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OB-GYN Abnormal Uterine Bleeding

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1. Acute AUB treatment: -if ultrasound shows <5 mm 8. AUB prognosis/complications: -most will respond to treatment
endometrium, treat with estrogen -iron deficient anemia if bleeding prolonged or frequent
-if ultrasound >10-12 mm consider curettage (get biopsy) -unopposed estrogen exposure may lead to endometrial
-estrogen causes rapid growth of the endometrium carcinoma (exogenous or from chronic anovulation)
-premarin 2.5 mg orally QID or 25 mg IV q 4-6 hours until -infrequent or irregular periods, perimenopause, and
bleeding stops anovulation can result in infertility
-if bleeding stops add oral Progesterone 10 mg daily for 7-10 -ICD-9 codes: 626.2 excessive bleeding; 626.6 metrorrhagia;
days (sustain endometrium) 627.1 PMB
2. Acute blood loss treatment: -oral contraceptives: 1 pill by 9. AUB risk factors: -vaginal/pelvic/abdominal trauma/foreign
mouth, 3 times daily x7 days or 1 pill twice daily x 5 days, then body
one pill daily until pack is finished -personal of FH of AUB
-estrogen contraindications: h/o thrombosis, estrogen -personal or FH of coagulation defects
dependent cancers, active liver disease -FH of premature ovarian failure/ early menopause/atrophy
-D&C is the quickest way to stop acute bleeding; indicated in -associated symptoms of acne, weight gain or hirsutism
hypovolemic pt (polycystic ovaries)
3. Age groups: -age 12-18: immature HPO axis - irregular cycles -thyroid disorders, ITP, von Willebrand's, leukemia (organic
-age 19-39: common structural causes are polyps and fibroids disorders)
(molimina- nonmenstral systems, mood swings, fatigue, -medication use (neuroleptics, hormonal contraceptives)
headaches); PCO- common in reproductive age women, often -eating disorders/low BMI/ excessive exercise
causes anovulatory cycles; malignancy is less common in this -severe physical/emotional stress, including medical and
age group psychiatric illness
-age 40 and older: endometrial atrophy most common in this -intra-uterine device (IUD)
age group -oral/injectable steroids
4. amenorrhea: absence of period 10. AUB treatment options: -oral contraceptives induce
withdrawal bleeding in anovulatory women, reduce menstrual
5. Anovulation: -corpus luteum is not produced
flow, and improve cycle regularity in ovulatory women
-ovary does not produce progesterone
-cyclic progestins induce bleeding in anovulatory women with
-estrogen production continues causing endometrial
adequate estrogen (progesterone challenge test)(16-25 mg
proliferation (and cancer due to growth in uterine lining and
cycle progesterone; 10 mg provera)
becoming top heavy) and AUB
-Mirena IUD significantly reduces amount of blood loss
6. Antifibrinolytic therapy: -Tranexamic acid - FDA approved oral (intrauterine device)
form (Lysteda) for Rx of heavy menstraul bleeding -OCP's are helpful in women with PCOS
-could cause nausea, leg cramps, and thrombotic event
11. COEIN: nonstructural causes: -coagulopathy (AUB-C)
-no more than 6 tabs in 24 hours
-ovulatory dysfunction (AUB-O)
-slows fibrin activity
-endometrial (AUB-E)
-used as Rx of DUB associated with uterine fibroids
-iatrogenic (AUB-I)
-inhibits endometrial plasminogen activator and prevents
-not yet classified (AUB-N)
fibrinolysis and the breakdown of clot
-side effects uncommon - increased of thrombotic tendency 12. DUB: -dysfunctional uterine bleeding
-abnormal uterine bleeding for which an organic etiology has
7. AUB key points: -AUB is broad spectrum of menstrual
been ruled out
irregularities
-diagnosis depends on the pt's history, age, and physical exam 13. Endometrial cancer risk factors: -nulliparity (never been
findings pregnant)
-treating AUB depends on whether or not the pt ovulates -diet: high fat intake, alcohol, coffee/tea
(ovulatory vs. anovulatory) -diabetes, HTN
-normal: 28 days +,- 7 days; 3-7 days duration; volume 30-75 -obesity: estrogen produced by adipose tissue
cc -unopposed estrogen: 4-8 times greater risk, anovulation
-abnormal; <21 or >35 days length; more than 7 days duration; (given exogenous progesterone to counteract estrogen)
volume >80 mL
14. Goals of treatment: (rule out cancer and pregnancy before 21. Mechanisms of hemostasis: -vasoconstriction, localized
giving hormones) -platelet vasoconstriction
-control bleeding -platelet plug forms - at basis of endometrium basal layer
-prevent future episodes where period originates
-replenish iron stores (give sulfate by mouth) -reinforcement of the plug with fibrin
-restore cycle -fibrinolytic mechanisms remove coagulated material
-preserve fertility (if desired) -hemostatic plug formation - most important in proper
15. Hypomenorrhea: light periods endometrial function
-vasoconstriction - most important in the basalis layer
16. Imaging: -transvaginal ultrasound (TVUS) can detect structural
-prostaglandins regulate vasodilatation and vasoconstriction
lesions and measure the thickness of the endometrial lining
and the clotting process
(endometrial stripe, may be abnormal if >5mm and >45y/o)
-PGE2 produces vasodilation
-fibroid <5mm may not be detected
-PGF2a produces vasoconstriction
-polyps may not be visible unless sonohystography is
-progesterone is required to increase arachidonic acid, a
performed
precursor to PGF2
-sonohystography is operator-dependent and costly
-decrease in progesterone promotes vasodilation thereby
-bladder must be full
promoting AUB
17. Labs: -HCG - pregnancy test -PGF2/PGE2 ratio is decreased due to elevated estrogen/lack
-CBC - r/o anemia of progesterone secretion in anovulatory cycles
-TSH - thyroid stimulating hormone
22. menometrorrhagia: -heavy bleeding, occurring at irregular
-liver, thyroid or renal function testing may reveal another
intervals
medical cause/diagnosis
-prolonged, usually >7 days duration
-PTT, PT, platelet count, factor VIII or Von Willebrand's antigen
levels 23. menorrhagia: -heavy or prolonged menstrual bleeding (>7
-prolactin levels days duration)
-FSH >30 mIU/mL suggests premature ovarian failure -regular intervals
-FSH, LH, total testosterone, 17 hydroxyprogesterone, and -gushing of blood
DHEAS (POCS) 24. Metrorrhagia: -irregular bleeding between periods
18. Management: Estrogen: -screen for contraindications prior to -lighter flow
treatment (uteran cancer, thrombotic events) -may be associated with ovulation
-short term 25. NSAIDS: -vasocontriction/increased platelet aggregation by
-acute hemorrhage: 25 mg IV every 4-6 hours correcting Prostaglandin imbalance inhibiting Cycloxygenase
-for less severe bleeding: Premarin 1.25 mg 2 tabs orally four in the Arachidonic cascade
times daily until bleeding stops -reduce blood flow and dysmenorrhea but have no effect on
19. Management of NSAIDS: -reduces bleeding frequency (cycle length)
-ibuprofen 600-1200 mg/d, divided doses, with food -in severe cases GnRH agonists (Leuprolide, buserlin) may be
-Mefenamic acid (ponstel) 500-1500 mg/d, divided doses, FDA used to induce a hypogonadotropic state
approved for menorrhagia 26. oligomenorrhea: -periods more than 35 days apart
-Naproxen sodium (anaprox DA) 500 mg bid -infrequent uterine bleeding varies between 35-60 days
-other NSAIDS, COX 2 inhibitors? -usually anovulation from endocrine causes or systemic
20. Mechanism of action causes
OCP & progestins: -OCP: decreases estrogen through 27. PALM: structural causes: -polyp (AUB-P)
negative feedback, turning off intrinsic pathway, thereby -adenomyosis (AUB-A)
reducing estrogen -Leiomyoma (AUB-L) (uterine fibroid) - subtypes: submucosal
-Progestins: inhibit endometrial growth by inhibiting estrogen leiomyoma (AUB-SM), other leiomyoma (AUB-LO)
receptors; promote conversion of estradiol to estrone; inhibits -Malignancy, hyperplasia, endometriosis (AUB-M)
LH; stimulates arachidonic acid formation (precursor to PG2Fa)
causing uterine contraction and vasoconstriction
28. Physical exam: -breast exam (glactorrhea), speculum exam, bimanual exam, rectal exam, pap test, STI testing, examination of vaginal
discharge
-look for weight gain, acne, hirsutism, or other signs of virilization
-look for bleeding gums, easy bruising
-examine thyroid, neck, heart, and lungs
-wet smear may indicate signs of vaginitis, STI testing is indicated to r/o PID or cervicitis
-pap smear can evaluate for cervical changes (cancer) that may cause intermittent or post coital bleeding
-rectal exam - hemorrhoids, and tests for occult blood in fecal matter (GI bleeding)
29. polymenorrhea: periods that are too frequent, usually less than 21 days apart
30. post coital/post menopausal bleeding: bleed after sex
bleed after one year of no periods
31. procedures/surgery: -endometrial biopsy is indicated in women >35 to rule out hyperplasia or malignancy
-hysteroscopy and biopsy is "Gold standard" for diagnosis
-biopsy may be warranted in younger women with significant risk factors such as unopposed estrogen use, obesity, anovulation, FH of
breast, ovarian, or uterine cancer
32. Progestin secreting treatments: -cyclic medroxyprogesterone (Provera) 10mg daily for 10-14 days PO
-continuous Provera 2.5-5 mg daily
-Progesterone in oil, 100 mg every 4 weeks IM
-DepoProvera 150 mg IM every 3 months
-Mirena IUD (IUS) 5 years
33. signs and symptoms: -unusually heavy bleeding
-irregularities in the amount of flow or timing of menses
-bleeding after intercourse or defecation
-symptoms of anemia - fatigue, dyspnea, lightheadedness, fingers numb, ice chewing
34. Summary of AUB: -atrophy - most common cause of AUB in post menopausal female
-TVS (transvaginal ultrasound sonogram) - excellent screening tool for evaluation of AUB (especially PMB)
-women with recurrent AUB may require definitive follow up
-Gold standard for diagnosis - hysteroscopy and biopsy
-endometrial cancer risk factors - obestity, unopposed estrogen, DM, HTN
35. Surgical options: -Endometrial ablation (thermal/laser ablation) Thermachoice, Novasure - stop bleeding all together (beware of
uteran cancer)
-hysterectomy
-uterine artery embolization - destroys uterine lining
36. Tests: -first step is to r/o pregnancy: urine or serum HCG
-regular, cyclic menses is most likely ovulatory: BBT (basal body temp every morning) and cycle charting is helpful to determine if pt
ovulates regularly
-determine ovulatory status: luteal phase (day 20-22) serum progesterone level of >2 ng/mL is consistent with ovulation