Abnormal uterine bleeding (Gorey)
Terms in this set (76)
what is the interval of a normal menstrual cycle?
28 days +/- days
what is the duration of a normal menstrual cycle?
when is there more cycle variability?
5-7 years after menarche and 10 years before menopause
what do the follicular and luteal phase have to do with?
what do the proliferative and secretory phase have to do with?
Heavy menstrual bleeding; loss of > 80mL and/or increased duration of flow (>7 days) at regular intervals
Bleeding at irregular intervals or bleeding between periods
Increased loss or duration of bleeding occurring at irregular intervals
menstrual bleeding ocurring at < 21 day intervals
menstrual cycle length > 35 days
absence of menses, can be transient, intermittent, or permanent condition resulting from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina
- primary = absence of menarche by age 15
- secondary = lack of menstrual periods for more than 3 cycles or 6 months in previously menstruating female
Informal term for metrorrhagia that accompanies hormone administration
The predictable bleeding that results from the abrupt cessation of progesterone
Symptoms in the premenstrual/ luteal phase that indicate ovulation has occurred
These include ovulatory pain (Mittelschmerz), breast tenderness, bloating, and mood swings
Bleeding per vagina more than one year after final menstrual period (menopause)
A patient is complaining of excessive menstrual bleeding with 8 days of flow every 28 days. What is an acceptable term for this?
Heavy menstrual bleeding
what are uterine etiology of AUB?
what are medication etiology of AUB?
what are coagulation disorders that are associated with AUB?
von willebrands disease
what are systemic disorders associated with AUB?
what are the endocrine disorders associated with AUB?
estrogen producing tumors
what produces the most stable endometrium and the most reproducible menstrual characteristics?
E-P stimulation and withdrawal
what does E-P withdraw cause?
enzymatic degradation of an inflammatory response in the endometrium (bleeding)
what does progesterone withdrawal cause?
organized sloughing of functionalis layer
down to the basalis layer
spiral and basal artery vasoconstriction
and myometrial contractions
what does estrogen cause?
rising estrogen levels
cover up denuded basalis layer with new functionalis endometrium, limiting bleeding
what can progestin-only preparations cause?
atrophy of the functionalis layer of endometrium and
exposure of the capillaries of the spiral arteries
irregular spotting/ bleeding
what is the net affect of OCPs?
= causing bloating, constipation and weight gain
what can the copper IUD cause?
=> can breakthrough or intermenstrual bleeding
with too much progesterone
short term will correct this
what medications are associated with onset of
Corticosteroids, digoxin, propranolol, tricyclic antidepressants, phenothiazines, butyrophenones, major tranquilizers, MAO inhibitors
Tamoxifen= estrogen agonist (uterus) and antagonist (breast)
what medications and illness associated with
Hyperprolactinemia (physiologic and drug induced), thyroid, celiac, type 1 DM, PCOS, Asherman's syndrome
how can systemic diseases like liver and renal disease affect periods?
impair estrogen metabolism
and synthesis of clotting factors
too much estrogen =
feedback inhibition of pituitary hormones
A healthy 30 year old G2P2002 female presents to your office to discuss contraception and "something to help with my heavy periods". She is in a stable, monogamous relationship and her medical history includes migraine headaches with aura. What is the best option for her?
You had placed a Mirena IUD in a 28 year old patient for contraception and to control her heavy regular menstrual cycles. She tolerated the Mirena insertion well, came back for a string check 4 weeks later, and reported that her periods had significantly lightened. However, now she is coming to you 1 year after insertion complaining of spotting every day. After evaluating correct placement of the IUD and ruling out infection and pregnancy, you suspect the progestational effect has caused excessive atrophy of her endometrium. What can you offer her to help with her continuous spotting?
Leave the Mirena in place and give her 7-14 days of add-back oral estrogen
what are the causes of anovulation?
what is the pathophysiology of anovulation?
is produced when ovulation does not occur
prolonged periods of
leads to continued proliferation of the endometrium =>
unstable tissue and vasculature
how is anovulation diagnosed?
menstrual history = infrequent, irregular, unpredictable bleeding that varies in amt, duration, and character
no moliminal symptoms
A 49 year old female patient comes to your office complaining of irregular periods that began 6 months ago. She describes her previously normal, predictable bleeding pattern as changing to every 1-3 months with periods of spotting in between heavy menses. No other health problems, weight changes, no medications, and she is not sexually active x 2 years. What do you think is the most likely cause of her irregular bleeding?
Anovulation due to menopausal transition
what is the hyperprolactinemia effect?
prolactin blocks feedback of LH = anovulation is the net effect
You have an otherwise healthy G2P2002 28 year old patient who comes to your office because she has not had a period in 8 months. Before this, she states she had regular menses q month, lasting 5-6 days with moderate flow. bHCG in the office is negative. Past medical history is significant for bipolar disorder diagnosed this year and tonsillectomy. Denies any other symptoms, no significant family history, and she states she is in a monogamous relationship with her spouse with vasectomy used as contraception. What is the most likely etiology for her secondary amenorrhea?
what is the PCOS effect?
usually a genetic predisposition to excess ovarian androgen secretion => rising testosterone and LH levels causing
hirsutism (male pattern hair) => anovulation
elevated cholesterol and insulin resistance
how is PCOS diagnosed?
diagnosis of exclusion
= ovulatory dysfunction and hyperandogrenism
what is the rotterdam criteria for PCOS?
1) oligo or anovulation
2) clinical and/or biochemical signs of
3) polycystic ovaries
at least 2 out of 3
what are the short term consequences of PCOS?
Hirsuitism/ acne/ androgenic alopecia
Abnormal lipids/ glucose intolerance
what are the long term consequences of PCOS?
A 23 year old overweight patient comes to you complaining of irregular periods. She states that a few years after menarche, her periods would come every other to every 3 months at a time. She states that she hasn't had a period for 5 months now and is worried because that has never happened to her before. Medical history is unremarkable and physical exam is normal except for acne and hirsuitism. What is the first thing you want to assess in this patient?
For the previous patient, what is high on your differential diagnosis for her oligomenorrhea?
what are fibroids?
benign smooth muscle tumors arising for
what are fibroids sensitive to?
estrogen and progesterone
-- estrogen causes growth, progestins show both stimulatory and inhibitory effects
what are the characteristic of fibroids?
highly vascular = causes local dilation of venules and bleeding during menses can overwhelm hemostatis mechanisms
what are polyps?
fleshy overgrowths arising from
glands and fibrotic stroma
what are the risk factors for polyps?
what is the treatment of choice for polyps?
what is adenomyosis?
ectopic nests of endometrium
located deep within
= endometriosis inside the muscle
what are the symptoms of adenomyosis?
menorrhagia and dysmenorrhea
what are the risk factors of adenomyosis?
parity and age
90% of cases are in parous women and 80% develop in women in their 40s-50s
not associated with OCP but more common in pts on tamoxifen
what are the adenomyosis findings?
increased AP diameter or one wall thicker than the other
myometrial heterogenicity, linear striations projecting from endometrium to myometrium
what are the important factors to ask in medical history?
age of menarche and menopause
menstrual bleeding patterns
severity of bleeding (clots, flooding)
symptoms and signs of hemostatic disorder
what should be included in past obstetric history (POBH)?
year they had their baby, type of delivery, weight of the baby, any complications in pregnancy and delivery
what is key to diagnosis?
menstrual history and onset of bleeding
what are the initial lab tests for diagnostic evaluation of AUB?
vaginitis panel (culture = chlamydia, gonorrhea, trichomonas, BV, yeast)
what are the imaging for diagnostic evaluation of AUB?
when should endometrial sampling be done?
prolonged amenorrhea (6-9 months)
prolonged oligomenorrhea (2-3 year)
age > 35
endometrial lining > 4 mm in menopausal pts
tamoxifen therapy with AUB
what is the
for inspection of endometrium?
hyesteroscopy -- can be done in the office or ambulatory surgery
positive result is accurate to diagnose cancer
what is the use of MRI in AUB?
expensive, not first line
used only for pelvic assessment as a follow up to US and only when it will give info that is not available on US
what is the use of CT in AUB?
expensive, not first line
used to evaluate the abdomen/pelvic in metastatic disease but has no role in routine pelvic assessment
what is the treatment for anovulation due to menopausal transition?
too much estrogen => progesterone
too much progesterone => estrogen
uterine artery embolization
what does a positive screening for hemostatic disorder include?
any one of the following:
- heavy menstrual bleeding since menarche
- one of the following: postpartum hemorrhage, surgery related bleeding, bleeding associated with dental work
2 or more of the following:
- bruising 1-2 times per month
- episwtaxis 1-2 times per month
- frequent gum bleeding
- FH of bleeding symptoms
what is the most common dyscrasia in adolescents with uncontrolled bleeding and the most common inherited bleeding disorder affecting women?
von willebrand disease
what is the treatment of vWF?
tranexamic acid (lysteda)
=> stabilizes intrauterine clot, reduces bleeding by 50%
, can be used when attempting pregnancy
NSAIDS and AUB
effective and well tolerated
reduces volume of menstrual blood loss
most effective for
if used within onset of menses or just prior to start of menses
anovulatory bleeding treatment
Levonorgesterol IUD (Mirena)
most effective treatment!
for anovulatory bleeding
progestin effect is primarily local => less systemic effects
approved for up to 5 years
contraindications of IUD
Severe uterine distortion
active pelvic infection
known or suspected pregnancy
unexplained uterine bleeding
current breast cancer
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