ABNORMAL UTERINE BLEEDING

Diagnosis of Secondary Amenorrhea: __________ to rule out pregnancy & check _________ levels

Beta-HCG = beta human chorionic gonadotropin TSH and prolactin

Fibroids are muscular tumors that grow in the wall of the uterus. AKA _________ Fibroids are almost always benign. Fibroids can grow as a single tumor, or there can be many of them in the uterus.

"Leiomyoma"

EVALUATION OF MENORRHAGIA:

1. CBC 2. PELVIC ULTRASOUND 3. THYROID STUDIES 4. CLOTTING FACTORS: Especially for teens 5. PAP 6. ENDOMETRIAL BIOPSY - IF INDICATED > AGE 45 YRS

Other causes of postmenopausal bleeding:

1. Endometrial hyperplasia, endometrial polyps, estrogen secreting ovarian tumors. 2. Use of exogenous hormone replacement therapy.

Treatment of Dysfunctional Uterine Bleeding = DUB:

1. Hormonal OCP = estrogen/progestin, Nuvaring, Patch. 2. CI to estrogen ie: hx HTN, DVT --> Mirena, Depo, Implanon. 3. D&C: Dilation and curettage is a procedure to remove tissue from inside your uterus/endometrial ablation 4. Hysterectomy: reserved for refractory cases

Causes of Primary Amenorrhea: Outflow tract anomalies

1. Imperforate Hymen: occurs during fetal development, a solid membrane across the vaginal introitus. 2. Transverse vaginal septum: failure of the upper and lower vagina to fuse - requires surgery resection 3. Vaginal Agenesis: No patent vagina

Causes of Secondary Amenorrhea: Ovarian Failure

1. Ovarian torsion, surgery, infection, radiation or chemo 2. POF: premature ovarian failure - menopause occurring before the age of 40 without other identifiable diagnosis/cause.

Causes of Primary Amenorrhea: Central Disorders

1. Pituitary Disorder - rarely a cause of amenorrhea --> Causes include surgery or irradiation of pituitary tumor. 2. Hypothalamic Disorders - SUPER RARE --> Kallmann Syndrome, which is congenital absence of GnRH; Compression or destruction of the pituitary secondary to a tumor, sarcoidosis and irradiation; Defects in GnRH pulsatility - Anorexia, athletics, hypothyroidism, rapid weight loss.

Evaluation of AUB: History

1. Timing of bleeding 2. Quantity of bleeding: pads/hour 3. Menstrual history 4. Family History --> bleeding disorders

General Exam: systemic illness, thyroid exam, acanthosis nigricans, hirsutism: male pattern facial/body hair & associated with PCOS, galactorrhea = hyperprolactemia), bruising, petechiae = bleeding disorder

Evaluation of AUB: Pelvic Exam

A patient with a bleeding disorder would likely present with menorrhagia at menarche. Other symptoms collected in the history might include: easy bruising, bleeding gums, excessive bleeding after surgical procedures or childbirth. Labs would include CBC, PLT, PT/PTT, factor VII, and von Willebrand factor Ag.

Heavy cycles

BetaH CG/UPT, TSH, CBC: H & H to dx anemia, elevated WBC's with infection; Evaluation for bleeding disorder with clinical suspicion; 15-24% of women presenting with this will have some type of bleeding disorder

Heavy cycles

Causes of Secondary Amenorrhea: _____________ Prolactin release is inhibited by dopamine and stimulated by seratonin and thyrotropin releasing hormone.; Medications include: dopamine agonists: haldol, reglan; TCA's, opiates can increase prolactin levels; Prolactin secreting adenoma; Pregnancy / breastfeeding

Hyperprolactinemia: a condition of elevated serum prolactin. Prolactin is a 198-amino acid protein (23-kd) produced in the lactotroph cells of the anterior pituitary gland. Its primary function is to enhance breast development during pregnancy and to induce lactation.

regular menses, light flow

Hypomenorrhea = also known as short or scanty periods, is extremely light menstrual blood flow. It is the opposite of hypermenorrhea or menorrhagia.

Causes of Secondary Amenorrhea: ___________ Stress, exercise, anorexia, weight loss

Hypothalamic-Pituitary Axis imbalance

Imaging - AUB: Direct visualization of the endometrial cavity

Hysterscopy

Beta HCG/UPT, TSH, PRL, FSH = suspected PMOF or menopause; Androgen levels = PCOS

Light Cycles: Beta HCG is not always available. Ok to do a UPT and send a beta HCG regardless of UPT results. A positive UPT would prompt a beta HCG because the diff dx now includes ectopic pregnancy and spontaneous abortion.

Imaging - AUB: Second line after pelvic ultrasound

MRI = expensive, second line after u/s: Diagnose fibroids vs adenomyosis.

the onset of menstruation.

Menarche

excessive and prolonged bleeding at irregular intervals.

Menometrorrhagia = a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of metrorrhagia and menorrhagia.

heavy > 80ml/cycle or prolonged > 7 days regular interval

Menorrhagia or hypermenorrhea = menstrual periods with abnormally heavy or prolonged bleeding.

bleeding between regular menses, usually lighter than regular bleeding = inter menstrual bleeding

Metorrhagia = metro = womb, -rrhagia = excessive flow = uterine bleeding at irregular intervals, particularly between the expected menstrual periods. In some women, menstrual spotting between periods occurs as a normal and harmless part of ovulation.

Treatment AUB and HMB: medical management = option for patients who wish to avoid hormone therapy:

NSAIDs: NSAIDS reduce menstrual blood loss by reducing prostaglandin synthesis --> vasoconstriction and reduced bleeding.

Mean 28 days = range 21-35 days Duration of menses average 3-5 days = bleeding 30-50ml/cycle

Normal menstrual cycle

Common Causes of Hypomenorrhea: Patients on:

OCP, Depo and Mirena IUD

Treatment AUB and HMB: 1ST LINE medical management:

OCP/IUD mirena: OCP can be rx'd as cyclic, extended or continuous.

infrequent, irregular bleeding > 35 days apart

Oligomenorrhea; oligo = few

Causes of Primary Amenorrhea: End organ disorders

Ovarian failure - lack of estradiol seen with Turner Syndrome, which is 45XO short stature, wide webbed neck, shield shaped chest, absent menses and infertility.

Causes of Secondary Amenorrhea: Stein-Leventhal Syndrome, which is also called _________ - anovulation, oligomennorrhea/amenorrhea, hirsutism, obesity, enlarged polycystic ovaries.

PCOS = Polycystic Ovarian Syndrome: anovulation leads to increased levels of estrogen and androgen

Most common cause of ________: endometrial/vaginal atrophy. Vaginal atrophy - due to lack of estrogen. Usually presents with small amount of bleeding. Patients complain of vaginal dryness, soreness, and dyspareunia = difficult or painful sexual intercourse.

POSTMENOPAUSAL BLEEDING

Profuse or continuous vaginal bleeding or the presence of a blood stained, offensive discharge is an ominous sign and can indicate cervical or endometrial malignancy.

POSTMENOPAUSAL BLEEDING

This is always abnormal!!!

POSTMENOPAUSAL BLEEDING

Vaginal Bleeding after menopause

POSTMENOPAUSAL BLEEDING

Postmenopausal Bleeding - Diagnosis: first tests include:

Pap Smear, Digital Rectal Exam with occult blood.

Causes of Secondary Dysmenorrhea: _________ - history of pelvic infections, such as cervicitis, PID, pelvic surgery. Pain associated with activity.

Pelvic Adhesions

Postmenopausal Bleeding - Diagnosis: After pap smear, DRE with occult blood, endometrial biopsy:

Pelvic Ultrasound Hysteroscopy D & C = Dilation and curettage, which can be diagnostic and therapeutic

Imaging - AUB: First line =

Pelvic Ultrasound (U/S) = First line: Identify polyps, fibroids, hyperplasia, cancer, masses

frequent regular cycles < 21 days apart

Polymenorrhea; poly = many

Most common cause of Secondary Amenorrhea:

Pregnancy

Women who have not undergone menarche by age 16 Women who have not menstruated 4 years after thelarche (female breast development).

Primary Amenorrhea = Prevalence 1-2%

Occurs from menarche

Primary Dysmenorrhea

Presents in young women in their late teens. Generally associated with anovulatory cycles, symptoms present when cycles become ovulatory.

Primary Dysmenorrhea

The cause is not well understood, but prostaglandins, which can cause uterine contractions and vasoconstriction, have been implicated. Rare cases demonstrate anatomic abnormalities.

Primary Dysmenorrhea

Primary Dysmenorrhea is commonly misdiagnosed as endometriosis, how do we tell them apart?

Primary Dysmenorrhea: pain during days 1 and 2 of cycle Endometriosis: Pain 1-2 weeks before menstruation and relieved with menstrual flow

Treatment AUB and HMB:

Primary etiologies include fibroids and adenomyosis. Although surgery is an option many prefer medical management as an initial treatment method.

Diagnosis of Secondary Amenorrhea: if normal prolactin level:

Progesterone challenge: evaluates the adequacy of estrogen production. Withdrawal bleeding indicates the presence of estrogen and a patent outflow tract. Absence of withdrawal bleeding requires re-treatment with estrogen and progesterone - no bleeding = evaluate outflow tract. -bleeding = intact uterus with inadequate estrogen.

the appearance of sexual hair.

Pubarche

Absence of menstrual cycles for 3 cycles or a total of 6 months in women who have previously menstruated.

Secondary Amenorrhea

Occurs in women who previously had normal periods and generally secondary to an identifiable cause ie: endometriosis, cervical stenosis, pelvic adhesions

Secondary Dysmenorrhea

Progesterone challenge: If the patient experiences bleeding after the progestin,

She has estrogen present but is not ovulating = anovulation.

the onset of female breast development.

Thelarche

Treatment - AUB: Uterine Fibroids -

Uterine Fibroids - Myomectomy/Hysterectomy

Evaluation of AUB: Pelvic Exam --> Abnormal findings along the genital tract ulceration, mass, discharge vaginal/cervical, FB.

Uterus size --> Enlarged: Pregnancy, fibroids, malignancy Bleeding --> Bleeding from the os, clots Adenexal Mass/Tenderness Pap Smear = screen for cervical dysplasia, Cervical Culture --> to rule out infection GC/Chlamydia)

Evaluation of AUB: Physical Exam Verify source of bleeding --> Rule out ______

Verify source of bleeding --> Rule out rectal, urethral bleeding.

Will previously have had normal periods. Symptoms are secondary to an identifiable cause.

Women with secondary dysmenorrhea

Diagnosis of Secondary Amenorrhea: If both TSH and prolactin levels elevated: treatment =

Treatment for hypothyroidism and monitor prolactin levels

Treatment of Primary Dysmenorrhea:

Treatment of Primary Dysmenorrhea: First Line: NSAIDS = ibuprofen, naproxen Second Line: OCP's, patch, ring * Non-medical relief: heating pads, exercise, massage

pain and cramping during menstruation that interferes with normal activity.

Dysmenorrhea

Pain and cramping with menstruation. Common during adolescent years.

Dysmenorrhea: can be primary or secondary

Primary Dysmenorrhea Diagnosis:

Diagnosis: H&P and the absence of identifiable cause.

Diagnosis of exclusion Made if no pathologic cause of AUB is determined. Cycles are primarily anovulatory.

Dysfunctional Uterine Bleeding = DUB

Estrogen is produced by the ovary although no corpus luteum is formed and subsequently no progesterone is released. The endometrium with continue to thicken without progesterone induced bleeding and eventually slough off.

Dysfunctional Uterine Bleeding = DUB

Is usually described as cramping pain that often radiates into the back or the upper thighs.

Dysmenorrhea

AUB is present despite treatment or in the presence unopposed estrogen exposure, seen with obesity and chronic anovulation ie: PCOS. Peripheral conversion of androgens to estrogen in adipose tissue contributes to increased estrogen exposure

< 45 years with AUB - consider - Endometrial Biopsy

Common causes of AUB - Menorrhagia or Heavy Menstrual Bleeding - HMB:

Common causes: uterine fibroids, endometrial polyps, adenomyosis, IUD = Paraguard

Endometrial Biopsy to rule out endometrial hyperplasia/cancer

ALL women > 45 year of age with AUB

Mass at the inner lining of the uterus. Can be penduculated. Bleeding from a blood vessel associated with the _____ can contribute to HMB. They are most commonly associated with intermenstrual bleeding but may also present with HMB.

AUB - Endometrial Polyps

Regular menses with light flow

AUB - Hypomenorrhea

Causes: uterine fibroids, adenomyosis, endometrial polyps, hyperplasia and cancer

AUB - Menometrorrhagia

excessive or prolonged bleeding at irregular intervals. AND GO BY THEIR AGE

AUB - Menometrorrhagia

Patient reports "gushing/clots". Number of pads per hour > 1 / 2 hours.

AUB - Menorrhagia or Heavy Menstrual Bleeding - HMB

Regular Cycles with either heavy flow > 80mL or long duration > 7 days.

AUB - Menorrhagia or Heavy Menstrual Bleeding - HMB

bleeding between regular periods

AUB - Metrorrhagia

periods > 35 days apart Causes: Common: PCOS, pregnancy

AUB - Oligomenorrhea

frequent periods (< 21 days apart) Common Cause: Anovulation

AUB - Polymenorrhea

Treatment - AUB: Adenomyosis, which is a condition in which endometrial tissue exists within and grows into the uterine wall:

Adenomyosis - Hormonal regulation = estrogen/progesterone, endometrial ablation which will stop from proliferating, hysterectomy

the onset of androgen-dependent body changes such as growth of axillary and pubic hair, body odor, and acne.

Adrenarche

This can be a normal feature in pre-pubertal, pregnant, and postmenopausal females. In females of reproductive age one must first evaluate the patients pregnancy status.

Amenorrhea

the absence of menses: primary or secondary

Amenorrhea; a = without

Common cause of Hypomenorrhea:

Anorexia, athletes --> Hypogonadotropic hypogonadism

Treatment - AUB: Anovulation -

Anovulation - menstrual regulation Hypothyroidism: treat with Synthroid and restore ovulatory cycles.

Diagnosis of Secondary Amenorrhea: If elevated prolactin level only:

Careful H & P including all medications. MRI to r/o hypothalamic/pituitary tumor.

Cause of Hypomenorrhea: Also can be seen in patients with cervical stenosis

Cause of Hypomenorrhea: Also can be seen in patients with cervical stenosis

Causes of Secondary Dysmenorrhea: ________ - obstructs blood flow during menstruation Patient may complain of light periods with severe cramping.

Cervical Stenosis

Causes of Secondary Amenorrhea, Anatomic Abnormalities:

Cervical Stenosis: Scarring at the cervical os secondary to surgical trauma

Treatment - AUB: Cervical polyps -

Cervical polyps - Polypectomy (in office)

Treatment AUB and HMB: medical management = Expectant management for those who are not anemic:

Check H and H every 12 months.

Progesterone challenge: If no withdrawal bleeding occurs,

Either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae, or adhesions, or cervical stenosis, or scarring).

< 45 years with AUB - consider - ___________

Endometrial Biopsy

Postmenopausal Bleeding - Diagnosis: ___________ evaluate for endometrial Cancer

Endometrial Biopsy

Treatment - AUB: Endometrial Hyperplasia -

Endometrial Hyperplasia - Progesterone therapy, D&C

accounts for 10% of postmenopausal bleeding.

Endometrial cancer

MUCH Less common causes of AUB - Menorrhagia or Heavy Menstrual Bleeding - HMB:

Endometrial hyperplasia/carcinoma --> POSTMENOPAUSAL WOMEN = IF BLEEDING, THEN YOU SHOULD BE CONCERNED THAT PATIENT HAS CANCER

Treatment - AUB: Endometrial polyps -

Endometrial polyps - polypectomy

Causes of Secondary Dysmenorrhea: Uterine: ___________ VERY COMMON AND THEY BLEED

Endometriosis, uterine fibroids