Dysfunctional Uterine Bleeding
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