOS. Prolactin levels may be elevated in amenorrhea but are not elevated in patients with PCOS.

A 14-year-old G0 adolescent reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Her previous medical history is unremarkable. The patient has a normal body habitus for her age. Appropriate breast and pubic hair development is present. Her hemoglobin is 9.1 mg/dl, hematocrit 27.8%, urine pregnancy test negative. Which of the following etiologies for menorrhagia is most likely the cause of her symptoms? A. Uterine leiomyoma B. Thyroid disorder C. Coagulation disorder D. Endometrial hyperplasia E. Chronic endometritis

C Correct! Disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common. Leiomyomas typically present in women in their 30s and 40s. Endometrial hyperplasia can occur in younger anovulatory patients, but the short duration of this patient's symptoms makes this less likely. She does not have any signs of infection or thyroid disease.

A 45-year-old G2P2 comes to the office because of heavy and irregular menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow over time. The periods are interfering with her daily activities. The patient has had two spontaneous vaginal deliveries, followed by a tubal ligation three years ago. On pelvic examination, the cervix appears normal and the uterus is normal in size without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, she has a normal size uterus and a 2 cm simple cyst on the right ovary. Endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. What is the most likely diagnosis in this patient? A. Polycystic ovarian syndrome B. Mid-cycle bleeding C. Abnormal uterine bleeding D. Benign cystic teratoma E. Ovarian cancer

C Correct! Dysfunctional uterine bleeding is defined as irregular or increased menstrual bleeding without identified etiology. This patient had a complete workup, including TSH, Prolactin, pelvic ultrasound and endometrial biopsy, which were all normal. Mid-cycle bleeding at the time of ovulation is due to the drop in estrogen. Ovarian teratomas are not associated with abnormal menses. They typically present with abdominal or pelvic pain which may be associated with torsion. The 2 cm cyst is a functional cyst and is a common finding in ovulatory patients.

A 41-year-old G3P3 reports heavy menstrual periods occurring every 26 days lasting eight days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every two hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient's complaint? A. Follicle stimulating hormone level B. Prolactin level C. Coagulation studies D. Pelvic ultrasound E. Hysteroscopy

D Correct! A pelvic ultrasound would image the endometrium and assess for endometrial pathology such as polyps or submucosal fibroids. In the absence of menopausal symptoms, FSH is unlikely to be helpful. The patient is unlikely to have a coagulation disorder, as she has had three spontaneous vaginal deliveries without postpartum hemorrhage. Hysteroscopy would not be helpful if the cause of abnormal bleeding is myometrial pathology such as intramural and subserosal fibroids or adenomyosis. Hyperprolactinemia is found with prolactin-secreting adenomas associated with amenorrhea.