PC615 Module 6 Abnormal Uterine Bleeding

MANY days of bleeding
Regular, prolonged and heavy bleeding

Irregular bleeding
Bleeding BETWEEN periods

Regular periods that are
Heavy and many days long AND
Bleeding betweenperiods

Small amount of flow OR
Long intervals (cycles more than 35 days long)

Frequent periods, short cycles (less than 21-24 days long)

no corpus luteum is being produced so there is no progesterone to keep endometrium stable so you have unopposed estrogen which causes Continuously proliferating, fragile endometrium
Outgrows its blood supply
Unpredictable sloughing and irregular periods

Immediate post-menarche
Perimenopausalwomen

No period for 6 months OR
No period for 3 of her normal cycles - first r/o pregnancy then go with H&P

May have thyroid or pituitary problem. Check TSH & prolactin (if elevated refer), do a progestogen challenge test (given progestogen 7-10 days pos test woman see withdrawal bleeding - if no bleeding then neg test)- Answers is there adequate estrogen & can bld get out

Is there adequate estrogen to build up an endometrium? Menstrual flow is a reflection of the endometrium—presence and amount
Estrogen (from the follicles/estrogen factories in the proliferative phase) builds the endometrium…thus…

Can the blood get out?
To see a withdrawal bleed, the blood must be able to get OUT
Another self test…What can cause the blood to not be able to get out? OUTFLOW TRACT problems like…

Ovaries with multiple large follicles
Irregular or no ovulation
High levels of androgens

12 or more folliclues that are 2-9mm in diameter no dominant follicle so not mature and estrogen keeps being produced so no progesterone produced. Endo metrium keeps progressing. so ovary confused so do not ovulate

high levels of androgens - testosterone, DHEAS, DHEA, 17-OHP - some come from ovaries and some from adrenal glands.

Hirsutism, particularly on face, chin, lower abdomen
Acne, persisting past adolescence
Alopecia, especially in male pattern

see obesity, metabolic syndrome, PCOS

pregnancy, vaginal infections, cervical infection, PID, CA of cervix

post menopausal bleeding, CA or precancerous cells, periods of unopposed estrogen, Give NSAIDS 20 before can cause severe cramping

Both are annovluatory times - teenagers have immature follicles which do not always produce a corpus luteum, older women have ovaries that are tired which do not always produce a corpus luteum

Pain with periods, low back pain, low abd pain, cramping
Primary= no evident pathology; diagnosis of exclusion
Secondary= underlying pathology that causes pain with menses

Associated with ovulatroy cycles & happens with bleeding. Important role - prostaglandin release causes Uterine contractions
Decreased uterine blood flow
Uterine hypoxia
Pain

Management: NSAIDs, combined hormonal contraceptives are mainstays of pharmacologic management

PMS= symptoms with specific timing that are distressing to the woman
PMDD= small subset of women with severe PMS that causes impairment

Mood—irritability, mood swings, depression, anxiety
Behavioral—tearfulness, social withdrawal
Cognitive—feelings of confusion, poor concentration
Physical—bloating, breast tenderness, insomnia, headache, fatigue, weight gain, appetite changes, food cravings

Symptoms beginning at or soon after ovulation, with escalation in the LUTEAL PHASE (link PMS & Luteal phase), Worst symptoms in week preceding menses
Symptoms gone or much better at onset of menses and for first two weeks of new cycle

true

no lab or diagnostic testing - validate concerns, exercise; reduce caffeine, sodium, and alcohol & simple CHO; increase complex CHO

calcium, magnesium, chasteberry

OCP & NSAIDs

Luteal-phaseor beginning-with-symptomsdosing are often great options. Start meds when symptomatic and then stop when period starts and stay off till see s/s again. Usually see results instantly
Response often seen in first cycle of use
Choose a long-half-lifeSSRI if using therapy intermittently which will decrease any side effects from discontinuing:
Fluoxetine(Prozac)
Sertraline(Zoloft)

start as follicles & if keep growing becomes a cyst. Follicle= fluid-filled sac (usually <2 cm)
Cyst= fluid-filled sac (usually >2 cm)

often none, Often unilateral, adnexalpain
Gradual or sudden
Mild or SEVERE
Be mindful of the patient’s emotional reaction! Is simple complex (more than just fluid can have tissue) or simple (non worrisome - only fluid filled sac) Small cyst 3-4 cm small, surgery for large comlex masses
Usually spontaneous management - use pain management

Use combined hormonal contraceptives that supppress ovulation function as this will also supress cyst formation. Remember corpus luteum is a cyst.

endometrial tissue leaves the uterus and implants elsewhere in the body (usually in the pelvis)

endometrial tissue invades inside uterine muscle tissue (add to uterine muscle in abnormal way)

Any menstruating woman
Higher prevalence in women with MORE periods—earlier, shorter cycles, heavier, longer…
risk for menstral flow to travel up tubes into pelvis and endometrial implants in pelvis

Scar tissue forms around abnormal endometrial tissues which causes back and pelvic pain, adhesions, dysparenunia, bowe & bladder problems, infertility
Can have severe s/s with small amount of endometrosis, need laporscopy to confirm endometrosis

contraception continouse hormonal which skips withdrawal bleed

Most common in women age 35-50
Sometimes asymptomatic…so often undiagnosed
Difficult to know true incidence—final diagnosis only with microscopic evaluation after hysterectomy

Sometimes it isn’t—it may be asymptomatic
May have pain—dysmenorrhea, non-cyclic uterine cramping, deep dyspareunia—perhaps from irritation of uterine muscle

Pain control with NSAIDs or narcotics
Hormonal contraceptives
Hysterectomy is the only definitive treatment

Large, boggy, tender uterus
May have irregular contour
Ultrasound may show myometrial lesions that look similar to fibroids

benign growth that originate in smooth muscle of uterus

Menorrhagia
Dysmenorrhea
Pelvic pressure
Increased abdominal size
Non-tender upon palpation

Often expectant management and aimed at symptom relief
Depends on whether fibroids are symptomatic/bothersome, fertility goals, proximity to menopause
Other possible treatments: medical therapy with combined hormonal contraceptives; anti-estrogen therapies like leuprolide; LNG-IUS; surgeries like myomectomyand hysterectomy; and uterine artery embolization

Poly cystic ovary syndrome (PCOS)

hirsutism (main sign) menstrual irregularity, acne, alopecia, and infertility (anovulation)

CVD, endometrial carcinoma d/t unapposed estrogen, ovarian ca, type 2 diabetes

increased androgen production from the ovaries or adrenal glands, testosterone and DHEAS main hormones

steady hormone level rather than fluctuations with normal menstrual cycle, LH increases and FSH low so follicle does not reach full maturation and ovulation

face, chin, upper lip, areolae (chest), lower abd, inner thighs, adn perineum

BCP

1/2 pt with PCOS are obese with obesityin abd region, more likely to develop insulin resistance & metabolic syndrome

total adn free testosterone, FSH LH, Prolactin, TSH, glucose and lipids, A1C

Need 2 of 3: oligo or anovulation, clinical or bichemical si/s of huperandrogenism, polycystic ovaries

1) weight loss for obese women, weight loss will decrease androgen levels, mechanical removal of hair, give Metformin, given progestins, to cause withdrawal bleeding to prevent endometrial hyperplasia & protect against CA so not exposed to unopposed estrogen, COC - low dose which inhibity LH secretion and decrease hiritusim & acne can add spironlactone to surpress hirsutism, tetrogenic only with with COC also, glucocorticoids supress adrenal androgens, topical eflornithine (Vaniqa) supresses hair growth

progesterone in luteal phase, leads to unstable endometrium

pregnancy

regular periods that have become heavy and accompained by clots,, sensation of pelvic fullness

blood dyscrasias, coagulpathies, liekleukemia, severe spsis, ITP, hypersplenism. thyroid disorders, pituitary disease, PCOS

glucocorticoids, tamoxifen nd anticoagulants,, ginsing, soy, ginkgo

atheletes, runner, gymnast, dancers - hypothalaic suppression - exercise induced amenorhea probably d/t low body fat

high dose estrogen stimulates rapid endoetiral proliferation ad resolves bleeding from denuded (bald: without the natural or usual covering) endometrium. May need antiemetics as nausea s/s with high estrogen. can also give COC twice daily taper to once daily after 5-7 days, Mirena IUD good to use with AUB r/t anovluations or leiomyomas

progestin can treat oligomenorrhea, dysfnctional menometrorrhagia, or polymenorrhea, give 7-12 each month and discontinue withdrawal bleed should occur if not consult physician

ablation, D&C, uterine artery embolization

pregnancy, Primary: anatomical problems. ovarian failure, chornic anovulation, anterior pituitary disorders and CNS disorders, endocrine disorders Age - menopause, eating disorders, long term use of oral contraceptives can cause endometrial atrophy, PCOS

pitiutary disease - test prolactin level

prolactin level, TSh and progestin challenge

bulemia, anorexia, obesity

unopposed estrogen - 75% (also Tamoxifen decreases breast CA, but increases endometrial CA) adn other Type II: 25% of unknown etiology (thin, multiparas, more black women) Poor prognosis

early menarche before 12, late menopause >55, hx of infertility or nulliparous (produce more progesterone during pregnancy), obesity, Chronic anovulation (PCOS), diabetes & hypertension, high-fat diet,breast or ovarian CA

abnormal vaginal bleeding or spotting - excessive flow or prolonged flow

endometrial biopsy, transvaginal US, D&C - treatment - TAH, radiation, chemo

noncyclic pain of 6 or more months in pelvic region - can arise from reproductive, genitourinary, or GI tract, can be somaic from belvic bones, ligaments, muscles and fascia.

anovulation

low estrogen levels or uterine outflow problem

low levels of estrogen

endometrosis, PID, pelvic adhesions, tumors, uterovagianl prolapse, menstrual cramps or mittlschmerz

cyclic or noncyclic, when pain began, pattern of pain, pain with intercourse?, activites that mitigate or allievate pain, asses use of narcotics, alcohol and drugs, sexual hx, STI exposure, sexual abuse, use pain mapping to help pt show where pain is

CBC, ESR, UA, Vaginal smears or cultures, stool gui, abd or vag US

IBS, Diverticulitis, constipation, bowel obstruction, appy, colon CA, cystitis, UTI, urinary retention, renal stones, scolosis, radiculopathy, arthritis, herniated disc

endometrosis, also see fibroids, cyts, CA, PID, STI, dyspareunia (painful sex)

exercise, hormonal treatment, progestin, NSAIDS, surgical intervention, yoga, relaxation techinques, massage

oral contraceptives & Progestin & GnRH agonists treat endometrosis

lesion of vulva - ask is has pruritis, pain, burning bleeding or vag discharge, ask sexual hx, - r/o vaginitis with wet mount, biopsy lesion, test STI if approp. Diff diagnosis: primary irritant (soaps or sprays, deodorants, bath bubbles, oil, scented TP, laundry detergents, pads, tampons, spermicides, riding a bike or horse, tight clothing - thong underwear) and allergic dermatitis (pollen, foods, topical & oral meidcation, latex, poison ivy & oak, semen)

skin disease seen in trunk neck, forearms, axillae under breasts and on vulva, inflammatio, epithelia thinning. most seen in women after menopause - high risk of vulvar CA if not treated, forms around urinary meatus and anus in figure 8 pattern, can cause stenosis - Treatment: relief of symptoms, steroids - high or very high steriod needed - topical - use ointment as creams can irritate, once desired response switch to lower potency, careful f/u required, usuall no vaginal involvement

inflammatory condition of skin, itchy, nails and mucous membranes. seen on vulva. irritating vaginal discharge, adn vulvar pruritis, pain adn buring, gradual or intermittant Physical Exam: papulosquamous, erosie nd hypertrophic, usually has vaginal involvement, topical steriod use

cysts of cervix, will resolve on own most of hte time, over 12 weeks,

benigh hyperplasia, can become malignant if infected iwth HPV, usually left alone unless causing irreg bleeding

benign growths arising from smooth muscle of uterus. Usually symptomless, can cause AUB, pain, pressure, diagnose by US, use a GnRH agonist (Lupron) to help decrease size of fibroid

presence of endometrial tissue in the myometrium, common ages between 40-50, causes heavy bleeding and pain, manage with contraceptives temporarily, hysterectomy definitive treatment

presence of endometrial gland and strome outside of uterus. Risks include early menarche, short mentrual cycles or periods longer than 7 days, s/s: pelvic pain, dysmenorrhea, dyspareunia, abnormal menstrual bleeding, & infertility. pressure and pain in rectum. & N/V - laporscopy best for diagnosis. therapy: continuous dosing COC, progestins,GnRH (side effect of bone loss) to eliminate or reduce menses

Cause usually anovulation and cyst does not turn into corpus luteum,, but keep growing, asymptomatic unless burstthen pain with abrupt onset. May see change in abdominal girth from growing cyst, US ordered, simple fluid filled cysts usually resolve on own, unless larger than 8cm just watch, complex cysts > 8cm needs to be removed

Oral contraceptive pills
Antipsychotics
Antidepressants
Antihypertensives
Histamine H2 receptor blockers
Opiates, cocaine

pregnancy test, TSH and prolactin levels

the absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea

Tranexamic acid - Women who experience heavy menstrual
bleeding have an elevated level of plasminogen
activators in the endometrium,
enzymes that facilitate the dissolution of
clots. These enzymes can be inhibited by
antifibrinolytic agents such as tranexamic
acid, which competitively blocks the conversion
of plasminogen to plasmin, thereby
reducing fibrinolysis

NSAIDS, naproxen sodium, and estrogen-progestin ocps. Cyclooxygenase inhibitors reduce the amount of menstrual prostanoids released, with concomitant reduction in uterine hypercontractility, while OCPs inhibit endometrial development and decrease menstrual prostanoids

These criteria require the presence of at least 5 symptoms; and at least one of these must be depressed mood, tension, affective lability, or irritability. Additionally, there must be impairment in at least one area of daily life.