ABNORMAL UTERINE/VAGINAL BLEEDING

ETIOLOGY
A. Systemic Diseases
1. COAGULOPATHIES
2. Blood Dyscrasias
3. Endocrinopathy
4. DRUG Effects: Heparin, Warfarin, Salicylates
B. Traumatic Causes
1. Accidental injury
2. Foreign Bodies
3. Traumatic Coitus
C. Inflammatory
1. Vulvitis/Vaginitis
2. Cervicitis
3. Endometritis
4. Pelvic Inflammatory Disease
D. Pregnancy
1. ABORTION: Threatened, Inevitable, Complete, Incomplete
2. Ectopic Pregnancy
3. Molar-Trophoblastic Disease/ Gestational Trophoblastic Disease
E. Neoplastic
I. VULVA
Clinical Presentation
Diagnosis
Management

IRRITATION/ITCHING
BIOPSY (Keyes Dermal Punch)
Topical Testosterone
Corticosteroids
Local Excision
Laser Therapy

Etiology:
1. Squamous Cell Hyperplasia
2. Lichen Sclerosus
3. Intraepithelial Neoplasia
4. Pagets Disease

II. VAGINA
*Premalignant Disease
Clinical Presentation
Diagnosis
Mngt
Etiology:

ASYMPTOMATIC
Pap Smear, BIOPSY (Colposcopically guided)
Wide Excision, Laser Therapy

*Malignant Disease
Clinical Presentation
Diagnosis
Management

BLEEDING, DISCHARGE, PAIN

BIOPSY
Radiation
Radical hysterectomy & Vaginectomy
Radical Pelvic Surgery

Etiology:
1. Squamous Cell Carcinoma (90%)

2. Clear Cell Carcinoma

3. Malignant Melanoma

4. Endodermal Sinus Tumor (Yolk-Sac Tumor)

5. Embryonal Rhabdomyosarcoma (Sarcoma Botryoides)

III. CERVIX
SQUAMOCOLUMNAR JUNCTION cervical landmark for neoplastic change
Locations:
Young adults
EXOCERVIX near external os
Pregnancy/After Child Birth
DISTALLY located, away from os
Menopause
ENDOCERVICAL CANAL
POTENTIAL RF for CERVICAL NEOPLASIA
EPIDEMIOLOGIC
OTHERS
Early intercourse, marriage, child-bearing
Oral Contraceptives
Multiple Sex Partners
Smoking
Prostitution
Vitamin C, A, E, Folates
High-risk consort
Prior Radiation
Socio-economic Status
Intrauterine DES Exposure
Race
SLE
STD
Immune Status
INTRAEPITHELIAL Neoplasia
Diagnosis
Pap Smear (screening)
BIOPSY (endocervial curettage)
Colposcopy
Management
1. Repeat Smear in 4-6mos
2. Colposcopically guided Biopsy
3. Excisional therapy
4. Hysterectomy
5. Cryotherapy
6. Laser therapy
7. Electrocautery

VIRAL
HPV 16/18
Herpes Virus
CMV
HIV

MALIGNANT DISEASES
Clinical Presentation

Diagnosis
Management

ABNORMAL UTERINE BLEEDING (Brownish DISCHARGE)

Back PAIN
LOSS of apettite
WEIGHTLOSS
cervical punch BIOPSY
Radical/Extrafascial Hysterectomy
Bilateral Pelvic Lymphadenectomy
Radiation therapy
Chemotherapy

Staging
I
II
III
IV

cervix
beyond cervix but not beyond pelvic wall
beyond pelvic wall
beyond true pelvis

Etiology:
1. Squamous Cell Carcinoma (Large Cell, Small Cell, Verracous)

2. Adenocarcinomas (Typical, Endometrioid, Clear Cell, Adenoid Cystic, Adenoma malignum)

3. Mixed Carcinomas (adenosquamous, glassy cell)

IV. UTERINE CORPUS

RISK FACTORS
INCREASES
Unopposed estrogen stimulation
Unopposed Menopause HRT
Menopause after 52 yrs
Obesity
Nulliparity
Diabetes
Feminizing Ovarian Tumors (GCT)
PCOS
Tamoxifen (Breast CA tx)

DECREASES
Ovulation
Progestin therapy
COC
Menopause prior 49
Normal Weight
Multiparity

ENDOMETRIAL HYPERPLASIA
Traditional
WHO
Cystic
Simple
Adenomatous
Complex (adenomatous w/out atypia)
Atypical Adenomatous
Atypical (adenomatous w/ atypia)
Architectural Atypia
Cytologic Atypia
Clinical Presentation
ABNORMAL UTERINE/Vaginal BLEEDING
Diagnosis
Endometrial BIOPSY
Transvaginal UTZ
Management
D&C
Progestin
OC
Clomiphene Citrate
Weight Reduction
Hysterectomy

ENDOMETRIAL CARCINOMA
Clinical Presentation
Postmenopausal BLEEDING
Perimenopausal abnormal BLEEDING
Diagnosis

Pap Smear (50%)

Endometrial BIOPSY
Endometrial Curettage

Clinical Factors

Age, Race, Tumor Stage

Staging:
I
corpus
II
corpus + cervix
III
outside uterus
IV
outside true pelvis
Tumor grade, Histologic type, Uterine Size, Depth of myometrial invasion, Steroid
receptor hormone

Pathologic Factors

Management

TAH-BSO
Paraaortic & pelvic node sampling
Radiotherapy
Chemotherapy

Etiology:
Endometrioid ACA
Clear Cell CA
Serous
Mucinous
Squamous

V. FALLOPIAN TUBE
RISK Factors: Older age/Postmenopausal, Nulliparous, Infertility/Low Parity, Hx Pelvic infection
Clinical Presentation

Abnormal/excessive BLEEDING
Abnormal/excessive DISCHARGE
Lower abd pain
Adnexal Mass

Diagnosis (Primal tubal Ca)

1 tumor w/in tubal lumen

Tubal mucosa involved w/ tumor w/ papillary pattens
Transition bet. Malignant and nonmalignant epithelium\

Management

TAH-BSO
Omentectomy
Radiotherapy
Chemotherapy

VI. OVARY
Classification:
1. EPITHELIAL STROMAL

2. GERM CELL

3. SEX-CORD STROMAL
Ganulosa Theca Cell Tumors
1. Estrogenic (Precocious puberty, postmenopausal bleeding, Endometrial Ca)
2. Mngt: OOPHORECTOMY

4. LIPID CELL

5. GONDOBLASTOMA

F. Dysfunctional Uterine Bleeding

Either postpuberty, reproductive age, Perimenopausal
Anovulatory vs Ovulatory
Diagnosis
Menstrual Hx
Indirect Measurment of MBL (Hgb, Serum Fe & Ferritin)
Det. Presence of Ovulation
(Luteal phase progesterone, BBT, premenstrual sampling of endometrium)
Management
a. ESTROGENS rapid growth of endometrium
Sequential:
CE 10mg/d 4 divided doses
CE+MPA 10mg once a day for 7-10 days
Combination: 50ug 4 tabs q 24 hrs until 1 week after bleeding stops
b. PROGESTINS stops endometrial growth; support & organize endometrium
- For Anovulatory DUB
- MPA 10mg daily q 10days each month
c. NSAIDS prostaglandin synthesis inhibitors
Dec. MBL by 20-50% (Mef acid 500mg TID, Ibuprofen 400mg TID)
d. Antifibrinolytic Agents
- Dec. MBL in ovulating women
- S/E: nausea, diarrhea, abd pain, dizziness, headache, Allergies
- Tranexamic Acid
e. Androgenic Steroids
- Effective, expensive
- Weight gain, acne
- DANAZOL 200-400mg daily
f. GnRH agonists
- Expensive
- Limited use
g. Surgical Mngt
D&C
Diagnostic & therapeutic
Indication: Acute bleeding resulting in hypovolemia
Older women @ risk of endometrial neoplasia
Endometrial Ablation
Laser Photovaporization
Roller-ball electrocautery

Hysterectomy

SURGICAL MNGT of AUB/AVB

PROCEDURE
Operative Hysteroscopy
Myomectomy
Abd, Laparoscopic, hysteroscopic
Transcervical Endometrial Resection
Endometrial Ablation
Uterine Artery Embolization
Hysterectomy

Complications: fluid overload, uterine hemorrhage/perforation,

hematometra, thermal damage
persistent OVULATORY DUB

PURPOSE
Intracavity abnormalities
LEIOMYOMA
Tx Resistant menorrhagia/menometrorrhagia
Tx Resistant menorrhagia/menometrorrhagia
LEIOMYOMA
Atypical Hyperplasia
Endometrial Ca

EVALUATION of AUB/AVB
DIAGNOSTIC STEP

CONDITION
Hypothy

HISTORY

Hyperthy
Coagulopathy
Liver Disease
PCOS
Cervical Dysplasia
Endocervical Polyps
Pituitary Adenoma
Hypothalamic Suppression
Hypothy
Hyperthy

PE

Liver Disease
Pregnancy, Leiomyoma,
Uterine Cancer
Uterine Cancer
Ovarian tumor, ectopic
pregnancy, cyst
PID, endometritis

Imaging/Sampling

Hyperplasia, Atypia,
Adenocarcinoma
Pregnancy, ovarian/uterine
Tumors
Intracavitary lesions,
polyps, submucous fibroids
Intracavitary lesions,
polyps, submucous fibroids

Signs/Symptoms
Weight Gain, Cold Intolerance, Constipation,
Fatigue
Weight Loss, sweating, palpitations
Easy Bruising, tendency to bleed
Jaundice, Hx of Hepatitis
Hirsutism, Acne, Acanthosis nigricans, Obesity
Postcoital bleeding
Galactorrhea, headache, visual-field
disturbance
Weight loss, excessive exercise, stress
Thyromegaly, weight gain, edema
Thyroid tenderness, tachycardia, weight loss,
velvety skin
Bruising, Jaundice, hepatomegaly
Enlarged uterus
Firm, Fixed uterus
Adnexal mass
Uterine Tenderness, cervical motion
tenderness
Endometrial Biopsy
D&C
Transvaginal UTZ
Saline-infusion sonohysterography
Hysteroscopy

MENOPAUSE
PERMANENT CESSATION of menstruation caused by ovarian follicular failure w/ elevated gonadotrpins
CLIMACTIC PERIOD: Physiologic period where there is regression of ovarian function
PERIMENOPAUSE: Time bet. ONSET of menstrual irregularity and menopause
ENDOCRINOLOGIC CHANGES
1. Dec. INHIBIN
2. Inc. FSH
3. Inc. LH
4. Estrone to Estradiol ratio

st

1 index of declining ovarian function

peaks 2-3 yrs post-menopause
peaks 1 yr post-menopause
>1

PHYSIOLOGIC ALTERATIONS
1. Inc. BW, Total Body Fat
- Shift of fat from periphery to abdomen
- Inc. serum cholesterol, LDL, TG
- Dec. HDL
- Risk Factor for CVD: Atherosclerosis (Women: >50y/o)
2. Dec. Collagen
Effects:
Dermis
Cardinal/uterosacral ligaments
Vaginal wall endopelvic fascial tissue
Urethrovesical endopelvic fascial tissue
3. Atrophy of epithelium
Effects:
Vaginal Epithelium

Bladder Trigone & Urethra Epithelium

Skin Wrinkling
Uterine Descensus
Cystocel, Rectocele,Enterocele
Urinary Stress Incontinence

Senile/Atrophic Vaginitis
Sx: Itching, Burning, Discomfort,
Dyspareunia, Bleeding
Urinary Urge Incontinence, Urinary Frequency,
Dysuria, Nocturia

4. Alterations in Hypothalamic Thermoregulation

HOT FLUSH/HOT FLASHES
Inc. digital perfusion => Inc. peripheral Skin temp.
Inc. LH & NE (ACTH, Cortisol)
Inc. HR
Occurs @ night => leads to INSOMNIA
Abrupt, unpredictable
Duration: 30 sec to 5min
Effect: 2-3 yrs
5. Dec. Plasma B-endorphins & B-lipoprotein
Effects:
ANXIETY
DEPRESSION
IRRITABILITY
FATIGUE
MOOD SWINGS
6. Inc. rate of BONE RESORPTION
Leading to OSTEOPOROSIS: 1.5% loss each year (Trabecular > Cortical bone)
i. FRACTURES:
a. Spinal compression 60 y/o
b. Femural 70 y/o
c. Hip 80 y/o

ii. RF
White/Asian, Dec. Wt for Ht
Early/Surgical Menopause
FH of osteoporosis
Dec. Calcium & Vit. D Intake
Inc. intake of CAFFEINE, ALCOHOL, PROTEIN
Cigarette Smoking
DM
Hyperthyroidism, Cushing Disease
iii. Dx Tools:
DEXA (Dual-energy X-ray Absorptiometry
X-RAY
CT SCAN
DUAL PHOTON ABSORPTIOMETRY

TREATMENT REGIMENS
Estrogen
1. 0.625mg euine estrogen/estrone sulfate
2. 1mg micronized estradiol
3. 0.05mg transdermal estradiol
4. Vaginal cream/tablet
Estrogen+Progestin
1. Sequential: Estrogen daily + 5mg progestin days 10-14
2. Combined: Estrogen + 2.5mg progestin daily or 5x/week
Estrogen + Norethindrone
Calcium: Dietary calcium @ least 500-800mg daily
Vitamin D: 400-800 IU/day
Alendronate: 10 mg/day
Calcitonin: Nasal spray
Exercise: Brisk walking daily
*ADVERSE EFFECTS of Estrogen Replacement
a. Metabolic
Inc. Serum globulins
Angiotensin => inc. BP
Hypercoagulable state => THROMBOSIS
Acceleration of Cholelithiasis Formation
b. Neoplastic
BREAST CA => HRT >5yrs
Inc. ENDOMETRIAL CA (w/o progestin)
Dec. COLON/RECTAL CA (Dec. bile acid synthesis/secretion)
OVARIAN CA?
*CONTRAINDICATIONS to ESTROGEN THERAPY
BREAST/ENDOMETRIAL CA
Acute Thrombophlebitis
Undiagnosed Uterine Bleeding
Prior thromboembolic event assoc w/ exogenous estrogen
Active Liver Disease
*Estrogen/HRT should be used for the symptoms of menopause and smallest effective dose for shortest time

PRIMARY AMENORRHEA

SECONDARY AMENORRHEA

INFERTILITY

CONGENITAL ANOMALIES of FEMALE REPROD SYSTEM

OVARIAN TUMORS

PELVIC SUPPORT DISORDERS

URINARY INCONTINENCE

FEMALE GENITAL TRACT INFECTIONS

AIDS