menstrual cycle and vaginal bleeding

~30–40 mL (≤80 mL)

normal blood loss associated with menses

follicle

FSH stimulates ____ development

estrogen

granulosa cells produce

endometrial proliferation

rising estrogen in the menstrual cycle---->

progesterone

________ stabilizs the endometrium

Bleeding that is abnormal in:

Frequency

Duration

Regularity

Volume

define abnormal uterine bleeding clinically

PALM COEIN

-structural=palm

-non-structural (coein)

acronym for abnormal uterine bleeding

Polyp

Adenomyosis

Leiomyoma

Malignancy/hyperplasia

main structural causes of abnormal uterine bleeding

local overgrowth of endometrium

pathophys of a polyp

adenomyosis

endometrial glands in the myometrium

Coagulopathy

Ovulatory dysfunction

endometrial (primary disorder of hemostasis)

iatrogenic (OCPs, anticoagulants)

Not otherwise classified

main non-structural causes of abnormal uterine bleeding

anovulation--> unopposed estrogen

how does ovualtory dysfunction--> abnormal uterine bleeding

anovulation

most common cause of abnormal uterine bleeding in adolescents

pregnancy first!

most common cause of abnormal uterine bleeding in reproductive age

anovulation

most common cause of abnormal uterine bleeding in perimenopausal women

malignancy until proven other wise

abnormal uterine bleeding in a post-menopausal woman is

rule out pregnancy!

initial eval of abnormal uterine bleeding

CBC

TSH

Prolactin (if indicated)

Coagulation studies (adolescents)

labs indicated for work up of abnormal uterine bleeding

transvaginal ultrasound

first line imaging for abnormal uterine bleeding

≥45 years

<45 with risk factors (obesity, PCOS, chronic anovulation)

indication for endometrial biopsy in abnormal uterine bleeding

sonohysterography

-saline injected into the uterus during ultrasound for bettter visualization of polyps, fibroids, endometrial lesions, infertility

sonohysterography (SHG)

imaging better than TVUS for intracavitary lesions

High-dose estrogen

Combined OCPs

Tranexamic acid

Progestins

management of acute heavy uterine bleeding in the hemodynamically stable

Levonorgestrel IUD (most effective) (mireena)

Combined OCPs

Progestin therapy

first line options for management of chronic abnormal uterine bleeding

Hysteroscopic polypectomy

Myomectomy

Endometrial ablation

Hysterectomy (definitive)

surgical options for abnormal uterine bleeding

hysteroscopic polypectomy

Surgical removal of endometrial polyps.

myomectomy

excision of a fibroid tumor (myoma) from the uterus

levonorgestrel IUD

best long term medical therapy for abnormal uterine bleeding

uterine leiomyoma

most common benign tumor in reproductive age women

Black women (2-3× higher prevalence)

Nulliparity

Obesity

Early menarche

populations in which leiomyoma is more common

abnormal uterine bleeding:

Heavy menstrual bleeding

Prolonged menses

Anemia

most common symptom of leiomyoma

Pelvic pressure

Urinary frequency

Constipation

Dyspareunia

bulk symptoms of leiomyoma

Enlarged uterus

Irregular, firm, mobile mass

Uterus may feel "bumpy"

physical exam findings associated with leiomyoma

Smooth symmetric enlargement suggests adenomyosis; irregular contour suggests fibroids.

uterine findings of adenomyosis vs fibroids

leiomyoma

well-circumscribed hypoechoic masses on transvaginal ultrasound

sonohysterography

best imaging for submucosal fibroids

submucosal fibroids

-fibroid under endometrium

-associated with heavy bleeding

intramural fibroid

-fibroid within the myometrium

-associated with bulk symptoms and bleeding

subserosal fibroid

-fibroid on the outer uterine surface

-associated with pressure symptoms

pedunculated fibroid

-fibroid on stalk

-torsion pain

GnRH agonists

Shrink fibroids

Used preoperatively

Side effects: menopausal symptoms, bone loss

med for temporary shrinkage of uterine fibroids preoperatively

myomectomy

Removes fibroids

Preserves fertility

Risk of recurrence

uterine artery embolization

Minimally invasive procedure

Shrinks fibroids

Not ideal if future pregnancy desired

endometrial ablation

procedure For bleeding only

Not for large or submucosal fibroids

No future fertility

Malpresentation

Preterm labor

Postpartum hemorrhage

pregnancy complications associated with leiomyomas

leiomyosarcoma

malignant tumor made of smooth muscle cells

No menses by:

Age 15 with normal secondary sexual characteristics

OR Age 13 without secondary sexual characteristics

clinical definition of primary amenorrhea

Absence of menses for:

≥3 months (previously regular cycles)

≥6 months (previously irregular cycles)

clinical definition of secondary amenorrhea

Infrequent menstrual cycles

Cycle length >35 days

clinical definition of oligomenorrhea

chronic anovulation

oligomenorrhea is often due to

Low BMI / anorexia

Excess exercise

Stress

Chronic illness

Malnutrition

hypothalamic causes of amenorrhea (decrease GnRH)

Hyperprolactinemia

Pituitary adenoma

Sheehan syndrome

Infiltrative disease

pituitary causes of amenorrhea (↓ FSH/LH)

suppresses

↑ prolactin ________ GnRH

Turner syndrome

Autoimmune

Chemotherapy/radiation

Premature ovarian failure

ovarian causes of amenorrhea

↑ FSH

↓ Estrogen

lab findings of primary ovarian insufficiency

Asherman syndrome

a syndrome characterized by endometrial adhesions that typically occur as a result of scar formation after some types of uterine surgery

-results in secondary amenorrhea

Mullerian agenesis

Everything is normal except no uterus and upper vagina

Have ovaries, normal hair distribution, and are 46XX

ovulatory dysfunction

-PCOS, thyroid disease, hyperprolactinemia

most common cause of oligomenorrhea

Low BMI

Bradycardia

Stress fracture history

Osteopenia

symptoms associated with hypothalamic amenorrhea

asherman syndrome

History of D&C

Light or absent periods

anovulation

in a progesterone withdrawal test, if there is a withdrawal bleed, suspect _________ as the cause of amenorrhea

low estrogen or outflow obstruction

in a progesterone withdrawal test, if there is no withdrawal bleed, suspect ___________ as the cause of amenorrhea

Weight restoration

Reduce exercise

Nutritional counseling

initial management of hypothalamic amenorrhea

Combined OCPs

Weight loss

Metformin (if insulin resistance)

Progestin withdrawal to protect endometrium

management of PCOS

Hormone replacement therapy

management of ovarian failure

Infertility

Endometrial hyperplasia (from unopposed estrogen in PCOS)

consequences of untreated amenorrhea/oligomenorrhea in the short term

Osteoporosis

Fractures

Cardiovascular risk

long term side effects of hypoestrogenic states

Endometrial hyperplasia

Endometrial cancer

long term side effects of chronic anovulation

Most common cause of secondary amenorrhea = pregnancy

Most common pathologic cause = PCOS

most common cause of secondary amenorrhea

endometrial cancer

PCOS increases the risk of this cancer

ovarian failure

high FSH is indicative of

premenstrual syndrome

Recurrent physical and/or emotional symptoms occurring in the luteal phase of the menstrual cycle that:

Begin after ovulation

Resolve within a few days of menses onset

Are absent in the follicular phase

Cause functional impairment

-PMDD is a DSM5 diagnosis , has a specific number of symptoms, and marked mood symptoms moreso than physical

main difference between PMS and PMDD

≥5 total symptoms AND

≥1 mood-related symptom

must occur in most cycles, cause clinically significan distress or impairment

diagnostic criteria of PMDD

SSRIs

-continuous daily dosing or luteal phase only dosing

-SSRIs work rapidly in PMDD unlike typical depression

first line treatment for PMDD

Calcium

Vitamin B6

NSAIDs (for physical symptoms)

supplements indicated for mild PMS

combined OCPs

med indicated for mild PMS

GnRH agonist

med indicated for refractory PMS/PMDD