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Abnormal Uterine Bleeding - Coggle Diagram

- - - - Endometrial
        
        Rounded tissue with endometrial glands, endometrial stroma, and thick walled vessels
      - Endocervical
        
        Rounded tisue with mucinous endocervical cells with invaginations, thick walled vessels and fibrous core
    - - All symptomatic polyps should be removed
      - If symptomatic Remove if
        
        1.5 cm, multiple polyps, prolapsed through cervix, infertility, risk of endometrial cancer
        
        Remove endometrial in all postmenopausal women
  - - - Ectopic endometrial glands and stroma within uterine musculature
      - Hypertrophy and hyperplasia of surrounding myometrium diffusely enlarged uterus (globular)
    - - Endymyometrial invagination vs mullerian rests
    - - Uniformly enlarged, boggy uterus, thickened myometrium
    - - Heavy menstrual bleeding, painful menstruation, chronic pelvic pain, enlarged globular uterus on exam
    - - By histopathology (hysterectopy)
      - Preoperative
        
        Clinical manifestations (menorrahgia, dyusmehorrhea, enlarged uterus), MRI is best imaging
    - - Hormonal Options
        
        Progestins, GnRH analogs, aromatsase inhibitors
      - Hysterectomy
        
        Definitive treatment
      - Conservative Surgery
        
        Endometrial ablation or resection
        
        Laparoscopic myometrial electrocoagulation
        
        Excision of adenomyosis
      - Uterine artery embolization
  - - - AUB, Pelvic pain or pressure, infertility or adverse pregnancy outcomes
    - - Uterus sectioned at coronal plane, well circumscribed tumor in the myometrium
    - - Incidence is 2-3 fold greater in black women, early menarche, red meats, alcohol
    - - Abnormal uterine bleeding
        
        Most common symptom, heavy prolonged menses, anemia, social embaressment, degree determined by fibroid location
      - Pelvic pressure, and Pain
        
        Bulk related symptoms, Dysmenorrhea, Dysparunia, Fibroid degeneration, torsion
      - Reproductive dysfunction
        
        Submucsal/intramural fibroids, diffiuclty conceiving, increased risk of misscarriage, adverse pegnancy outcomes
    - - Bimanual pelvic examination (enlarged uterus), speculum exam (prolapsed submucous fibroid)
    - - Transviginal Ultrasound (TVS)
        
        Most widely use modality
      - Saline infusion sonography
        
        Improved assessment of intracavitary fibroids
      - Diagnostic Hysteroscopy
        
        Ca be perfomed in office, saline, CO2 distension media
      - MRI
        
        To distinguish among leiomyomas, adenomyosis, and adenomyomas, reserved for complex surgical planning
    - - Medical management
        
        Estrogen, progestin contraceptives (Mirena IUD, Progestin Injections, Progestin Pills, GnRH agonists/antagonists, SPRMs
      - Surgical Management
        
        Myomectomy: hysteroscopy/Laparoscopy, Hyesterectomy: vaginal/Laparoscopic/Abdominal
  - - - Proliferation of endometrial glandfs that may progress or coexist with endometrial cancer, result of unopposed estrogen stimulation
      - Women may present with abnormla uterine Bleeding
    - - INidcations for EMB in women wioth abnormal uterine bleeding
        
        40 years, risk factors for cancer, failure of medical treatment, signifciant intermenstrual bleeding
    - - Endometrial hyperplasia
        
        Increased number of glands with less stroma betweeen
      - Atypical Endometrial Hyperplasia
        
        Increased number of glands with less stroma and nuclear atypia
      - Endometrial Carcinoma
        
        Bakc to back glands without stroma
    - - Pre-menopausal
        
        Fertility Sparing : High progestin therapy
        
        Completed childbearing: Total Hysterectomay
      - Post-menopausal
        
        Total Hysterectomy, bilateral salpingooophorectomy
- - - - Postpartum hemorrha,ge surgery related, bleeding with dental work
      - Brusing 1-2 times per month, epistaxix 1-2 times per month, frequent gum bleeding, FHx of bleeding
    - - CBC, Blood smear, Ferritin, Coagulation Panel
      - Plasma vWF, Ristoceitin, Factor VIII activity
    - - If pregnancy is desired
        
        Combined oral contraceptives, levonorgestrel-releasing IUS, Endometrial ablation
      - If pregnancy desired
        
        Antifibrinolytics, Factor replacement, dDAVP at onset of menses
  - - - Obesity, low body weight, weight change, psychological stress, elite athletes, endocrinopathy, idiopathic
  - - - Disorder of endometrial hemostasis
      - Endometrial inflammation/infection
      - Abnormal local inflammatory response
      - Abnormal vasculogenesis
  - - - Exogenous gonadal steroids (estrogens, progestogens, adnrogens)
      - Gonadal steroid related therapy (GnRH agonists, aromatase inhibitrs, SERMs, SPRMs)
    - - IUD
      - Inert
      - Copper
      - Progestin
    - - Antipsychotics, Antidepressants, corticosteroids, anticoagulants, herbs