Gyn 9: DUB COMPLETED
PCB tx for endocervicitis?
(pelvic inflammatory disease may be treated differently-protocols constantly changing due to resistant strains) -GC: Rx cefuroxime1000 mg PO x1 chlamydia: RX Zithromax 1 g PO x1
Other disorders commonly causing DUB has to do with?
-Alterations in the life span of the corpus luteum. -Luteal phase insufficiency
PCB tx for Vaginal condyloma:
-Biopsy; Rx 5-FU cream or cryotherapy
PCB tx for Fragile ectropion
-Exclude cervical intraepithelial neoplasia (CIN); cryotherapy
Name 3 Causes of anovulation related to hormones
-Hyperandrogenic anovulation:PCOS, adult onset Adrenal Hyperplasia (AH) -Hypothalmic anovulation: stress, weight loss -Hyperprolactinemia
Trauma/Foreign Body may cause irregular bleeding, how?
-Laceration of vaginal wall (sexual abuse) -Laceration of hymeneal ring -Vaginal foreign body *Most common cause of premenarchal bleeding
tx of DUB: minimal bleeding (a few days duration)
-Provera (MPA)10 mg PO QD x10 days or Prometrium 200 mg x 14 days (check peanut allergy)
PCB tx for endometritis
-Rx Doxycycline 100 mg po bid x14 days
reasons IUD may cause irregular bleeding?
-Side effect: menorrhagia -PID -Pregnancy (IUP or ectopic) -Perforation, expulsion
Progestin-containing contraceptives, bleeding often d/t? tx?
-bleeding often due to endometrial atrophy [reassure bleeding is possible SE] -Treatment: supplementary estrogen
Anticoagulants that may be the cause of bleeding:
-over-anticoagulation with coumadin [check INR], heparin: menorrhagia [not common, most women on this are postmenopausal] -therapeutic levels, without bleeding problems
avg iron loss: (in mg?)
16mg
Up to what % of women will experience irregular cycles in their lifetimes?
20%
leiomyomas occur in what % of women of reproductive age?
20%
Endometrial ablation indications and what is it?
Abnormal uterine bleeding unrelated to malignancy Conservative surgical approach in which only the lining of the uterus is destroyed or removed. Endometrial ablation is not intended to replace hysterectomy, but offers women another choice for treatment of abnormal uterine bleeding.
Treatment design based on site of bleeding in perimenopausal bleeding. [she totally skipped this]
Atrophic vaginitis: Topical estrogen -Endometrial hyperplasia: continuous Progesterone x 3-6 months, then re-biopsy -Endometrial atrophy: due to hypoestrogenism resulting in thinning of surface that is prone to bleeding Try cyclic or continuous HRT
What is next step after determining they are hemodynamically stable and they don't need to go to ED?
Baseline CBC, quantitative BHCG [actual number, helpful if worried about someone miscarrying] Coagulation panel Suspect in teens with menorrhagia TSH, PROLACTIN Recurrent anovulatory bleeds Can also do Pap smear Biopsy of suspicious lesion Check for STD's
Are leiomyomas benign or malignant?
Benign smooth muscle tumors of the uterus Rarely malignant
Post-coital Bleeding definition
Bleeding during or after intercourse
PCB cervical and vaginal exam.
Cervical Examination: -Friability of ectropion, leukoplakia or warts, mucopurulent discharge, endocervical polyp Vaginal Examination -Epithelial or urethral lesion, foreign body Pap Smear (if not done in 6 months) Test for GC, chlamydia Possible EMB if at risk for endometrial hyperplasia, if bleeding is heavy or recurrent *If endometrial biopsy is negative, consider SIS or hysteroscopy
Pelvic Infection/Inflammation abnormal bleeding of the cervix can be d/t what?
Cervix -Mucopurulent cervicitis (GC,chlamydia) -Benign ectropion [columnar epithelium coming out of os]
if suspect coagulopathy in a pt iwth menorrhagia, what should you be thinking of and want to check
Clotting factor deficiency -Liver disease-cirrhosis -Congenital (Von Willebrands Disease, factor deficiency, platelet abnormality) Thrombocytopenia -ITP, aplastic anemia with platelet count < 20,000/mm3
Systemic diseases that can cause irregular bleeding?
Coagulation disorders: platelet deficiency platelet function defect prothrombin deficiency Hypothyroidism Liver disease: Cirrhosis Chronic renal failure Malnutrition Stress
tx of recurrent DUB
Combination OCP's: one tablet per day for 21 days Intermittent progestin therapy: Medroxyprogesterone acetate 10mg per Day1-10 days of each month -Prolonged use of high doses associated with fatigue, mood swings, weight gain, lipid changes
note on hormone induced anovulation
Compartments intact, hormones not synchronous Normal (or high) estrogen levels Patients will experience progestin withdrawal bleeding due to Estrogen-induced priming of endometrium
tx of DUB: Extremely heavy bleeding:
Conjugated Estrogen (Premarin) 25 mg IV Q6H x 4 doses, then progesterone or surgical curettage
Leiomyomas
Corpus Neoplasms - Submucous myoma(fibroid)-the most common pelvic tumor in woman can cause menorrhagia - Leiomyosarcoma Can cause post-menopausal bleeding - Adenomyosis-endometrial glands infiltrating the uterine wall-benign Can cause dyspareunia, dysmennorhea, chronic pelvic pain
a word on danazol and GnRH agonists
Danazol: Androgenic steroid -200mg and 400 mg daily doses for 12 weeks Androgenic side effects: weight gain, acne GnRH agonists treatment results in medical menopause blood loss returns to pretreatment levels when d/c use add back therapy to prevent bone loss secondary to marked hypoestrogenism
what do leiomyomas come from?
Develop from smooth muscle cells Cause for growth is unknown [estrogen sensitive, but bot caused by estrogen]
tx of DUB: surgical options.
Dilation and Curettage: Quickest way to stop bleeding in patients who are hypovolemic appropriate in older women (>35) to exclude malignancy but is inferior to hysteroscopy Ablation: [have to be done having kids] Microwave ablation Electromagnetic ablation Thermal balloon ablation Novasure Hysterectomy
pathophys of anovulatory DUB?
Due to continuous E2 production without corpus luteum formation and progesterone production. The main cause of DUB is anovulation resulting from altered neuroendocrine and/or ovarian hormonal events.
Post coital bleeding (PCB) Ddx
Endocervical infection (GC,Chlamydia) Cervical or vaginal warts Friable ectropion Neoplasia (invasive): Vaginal, cervical, endocervical, or endometrial Endometritis (acute or chronic) Polyp: Endocervical or endometrial Vaginal foreign body; urethral lesion
a word on Malignant Pelvic Masses
Endometrial Neoplasm -Adenomatous hyperplasia(AH)->Atypical AH>Endometrial Ca Presentation: peri- or post- menopausal bleeding, Metrorrhagia from chronic anovulation -Endometrial polyp-benign Presentation: postcoital bleeding (PCB) or intermenstrual bleeding (IMB) age 30-50 Cervical Neoplasm -Squamous cell or adenocarcinoma Vaginal Neoplasm -Squamous cell ca, clear cell [related to diethylstilbestrol (DES)], -Childhood tumors
What kinds of Malignant pelvic lesions can cause abnml bleeding?
Endometrial hyperplasia Endometrial cancer Cervical cancer Less frequently: -vaginal,vulvar, fallopian tube cancers -estrogen secreting ovarian tumors -granulosa-theca cell tumors
Pelvic Infection/Inflammation abnormal bleeding of the endometrium can be d/t what?
Endometrium -postpartum [nml to bleed 6wks postpartum], postabortal endometritis -endometritis associated with PID
in perimenopausal women, you always need to consider doing what bc their risk of endometrial cancer increases after age 40?
Evaluate endometrium -Endometrial biopsy (EMB) -Endovaginal ultrasound (endometrial stripe < 5mm) -Saline ultrasound
if ablation doesn't work, what is the definitive surgical procedure?
Hysterectomy
What is the most common indication for pelvic surgery in women?
Leiomyomas
Benign pelvic lesions
Leiomyomata Endometrial or endocervical polyps Adenomyosis and endometriosis Pelvic infections Trauma Foreign bodies (IUD, sanitary products)
Preg test POS, then what do you want to know?
Location [if not in uterus, want to do something about that today] •Viability •GA Dating
Step 3 (adolescents):
Low risk for intracavitary or cancerous lesion High coagulopathy risk: coagulation profile -if abnormal, further testing and consultation is warranted TSH, Prolactina If screen is normal, diagnosis of anovulatory DUB is assumed and appropriate therapy begun
What's Luteal Phase Defect?
Luteal phase lasting 7-10 days (normally 14 days) or inadequate peak luteal phase levels of progesterone [imp if women desire fertility or if they want less freq periods-->put on OCP]
Iatrogenic causes of irregular bleeding?
Medications: Anticoagulants-menorrhagia Tranquilizers Antidepressants, Antipsychotics-anovulation Digitalis Dilantin HRT, oral contraceptives Chronic use of methadone or opiates steroids [MC] Medications, Trauma, IUD's
Amenorrhea definition
No bleeding for at least 3 cycles or 6 months
Ddx of abnormal uterine bleeding
Non-organic -DUB Organic -Systemic Disease -Iatrogenic causes -Reproductive tract disease
DUB evaluation: Hx
Onset, frequency, duration, cyclic vs.acyclic Molimenol symptoms (only in ovulatory cycles) Pain, change in menstrual pattern Age, parity, marital status, sexual hx, contraception medications, dates of pregnancies symptoms of pregnancy reproductive tract disease H/O menstrual disorder, dyscrasia,endocrinopathy
lateral pelvic massess
Ovary Normal premenopausal ovary - 3x2x1.5cms Early Menopausal ovary - 2x1.5x0.5cms Postmenopausal ovary - 1.5x0.75x0.5cms
What would be top of differential if on PE you find: BMI > 30, acne, hirsutism
PCOS
how do pts present with DUB?
Patients present with "abnormal uterine bleeding"
point of DUB evaluation slide: [in notes section]
Point of this slide is there are many questions that need to be asked Does she have sxs of infection Bleeding from multiple sights Symptoms of hypothyroidism etc... Cervical cultures and gram stain should be obtained Inspection of the vagina identifies trauma, severe infections, atrophy, foreign bodies Inspection of the cervix may identify polyps, erosions, cancerous lesions A symmetrically enlarged uterus may suggest adenomyosis if not pregnant A uterus with asymmetric contours may suggest fibroids
Presentation of luteal phase defect?
Polymenorrhea-frequent but regularly timed Episodes of bleeding with a cycle length of <21days
central pelvic massess ddx
Pregnancy Leiomyomata - uterine fibroids Endometrial malignancy or uterine sarcoma Ovarian or other laterally located masses may present centrally Bladder
May see Hegar's and Chadwick's sign in pts who are ??
Pregnant. Bimanual exam: uterine enlargement Hegar's sign: (softening of the cervical isthmus, the portion of the cervix between the uterus and the vaginal portion of the cervix) -Check for Adnexal masses -Speculum exam: Chadwick's sign (bluish appearance to vaginal mucosa caused by increased blood flow.)
coagulopathy, what may the presentation be?
Presentation may be menorrhagia
Step 6 (Adults):
Proliferative endometrium or hyperplasia without atypia -assume DUB -manage according to desired fertility Hyperplasia with atypia or CA -treat accordingly [Adults with bleeding, who are not pregnant, and whose biopsy reveals proliferative endometrium or simple hyperplasia without atypia most likely have anovulatory DUB]
Menorrhagia (hypermenorrhea) definition
Prolonged duration of menses (>7 days) and/or Increased amount of bleeding (> 80 ML) occurring at regular intervals
Stepwise approach to abnormal bleeding, step 1?
Rapid assessment of vital signs: Hemodynamically stable?
Leiomyomas: Indications for Hysterectomy
Rapid enlargement of the uterus may mean possible malignancy Abnml uterine bleeding not responding to other methods of tx, may -> anemia Pelvic pain, secondary dysmenorrhea Urinary sx's Uterine growth after menopause Patient has completed childbearing If uterus is < 12 weeks size, vaginal hysterectomy. can also do laparoscopic supracervical hysterectomy (LASH), Robotics
When do leiomyomas or fibroids typically occur? when do they grow larger?
Rarely occur before menarche or after menopause Grow larger during pregnancy
Step 5 (Adults):
Secretory endometrium: >50% have polyp or submucosal fibroid Do Saline Ultrasound (SIS) or dx hysteroscopy -lesion present: biopsy/excision -lesion absent: R/O systemic disease
tx of DUB: acute bleeding for missed physiologic luteal phase
Substitute a pharmacologic luteal phase
If someone (ie. adolescent) has an immature HPO axis, what do you do?
These patients respond ideally to progestins. Regular cyclic withdrawal bleeding can be induced until maturity of the positive feedback mechanism occurs. Therapy: Progestin therapy 10 days every month or every other until full maturity of the axis provides effective therapy Low dose OCP's
With ovulation the size of the follicle about to rupture can be as large as 2.5cms. Total ovary may be how big mid-cyle? Any cyst larger than ? hanging off the ovary needs further investigation
Total ovary may be 6cms at mid-cycle! any cyst > 3cms needs further investigation
Step 4 (Adults):
Transvaginal ultrasound [preferred over trans abd US] Lesion present? biopsy, hysteroscopy No lesion: High risk for neoplasia: endometrial biopsy
Leiomyomas: Symptoms
Usually asymptomatic Symptoms increase as tumors grow Common symptoms: pelvic pressure, bloating, pelvic congestion, feeling of "heaviness", urinary frequency, dysmenorrhea, dyspareunia, menorrhagia May report infertility Pregnant women complain more of pain
Pelvic Infection/Inflammation abnormal bleeding of the vagina can be d/t what?
Vagina -Atrophic vaginitis, severe trichomonas, bacterial vaginosis
Tx of Luteal Phase Defect?
When unexplained infertiliy: If desires pregnancy: treat with clomiphene + progesterone
Can Pregnancy cause abmml bleeding?
Yes. [can have implantation bleeding] Spontaneous abortion (SAB): Retained products of conception Ectopic Pregnancy: Spotting 2o to fluctuating estrogen and progesterone levels leading to withdrawal bleeding Gestational Trophoblastic Neoplasms: (molar pregnancy) [abmnl levels of HCG, not a viable pregnancy] Placental polyp !Complications of pregnancy are the MCC of abnormal bleeding in reproductive age women; should be considered until proven otherwise bc several of these conditions can be life threatening.!
Abdomen: pain,uterine enlargement, what would be first on differential?
[fibroids, pregnancy, PID?, ectopic or TOA]
Lateral Pelvic Masses: ddx
[ovarian cysts] Pelvic kidney PID with tubo-ovarian abscess Ectopic pregnancy GI causes Crohn's Disease Diverticuli GI neoplasm
Breasts: galactorrhea, what would be first on differential?
[prolactinoma, prolactin >20 then consider prolactinoma]
Ovulatory DUB occurs most commonly after _____ and before _____?
after the adolescent years and before the perimenopausal years.
The main cause of DUB is :
anovulation resulting from altered neuroendocrine and/or ovarian hormonal events. In premenarchal girls, FSH > LH and hormonal patterns are anovulatory. The pathophysiology of DUB may also represent exaggerated FSH release in response to normal levels of GnRH (Gonadotropin-releasing hormone). After menarche, normal adult FSH and LH patterns eventually develop with mid-cycle surges and E2 peaks.
Two types of DUB:
anovulatory and ovulatory
What is the MCC of DUB in adolescents?
anovulatory cycles d/t (maturing hypothalamic-pituitary axis)
most are of what type?
anovulatory. Most women with DUB do not ovulate.
define dysfunctional uterine bleeding (DUB)
as ABNORMAL uterine bleeding with no demonstrable organic cause, genital or extragenital.
DUB evaluation: tests
based on H + PE findings
Intermenstrual bleeding definition
bleeding of variable amounts occurring between regular menstrual periods
DUB is most frequently associated with ?
chronic anovulation (In women with DUB secondary to anovulation, endometrial blood flow is variable and follows no orderly pattern)
Tx of DUB goals:
control bleeding prevent recurrence preserve fertility correct associated conditions induce ovulation in patients who want to conceive
Dx of Luteal Phase Defect?
endometrial biopsy (EMB) >2days out of phase of cycle
Tx of DUB, medical management is preferred initial tx before surgery, such as?
estrogens, progestins [OCP usu first choice] NSAID's [for pain] antifibrinolytic agents [not usu used as much] danazol GnRH agonists [depends on age, desire to return to fertility]
Polymenorrhea definition
frequent but regularly timed episodes of bleeding with a cycle length of <21days (opposite of oligomenorrhea)
What are common sx's of DUB?
heavy menses, prolonged menses, or frequent irregular bleeding.
NSAIDs usu used in conjunction with?
hormone therapy NSAID's: Cyclooxygenase inhibitors inhibits prostacyclin formation First 3 days of menses. Treatment results in a sustained reduction in blood loss so side effects tend to be mild Most effective in ovulatory DUB
[take home for coagulopathy?]
in teenagers c/o heavy periods, ask FH and do coagulopathy w/u Congenital factor deficiencies mainly in teenagers with menorrhagia since menarche Thrombocytopenias -Easy bruising, bleeding gums, slow to clot -Suppress menses with oral progestins (e.g. continuous OCs) until platelets increase
Leiomyomas in Pregnancy
interfere with fetal growth and nutrition increase the risk of: spontaneous abortion during the first and second trimesters & preterm labor
Classification of leiomyomas are based on what?
location submucous - protrude into the uterine cavity intramural - within the myometrial wall subserous - growing toward the serous surface of the uterus intraligamentous - located in the cervix or in between the folds of the broad ligament
Oligomennorhea definition
menstrual bleeding with cycles that are > than 35 days apart occurring at regular intervals
tx of DUB: moderate bleeding (>3days)
monophasic oral contraceptive BID-TID x 5-7 days
what demographics are more likely to get leiomyomas?
most often occurs among African American nulliparous women women older than 35 nonsmokers oral contraceptive
nml cycle length range ? abnml:?
nml: 21-35d abnml: <21d, >35
nml menstrual period volume is how many cc's? abnml?
nml: 30-35cc abnml: >80cc [can look on tampon box to see how much mL's a super holds, etc]
nml mensturual period lasts how long? and its abnormal if it lasts how long?
nml: 4-6d abnml: <2d, >7d
Leiomyomas: Physical Exam
normal bowel sounds enlarged uterus that is firm and irregular but not tender may be mistaken for adnexal mass if situated laterally if mass moves with the uterus, likely to be a leiomyoma [measure the uterus in weeks, above pubic symphysis is 12wks, naval at 20wks]
Leiomyomas: Differential Diagnoses
ovarian neoplasm tubo-ovarian inflammatory mass diverticular inflammatory mass pregnancy ectopic pregnancy adenomyosis pelvic kidney malignancy
if Preg test neg, want to know if they have ?
ovulatory or anovulatory cycles
DUB evaluation: PE tests
pelvic exam pap smear
age-related anovulatory bleeding:
peri-menarche, perimenopause
androgen excess anovulatory bleeding can be caused by:
polycystic ovary syndrome (PCOS)
prolactin excess anovulatory bleeding can be caused by:
prolactinoma, medication
DUB occurs most often when in life?
shortly after menarche and at the end of the reproductive years. -50% of cases in 40-50 year olds
what can be the cause of DUB in perimenopausal women?
the mean length of the cycle is shorter compared to younger women. Shortened follicular phase -Diminished capacity of follicles to secrete Estradiol
estrogen excess anovulatory bleeding can be caused by:
unopposed endogenous or exogenous estrogen
Hypomenorrhea definition
unusually scanty menstrual bleeding lasting for less than two days. Menses occur at regular timed intervals
Metrorrhagia definition
uterine bleeding at irregular intervals, particularly between the expected menstrual periods
Postmenopausal bleeding (PMB) definition
uterine bleeding that occurs more than one year after the last menstrual period.
Menometrorrhagia definition
uterine bleeding, prolonged and occurs at completely irregular intervals
Leiomyomas aka
uterine fibroids
Is DUB a dx of exclusion?
yes