Untitled Flashcards Set

ABNORMAL UTERINE BLEEDING

A change in the pattern or volume of menstrual bleeding is a common health concern of female patients from puberty to menopause. The literature suggests that during their reproductive years, 10% to 20% of females have abnormal uterine bleeding (AUB) at least once. Patients may describe these abnormal bleeding episodes as infrequent, occurring between regular menstrual periods, prolonged in duration, and/or excessive in volume. Acute AUB is defined as an episode of bleeding in a nonpregnant female of reproductive age that, in the opinion of the provider, requires immediate intervention to prevent further blood loss. Chronic AUB is uterine bleeding that is abnormal in duration, volume, and/or frequency, which has been pre sent for the majority of the past 6 months. Chronic AUB has been associated with a reduction in work productivity by as much as 30%.

Traditionally, genital bleeding in females has been vaguely defined, with inconsistent and confusing terminology. Heavy menstrual bleeding describes a patient’s perception of excessive menstrual blood loss without regard to regularity, duration, or frequency of menses. In an effort to develop consistency, consensus, and clear terminology, the International Federation of Obstetrics and Gynecology Menstrual Disorders Committee developed a flexible classification system in 2011. This system, known as PALM-COEIN, classifies the causes of AUB in the reproductive years. The normal frequency of menses is every 24 to 38 days, with an average duration of 4.5 to 8 days and approximately 5 to 80 mL of blood loss per month. The determination of abnormal bleeding involves recognizing variations in frequency, regularity, duration, and volume of flow. Causes of AUB are categorized by the PALM-COEIN mnemoic, which stands for the following possible causes:

Polyp

Adenomyosis

Leiomyoma

Malignancy and hyperplasia

Coagulopathy

Ovulatory dysfunction

Endometrial disorders

Iatrogenic

Not yet classified

Factors of the “PALM” group are considered structural causes; however, entities of the “COEIN” group cannot be defined by imaging or histopathology.

DIFFERENTIAL DIAGNOSIS

The initial evaluation of bleeding from the vagina involves determining its source. Structural causes due to a polyp, leiomyoma, or adenomyosis can be identified via ultrasound. Anovulatory bleeding is the cause of AUB in approximately 95% of patients younger than 20 years and in 90% of perimenopausal patients who experience AUB for 2 to 3 years before the onset of menopause. In contrast, ovulatory cycles are associated with certain features such as midcycle pain, specific vaginal mucus changes, dysmenorrhea, and premenstrual breast tenderness. Approximately one-half of ovulating patients experience midcycle spotting that is self-limited. Irregular endometrial shedding may occur with the prolonged production of progesterone due to a persistent corpus luteum, resulting in AUB.

A thorough history, physical examination, pelvic examination, and selected laboratory tests will usually identify the cause of AUB. The history should include the patient’s age, date of last menstrual period, birth control method, frequency of menses, amount of menstrual blood flow (e.g., the estimated number of pads or tampons used daily), duration of menses, and if there is a menstrual pattern change. In patients who report profuse acute bleeding episodes, the diagnosis of pregnancy or miscarriage (e.g., passing tissue, nausea, vomiting, breast tenderness) must be excluded. In an ectopic pregnancy, the patient may complain of abdominal pain. Complaints of fainting spells may be indicative of a ruptured ectopic pregnancy. If the patient describes bleeding only with urination or defecation, or when wiping with toilet tissue, bladder or GI disorders should be explored.

Up to 10% of patients who use oral contraceptive pills (OCPs) or other forms of hormonal contraception report irregular bleeding episodes. Any patient who presents with AUB and is 35 years of age or older should be evaluated for cervical and uterine cancers. Endometrial biopsy is an office procedure to rule out unchecked proliferation of the endometrium that can lead to hyperplasia and potentially endometrial adenocarcinoma. Similarly, a colposcopy, cervical biopsy, and endocervical curettage are used to diagnose cervical cancer. Patients older than 30 years who are positive for human papillomavirus (HPV) and have atypical squamous cells of undetermined significance (ASC-US) or another abnormal Papanicolaou (Pap) test result should be referred for colposcopy. Patients 25 years of age and older with a low-grade squamous intraepithelial lesion should be referred for colposcopy, and any patient with ASC-H (H indicates that high-grade squamous intraepithelial lesion cannot be excluded) should also be referred for colposcopy. Trauma and foreign bodies as causes of bleeding from the vagina are seen more commonly in children. A less common cause of uterine bleeding is a blood dyscrasia that creates a tendency to bleed, such as von Willebrand’s disease or thrombocytopenic purpura. This is particularly true if the patient is an adolescent and presents with heavy menstrual bleeding.

The physical examination should focus on findings pointing to possible sources of bleeding, such as an anal fissure; cervical laceration; or an enlarged, irregular, or boggy uterus, blood clots in the vaginal vault, uterine tenderness, copious blood flow, or adnexal masses or tenderness. The laboratory work-up is directed by the history and physical examination findings and usually consists of hematocrit, hemoglobin, platelet count, peripheral smear with differential, pregnancy evaluation, and Pap test. In severe bleeding, tests for partial thromboplastin time, prothrombin time, international normalized ratio, and possibly bleeding time (to detect platelet defects) are indicated. Hysteroscopy may be performed immediately before a cervical dilation and curettage of the uterus to assist in the diagnosis of polyps, exophytic endometrial cancer, or fibroids (leiomyomata) as a source of AUB. A prolactin level and thyroid function tests are ordered to rule out hyperprolactinemia and hypothyroidism, respectively.

MANAGEMENT

Management of AUB is directed toward controlling bleeding and preventing a recurrence. For teenagers, management includes observing those with mild cases and no anemia and prescribing medroxyprogesterone or an OCP. For patients of reproductive age, treatment is based on the patient’s desire for fertility or contraception. For those who cannot take OCPs, medroxyprogesterone can be used. OCPs containing ethinyl estradiol are used in acute bleeding episodes. For patients with severe acute bleeding who remain hemodynamically stable, conjugated estrogen is used until the bleeding stops.