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Menstrual Period

2 phases of ovarian cycle (egg maturation) Follicular days 1-14 Luteal 15-28
Follicular phase variable length Increased FSH/LH & estradiol (dominate follicle) Decreased FSH LH surge peaks 10-12 hr before ovulation Thin cervical mucus
Ovulation Prostiglandins break down follicular wall Oocyte released 32-44 hrs after LH surge begins spinnbarkeit peak sexual desire increase BBT
Luteal phase Begins after ovulation occurs lasts approx 14 days Corpus luteum formed from ruptured follicle and secretes progesterone (peaks 7-8 days) Thick cervical mucus Maintained increased BBT No pregnacy CL decenegrates and decrease progesterone
3 phases of uterine cycle (endometrial changes) Proliferative , secretory, menstruation
Proliferative phase estrogen endometrium thickens last 10 days from end of menses to ovulation
Secretory phase progesterone 12-16 day average from ovulation to menses endometrial hypertrophy increased vascularity favorable for implantation of fertilized ovum
Menstruation progesterone decreases endometrial lining undergoes involution, necrosis and sloughing because egg was not fertilized Simultaneous in all regions of the endometrium Average 3-6 days
Acute uterine bleeding Any episode in nonpregnant, reproductive-aged women, who has sufficient bleeding to require immediate treatment to prevent further blood loss or anemia
Chronic uterine bleeding Has been present for 6 months or longer, abnormal in duration, volume, and/or frequency
Heavy menstrual bleeding Blood loss that interferes with the physical, emotional, social, quality of life, and that can occur alone or in combination with other symptoms
Prolonged menstrual bleeding: Bleeding longer than 8 days
Shortened menstrual bleeding bleeding < 2 days
Light menstrual bleeding reduced amount of bleeding from normal
Intermenstrual bleeding Bleeding between menstrual cycles. Can be cyclic and predictable or follow no particular pattern
Types of Bleeding that is NOT AUB Bleeding before menarche Always requires evaluation • Endocrine cause is likely • Sexual abuse must be considered • Foreign object is a possibility • Requires a very special approach to the history and the exam by someone with expertise in pediatrics
Types of Bleeding that is NOT AUB Bleeding after menopause Always requires evaluation • Reproductive track cancer or pre-cancer is the predominant concern • Requires careful assessment of all of the reproductive organs • Uterus is the most common cause but the vagina, cervix and ovary can all be causes
PALM-COEIN Polyp; Admyosis; Leiomyoma; Malignancy and hyperplasia Coagulopathy; Ovulatory; Endometrial:I atrogenic; not yet classified
Polyp -hyperplastic overgrowths of endometrial glands & stroma form a projection from the surface of the endometrium -great majority are benign Symptoms are intermenstrual bleeding, small volume, after intercourse
Polyp risks • Obesity • Metabolic syndrome (or any of the components) • Postmenopausal women treated with hormones
Adenomyosis Endometrial tissue in the myometrium Contractility affected
Adenomyosis risk factors • Parity • Hx miscarriage • Curettage • Endometrial resection • c/s • tamoxifen use
Adenomyosis symptoms heavy periods, flooding, very painful, subfertility -rarely >12 week size uterus -more common in parous women -prior uterine surgery may be a risk factor -some models suggest estrogen leads to this
Adenomyosis treatment hysterectomy or progetins (LNG IUD) or GnRH analogs (Lupron)
What type of Leiomyoma is less likely to cause AUB Pedunculated fibroid (these fibroids are attached to the uterine wall by a stalk-like growth
Leiomyoma treatment COCs maybe to treat heavy bleeding but won’t treat other symptoms (like pressure, bowel/bladder/bloating).
Endometrial hyperplasia & cancer: Risk factors “OLD aUNT” Obesity Late menopause (after 52) Diabetes mellitus Cancer: Ovarian, breast colon Unopposed estrogen: PCOS, anovulation, hormone replacement Nulliparity Tamoxifen (chronic use)
COEIN Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
Types of Coagulopathy Von Willebrand’s Disease Other considerations: • Hereditary • Congenital afibrinogenemia • Factor V, X, XII defencies • Other • Infectious • Liver failure • Drug reaction
Ovulatory dysfunction Hyperthyroid including vaginal spotting, heavy mensural bleeding or amenorrhea • PCOS, GnRH deficiency, Adrenal tumors • Zebras: kallmann syndrome (hypogonadotropic hypogonadism) – also lack of smell • Non-classical congenital adrenal hyperplasia
Prolacinoma noncancerous tumor (adenoma) of the pituitary gland in your brain overproduces the hormone prolactin and deceased estrogen)
What do high estrogen levels cause High estrogen levels increased thickness of the endometrium = heavy menstrual bleeding
Most common time for woman to experience irregular bleeding beginning and the end of her reproductive life cycle (postmenarche and perimenopause) • HPOA is most affected by the normal life cycle transitions that occur during the first 2 years after menarche and 3 yrs prior to menopause
Characteristics of ovulatory abnormal bleeding • HPOA is intact and steroid hormone profile is normal • Usually uterine fibroids, adenomyosis or endometrial polyps
Endometrial bleeding • r/o other causes • Primary disorder of endometrium with predictable and cyclic menstruation (ie normal ovulation) • Example: endometritis, untreated GC/Chlamydia
Iatrogenic bleeding Corticosteroids, HRT, Anticoagulants (ASA, warfarin) • Psychotropic drugs • SSRIs • Antipsychotics • Digitalis (CHF, irregular heart beat) • Dilantin • Ginsing, ginko, soy protein • And of course hormonal contraceptives • Anticoagulants
Special considerations that can cause AUB Trauma of the genital tract • Tampon irritation • Hymenal tearing • Consensual intercourse
Molimina symptoms occurrence of three or four mild symptoms such as breast tenderness or mastalgia, food cravings, fatigue, sleep problems, headaches, and fluid retention that occur during the luteal phase of the menstrual cycle
Dyspareunia pain when sexual intercourse or other sexual activity that involves penetration is attempted or pain during these activities. The pain may be superficial or deep. It may result from vaginal dryness or disorders of the genital organs.
Lab for AUB CBC; Beta Hcg;Platelets < 150,000; Serum ferritin- decreased levels 2 to 150 ng/mL ; Hypothyroidism or hyperthyroidism- <0.8 or >4.0; FSH- amenorrhea due to menopause or premature ovarian failure- > 30Mu/mL
Dx of abnormal uterine bleeding a woman with a hx of irregular, unpredictable bleeding for 6 months or longer
Additional testing for AUB Transvaginal ultrasound Done between days 4-6 of the menstrual cycle in postmenopausal women Measures endometrial thickness and r/o endometrial carcinoma in women with a thin endometrium (<5 mm) • Sonohysterography or saline infused sonogram if looking f
Hysteroscopy Allows for direct visualization of the endomentrial cavity and permits the clinician to take directed biopsies
Indication for Endometrial bx 30-45 yrs old • Neg B-hCG • Not responded to medical tx • Considered for women age19-29
First line therapy for AUB – treatment of choice COC momophasic: 1 pill 2X day, bleeding should decrease within 24 hrs. if flow doesn’t stop within 48 hrs further evaluation is indicated.
Progestin Stops endometrial growth (offsets the stimulatory effect of E) To induce normal bleeding, progesterone is given for 7 to 10 days each month. Withdrawal bleeding should occur within 2-7 days of d/c progestogen
Treatment for AUB Medroxyprogesterone acetate (Provera, Amen) 10 mg x 10 days • Norethindrone acetate (NETA) 5 mg BID for 10 days • Depo-provera 150 mg IM q 12 wks • Levonorgestrel IUD (Mirena)
Estrogen tx for AUB • Conjugated equine estrogen (CEE) 25 mg IV q 4-6 hr as needed, then 2.5 mg-5 mg PO 4X/day for 2-3 days, then add medroxyprogesterone acetate (MPA) 10 mg for 10-14 days • COC 2X-3X/day, then taper
GnRH analogues for AUB Lupron - leuprolide b. Zoladex - goserelin c. Synarel - nafarelin
Abnormal Uterine Bleeding: Surgical Management • D & C • Endometrial ablation- may work for fibroid • Procedures to remove polyps(Polypectomy)
AUB Fibroids o Resection of submucosal fibroids o Myomectomy o Uterine artery embolization- o Myolysis (myocoagulation - cautery) o Cryolysis (cryotherapy - iceball)
Uterine artery embolization shrink fibroid, moderate to intense cramping and light vaginal bleeding after procedure for a week. Takes 2-3 months to see improvement in menses
Endometrial Ablation Less invasive operative procedure which results in the destruction of the endometrium using heated fluid (contained within a balloon or circulating freely within the uterine cavity), tissue freezing, microwave or radiofrequency electricity.
Candidates for endometrial ablation Cancer has been ruled out no previous myomectomy None distorted uterine cavity Past childbearing Other medical treatments haven't worked
Risk factor for endometrial cancer • > 40 years old; Anovulation; (PCOS); Family hx of endometrial cancer; New onset of heavy irregular bleeding particularly after menopause; Nulliparty; fat • Unopposed estrogen stimulation of endometrium • Tamoxifen therapy, diabeses; Infertility
Menometrorrhagia abnormal uterine bleeding
Created by: shirley.w.wscott



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