Abnormal Uterine Bleeding

Menometrorrhagia:

Heavy, prolonged flow at irregular intervals

Oligomenorrhea:

Infrequent menses Decreased, scanty flow; regular cycle length >35 days

Metrorrhagia:

Irregular menses; bleeding at irregular intervals (subway/metro is irregular)

Abnormal Uterine Bleeding Treatment: -Pain treatment, how much, why?

NSAIDS -REDUCE PROSTAGLANDIN SYNTHESIS -REDUCE MENSTRUAL CRAMPING AND BLOOD LOSS IBUPROFEN 600MG EVERY 6 HOURS OR 800MG EVERY 8 HOURS THE FIRST 3 DAYS OF CYCLE

Environmental factors that can effect CNS and menstrual cycle?

Stress, exercise, diet, travel (impact CNS, hypothalamus, CNHR, Anterior pituitary, FSH/LH, Ovary, E/P, Uterus and thus menses)

When evaluating "what is normal" consider __ and __

what is within normal limits and what is normal for the patient

most common cause of a bleeding pattern that is suddenly different from a woman's established menstrual pattern is?

"In women of reproductive age, the most common cause of a bleeding pattern that is suddenly different from a woman's established menstrual pattern is a complication of pregnancy, including threatened or incomplete abortion, ectopic pregnancy, retained products of conception, and gestational trophoblastic disease" =Always exclude pregnancy first!

Endometrial biopsy indicated for? (4) -can do...

-(1) WOMEN OLDER THAN 35 WHO PRESENT WITH IRREGULAR BLEEDING, (2) WOMAN WHO APPEAR TO HAVE ANOVULATORY BLEEDING (3) WITH PCOS, (4) ON TAMOXIFEN AND PRESENTING WITH VAGINAL BLEEDING -Transvaginal u/s FIRST AND THEN IF ENDOMETRIUM IS >4MM DO EMB

Differential Diagnosis of Abnormal Uterine Bleeding: -Early postmenarchal (6)

-Anovulation -Bleeding diathesis -Stress -Pregnancy -Infection -PCOS

Differential Diagnosis of Abnormal Uterine Bleeding: -Reproductive Year (8) *2 to consider with Adolescents

-Anovulation -Pregnancy (*w/adolescents) -Cancer -Polyps, fibroid, adenomyosis -Infection -Endocrine dysfunction (PCOS, thyroid, pituitary adenom) -Bleeding disorders (*Von Willebrands) -Medication-related (OCP, antipsychotic)

Adolescents: Abnormal Uterine Bleeding: -Think __ after you have ruled out __. Often due to ?

-Anovulation, pregnancy -Immaturity of HPO axis

Abnormal Uterine Bleeding Treatment: Tranexamic acid -MOA -Effective in... -Dose

-BLOCKS LYSINE BINDING SITES ON PLASMINOGEN, PREVENTING PLASMIN AND FIBRIN POLYMER INTERACTION - STABALIZES CLOTS AND REDUCES BLEEDING -EFFECTIVE IN IDIOPATHIC HEAVY MENSTRUAL BLEEDING -UNSCHEDULED BLEEDING WITH DMPA (Depo) AND IUDS -1300MG 3X A DAY FOR 5 DAYS

Abnormal Uterine Bleeding: -Lab tests -If irregular menses? -If you suspect PCOS

-CBC w/platelets, FSH/LH with estradiol (ovarian reserve - may be premature peri-menopausal) -Thyroid function & prolactin -Androgen level & testosterone level

Differential Diagnosis of Abnormal Uterine Bleeding: -Neonate (8)

-Estrogen withdrawal -Premenarchal -Foreign body -Trauma, sexual abuse -Infection -Urethral prolapse -Ovarian and vaginal tumor -Precocious puberty

Endometrial Ablation: -Procedure used to treat -MOA

-Procedure used to treat dysfunctional or abnormal uterine bleeding. -destroys (ablates) the uterine lining, or endometrium with laser, heated baloon or saline, freezing, electricity ect. The endometrium heals by scarring, which usually reduces or prevents uterine bleeding.

Differential Diagnosis of Abnormal Uterine Bleeding: -Perimenopausal (3) -Menopause (3)

-Rule out endometrial cancer and pregnancy -Anovulation -Polyps, fibroid, adenomyosis -Cancer -Atrophy -Cancer -Estrogen replacement therapy

ENDOMETRIAL HYPERPLASIA

-get a biopsy to rule out cancer... It is not cancer, but in some cases, it can lead to cancer of the uterus. -Endometrial hyperplasia is characterized by a thickening of the endometrium that is more than the typical pre and post-menstrual build up of endometrial tissue. -The symptom most frequently associated with endometrial hyperplasia is heavy, extremely long, or continuous bleeding without large blood clots. Large blood clots are typical of fibroids, but not with endometrial hyperplasia.

-Endometrial polyps treatment -Fibroids treatment (4)

-polpectopmy for pre/postmenopausal women -Surgery (resection) if submuccosal -Mirena IUD -Uterine artery embolization ( SMALL PARTICLES TO OBSTRUCT ATHER ARTERIAL SUPPLY TO THE UTERUS - CAUSES ISCHEMIC DEGENERATION OF FIBROIDS) -Last resort: Hysterectomy

Abnormal Uterine Bleeding Treatment: Combined oral contraceptive appropriate for? (3) -2 alternative (same family) options?

1) OLIGOOVULATION 2) ANOVULATION (can do progesterone therapy 1st to complete shedding of endometrium, next COCP to regulate cycle) 3) MENORRHAGIA - TO REDUCE BLEEDING -LNG IUD, Depo

Average age of menarche: Normal cycle length: Average number of days of menses: Average age of menopause: Strongest correlation for age of onset of menses is?

Average age of menarche: 12-15 Normal cycle length: 21-35 days Average number of days of menses: 4-6 (2-8 is normal) Average age of menopause: 50-52 Strongest correlation for age of onset of menses is w/BMI: higher BMI, earlier menses

Intermenstrual bleeding:

Bleeding or spotting between nml menses

Postmenopausal bleeding: Post Coital Bleeding:

Bleeding that occurs more than 12 months after the last menstrual cycle bleeding or spotting after sex

Menorrhagia:

Heavy menses; increased amount and/or prolonged of flow occurring at regular intervals; loss of >80 mL of blood

Amenorrhea:

Absent menses for 6 months or absence of menstrual cycle for three cycles

Incidence of Abnormal Uterine Bleeding/Dysfunctional Uterine Bleeding or Anovulatory Uterine Bleeding -% women affected -% menorrhagia

50% women affected 30% menorrhagia Menorrhagia (and fibroids): account for 75% hysterectomies worldwide Most common complaint brought to clinicians by women

Adolescents: Abnormal Uterine Bleeding: __% OF MENSTRUAL CYCLES ARE ANOVULATORY IN THE FIRST YEAR AND __% ARE OVULATORY IN THE __ YEARS AFTER MENARCHE

85% 56% 4

Polymenorrhea:

Frequent menses; regular interval; cycle length <21 days

Define: -Abnormal Uterine Bleeding -Dysfunctional Uterine Bleeding or Anovulatory Uterine Bleeding

all encompassing dx- any uterine bleeding that is irregular in amount, frequency, duration, or timing Dx of exclusion - Abnormal bleeding for which no pelvic pathology or underlying medical cause is found Unrelated to pregnancy, systemic disease, medication, genital tract pathology