abnormal bleeding

What triggers the shedding of the uterine lining through the vagina in a normal menstrual cycle? [2]

Menstruation occurs if the egg released from the ovary every month is not fertilized, causing the lining of the uterus to shed.

What is the average rhythm (cycle length) of normal menstruation, and what is considered a regular range? [2]

Average: 28 days.
Regular range: 21–35 days.

What is the normal duration of menstrual bleeding? [2]

3–7 days.

What is the typical volume of blood lost during a normal menstrual period? [3]

30–50 ml.

What are the characteristic features of normal menstrual flow? [3]

It is a non-clotted fluid blood.

How is Menorrhagia defined? [5]

Heavy or prolonged menstrual bleeding, characterized by a loss of more than approximately 80 ml of blood or bleeding lasting > 7 days.

What is the definition of Metrorrhagia? [6]

Intermenstrual bleeding; specifically, non-normal bleeding that occurs at irregular intervals and is not associated with the menstrual cycle.

What is Polymenorrhea? [7]

A menstrual cycle abnormality where uterine bleeding occurs at intervals of less than 21 days.

What is Oligomenorrhea? [8]

Infrequent menstrual periods occurring at long intervals of > 35 days (resulting in fewer than six to eight periods per year).

What was Abnormal Uterine Bleeding (AUB) previously called, and what is its primary cause? [10]

Formerly called Dysfunctional Uterine Bleeding (DUB).
Main cause: Imbalance in sex hormones.

AUB is broadly divided into which two categories based on the ovulation cycle? [10]

1. Ovulatory bleeding.
   2. Anovulatory bleeding.

What are the common causes of Ovulatory AUB? [11]

1. Luteal phase defects.
   2. Irregular corpus luteum function.
   3. Imbalanced progesterone.

Describe the pathophysiology of Anovulatory AUB. [12]

The corpus luteum does not form, leading to no progesterone secretion. This leaves estrogen unopposed, causing the endometrium to proliferate until it outgrows its blood supply, resulting in irregular or heavy bleeding.

At which stages of reproductive life is Anovulatory AUB most common? [13]

At the extremes of reproductive age, such as early puberty and perimenopause.

In younger patients, which system's disorders often contribute to anovulatory bleeding? [13]

The hypothalamic–pituitary system.

What is the "Important Note" regarding the first step in managing any woman of reproductive age with abnormal bleeding? [15]

Rule out pregnancy first.

What are the three broad categories of causes for abnormal bleeding? [16]

1. Organic causes.
   2. Iatrogenic causes.
   3. Systemic disease.

What is Polycystic Ovary Syndrome (PCOS)? [17]

A common disease (affecting ~1 in 10 women in the UK) where ovaries become enlarged and contain many fluid-filled sacs (follicles) that are unable to release an egg, leading to anovulation and hormone imbalance.

Which clinical sign is associated with excess androgen in PCOS? [17]

Excess facial or body hair (hirsutism).

According to the Rotterdam criteria, how many criteria must be met to diagnose PCOS? [18]

2 out of 3 criteria (after excluding other diagnoses).

What are the specific cycle length requirements for "Irregular cycles" under the PCOS Rotterdam criteria? [18]

1. If > 3 yr post-menarche: Cycles > 35 d or < 21 d apart.
   2. < 8 menstrual cycles per year.
   3. > 90 d for any single menstrual cycle.

What are the three Rotterdam criteria for PCOS diagnosis? [18]

1. Irregular cycles.
   2. Clinical hyperandrogenism (acne, hirsutism, alopecia) or biochemical hyperandrogenism.
   3. Polycystic ovarian morphology on ultrasound or high AMH.

At what time in the menstrual cycle should initial hormonal investigations for PCOS be completed? [19]

During the early follicular phase (Day 2–4) in non-amenorrheic patients.

What are the suggested initial investigations for suspected PCOS? [19]

Prolactin, TSH, LH, FSH, Estradiol, (\beta)-hCG, 17-OHP, Testosterone (total/free), AMH, and Transvaginal ultrasonography.

In the context of PCOS testing, what does a markedly elevated Prolactin level suggest and what are the next steps? [20]

Diagnosis: Pituitary tumour.
Next steps: Repeat early morning fasting prolactin, test macroprolactin, consider pituitary MRI, and refer to endocrinology.

What is the clinical significance of Elevated TSH vs. Depressed TSH when investigating AUB? [20]

Elevated TSH: Hypothyroidism (consider levothyroxine).
Depressed TSH: Hyperthyroidism (measure T3/T4, refer to endocrinology).

What does a Normal–high LH and normal FSH with low follicular phase estradiol typically indicate? [20]

It is the expected result for a patient with PCOS.

What does a High FSH and LH in the context of low follicular phase estradiol suggest? [20]

Premature Ovarian Insufficiency (POI).

An elevated 17-hydroxyprogesterone (17-OHP) level is an indicator of which alternative diagnosis? [20]

Non-classic adrenal hyperplasia.

A markedly elevated total testosterone (( > 5.2 \text{ nmol/L} )) suggests which serious condition and requires which imaging? [20]

Diagnosis: Ovarian or adrenal tumour.
Imaging: Transvaginal ultrasonography and Adrenal CT or MRI.

What ultrasound findings define Polycystic Ovarian Morphology (PCOM)? [21]

\(\ge 10 \text{ mL}\) ovarian volume OR \(\ge 20 \text{ follicles}\) in either ovary.

What is the typical Anti-müllerian hormone (AMH) level in PCOS? [21]

Typically greater than 34 pmol/L.

What is the first-line lifestyle intervention for PCOS patients with menstrual irregularity? [22]

Diet and exercise aimed at weight reduction by 5%–10% (while being aware of weight stigma).

Which progestins and dosages are used to treat PCOS-related heavy bleeding? [22]

1. Oral medroxyprogesterone (5–10 mg for 5–10 d every 30–90 d).
   2. Oral norethindrone acetate (5 mg daily for 7 d every 30–90 d).
   3. Levonorgestrel IUD (52 mg over 5 yr).
   4. Etonogestrel implant (68 mg over 3 yr).
   5. IM medroxyprogesterone (150 mg every 3 mo).

What is the dosing recommendation and specific limitation for Metformin in PCOS? [23]

Dose: 1500–2000 mg daily (start at 500 mg and increase every 1–2 wk).
Limitation: Cannot be used for endometrial protection in amenorrhea.

What is the first-line medication for ovulation induction in PCOS and its specific instructions? [24]

Letrozole (2.5 mg–7.5 mg for 5 d).
Start on Day 2–5 if cycling regularly; if irregular, start after negative pregnancy test or withdrawal bleed.

To which specialists should a patient be referred for the treatment of PCOS-related symptoms? [24-25]

Dermatologist (Acne/Alopecia), Dietician/Weight Management (Obesity), and Gynecologist/Reproductive Endocrinologist (Infertility).

What are Uterine Polyps? [26]

Small growths within the uterus made of endometrial tissue, heavily influenced by estrogen, which can cause AUB and spotting between periods.

What are Uterine Fibroids? [27-28]

Small growths made of thick muscle tissue (myometrium) that occur within the uterus or muscle. Their growth is influenced by estrogen.

What is the "Gold Standard" for diagnosing and visualizing the uterine cavity for polyps or fibroids? [28]

Hysteroscopy or Transvaginal ultrasound.

When is an endometrial tissue biopsy specifically indicated during AUB investigation? [28]

When malignancy is suspected.

What is the surgical gold standard for managing symptomatic uterine polyps? [29]

Hysteroscopic polypectomy.

List three hormonal therapies for managing Fibroids. [30]

1. GnRH agonists (induce hypoestrogenism).
   2. Progesterone receptor modulators (e.g., ulipristal acetate).
   3. Levonorgestrel IUD (relieves bleeding but doesn't shrink fibroids).

What are two minimally invasive procedures for fibroid management? [30]

1. Uterine Artery Embolization (UAE) (blocks blood flow).
   2. MRI-guided Focused Ultrasound Surgery (FUS) (uses ultrasound waves).

Compare Myomectomy and Hysterectomy for fibroid treatment. [31]

Myomectomy: Removes fibroids while preserving the uterus (for fertility).
Hysterectomy: Complete removal of the uterus (definitive solution).

Which factors influence the choice of treatment for polyps and fibroids? [31]

Age, symptom severity, desire for future fertility, and fibroid size, location, and number.

What pharmacological agents are used for relieving symptoms of heavy bleeding and pain in organic diseases? [32]

1. NSAIDs for pain relief.
   2. Tranexamic acid for heavy bleeding.

Define Endometriosis and its common diagnostic challenge. [32-33]

Definition: Uterine lining grows outside the uterus.
Challenge: Average diagnostic delay of 7 years; no definitive non-invasive tool.

What are the symptoms and diagnostic "Gold Standard" for Endometriosis? [34]

Symptoms: Chronic pelvic pain, dysmenorrhea, deep dyspareunia, and infertility.
Gold Standard: Laparoscopy.

What are the Non-Medical and Multidisciplinary care options for Endometriosis? [35]

Non-Medical: Physiotherapy (pain) and CBT (coping).
Multidisciplinary: Specialists in pain management, fertility, and mental health.

Which STDs are known to cause inflammation and subsequent abnormal bleeding? [35]

Gonorrhoea and Chlamydia.

When does bleeding caused by STDs typically occur and how are they best diagnosed? [36-37]

Timing: After sex (post-coital).
Diagnosis: Nucleic Acid Amplification Tests (NAATs).

What is the first-line treatment for Gonorrhoea, Chlamydia, and Syphilis? [37-38]

Gonorrhoea: IM Ceftriaxone.
Chlamydia: Doxycycline (7 days).
Syphilis: Benzathine penicillin G.

What are the first-line treatments for Trichomoniasis and Genital Herpes? [38]

Trichomoniasis: Metronidazole.
Herpes: Acyclovir, valacyclovir, or famciclovir.

What are some Iatrogenic causes of abnormal bleeding? [40]

1. IUDs.
   2. Contraceptive steroids.
   3. Anticoagulants/antiplatelets.
   4. Neuropsychiatric drugs.
   5. Rifampin and Tobacco abuse.

How do Systemic Diseases like Cirrhosis or Sepsis cause abnormal bleeding? [41]

Cirrhosis: Reduced capacity of the liver to metabolize estrogens.
Sepsis/Leukaemia: Produces platelet deficiency leading to irregular bleeding.

Which blood disorders present as vaginal bleeding during adolescence? [41]

von Willebrand disease and prothrombin deficiency.

What specific elements must be included in the Medical History for AUB? [42]

Cycle history, Sexual history (partners, contraception, STI exposure), Medication history (birth control), and history of abnormal cervical cancer screening.

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