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Vaginal Bleeding 3 (reproductive age) (Anatomic causes (Fibroids (the only…
Vaginal Bleeding 3 (reproductive age)
Anatomy & DOE of abnormal uterine bleeding
non-pregnant repro age female :woman::skin-tone-2:
PALM COEIN
(structural causes)
P
olyps
A
denomyosis
L
eiomyomas (fibroids)
M
alignancy :crab:
endometrial or cervical
won't discuss in this lec
(non-structural)
C
oagulopathy
O
varian dysfunction
E
ndometrium
I
atrogenic
IUD's
N
ot yet classified
everything else
Abnormal Uterine Bleeding
Path:
Anovulation
Estrogen predominant
in 1st 1/2 of cycle
increases proliferation
Ovulation @ day 14
Progesterone in 2nd 1/2:
reduces proliferation
No switch to progesterone,
Estrogen predominates
builds endothelium
Endo exceeds vascular supply and dies :skull:
irregular bleeding
(heavy or light)
This is NORMAL near menarche :girl::skin-tone-2: or menopause :older_woman::skin-tone-2:
ABNORMAL: If in reproductive age :woman::skin-tone-2: &
after
normal menses have occurred
its a trash can diagnosis
Dx:
DOE
(-) CBC, TSH, prolactin
(-) US, MRI (suspecting disease only)
Tx:
Decrease stress/anxiety
(HPA causes)
probably won't work
Weight gain
unless person has super low BMI (marathon runner :woman-running::skin-tone-2:) won't help
:pencil2: The above causes amenorrhea,
not
excess bleeding
OCP
(1st line)
= IUD
NSAIDs
can
actually reduce bleeding
predominant uterine effect on
prostaglandins
, not platelets
Continued bleeding = Sx :hocho:
Ablation
Hysterectomy
both cause infertility
but stops the bleeding
Mnemonic: AUB -
"COC 'em, Cut 'em"
PCOS (1 cause of anovulation)
Path: Anovulation
too much E
Atretic follicles
too much Testosterone
Pt:
Fat & Hairy
Endocrine disease
Metabolic Syndrome
HTN
dislipidemia
DM :candy:
obesity
Infertility
Menometorragia
no control over periods
highly variable
Dx: Criteria
Hx of anovulation
just talking to pt about s/s
AND 1 of 2 things
biochemical evidence of
hyperandrogenism
high DHES, T,
LH:FSH >3:1
:stars:
imaging evidence of
lots of follicles
US shows follicles
don't need the US, just use the LH:FSH ratio
(Pretest FM): Progestin Challenge
Progesterone injection causes menses (
withdrawal bleeding
)
indicates theres enough Estrogen, anovulatory cause of amenorrhea
Tx:
weight loss & exercise
positive results, but not used as monotherapy
Metformin
insulin insensitivity
also
helps push them to ovulation
anti-androgens:
Spironolactone
helps w/ the hair
No pregnancy needed
OCPs
= IUD
take control over the cycle
Pregnancy needed
Clomiphene
big push to get those eggs to ovulate
Mnemonic: PCOS-
"COC 'em, Form 'em, Clothe 'em
Anatomic causes
Fibroids
(the only ones we care about)
so common
benign growths
in endometrium
replaces normal looking w/ nodularity
asymmetric nodular uterus
Path: Benign growth
doesn't progress to sarcomas :crab:
estrogen responsive
proliferate during cycles :woman::skin-tone-2:
regress after menopause :older_woman::skin-tone-3:
Pt: Asx (nodularity on PEx)
±
bleeding
±
painful
±
infertility
if they are big enough: visceral obstruction (ureters, bowel, bladder)
Dx:
Transvaginal US
:stars:
best radiographic:
MRI
can distinguish leiomyoma from leiomyosarcoma :crab:
:warning:don't get; too expensive :money_with_wings:, not much benefit
only indication: malignancy suspicion on US
absolute best :stars::stars::
Biopsy
unnecessary, can dx w/ clinical pic & TV US
Tx:
Meds
OCP
(preferred)
we also mean
IUDs
IUDs are hard to plant w/ fibroids
:seedling:
NSAIDs: px control (not monotherapy)
Sx :hocho:
Does she want kids?
Yes: Myom
ectomy
scoops out fibroids
not great, recurrence or Sx/fibroids
maintains fertility
NO; Total Abn
Hysterectomy
high satisfaction rates
Sx but…
Fibroids too big?
Leuprolide
continuous GnRH therapy
shuts off HPA axis, induces menopause :older_woman::skin-tone-2:
then cut them out
Mnemonic: Fibrioids-
" COC em, Cut 'em, Loop 'em"
COC = combined oral contraceptive
Adenomyosis
proliferation of glandular tissue
into myometrium
Thick tissue, narrow lumen
symmetric, smooth, boggy
Polyps
normal feeling uterus
w/ ganglion
in it
can only see when looking inside :eyes:
