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Normal and Abnormal Uterine Bleeding. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series. Objectives for Normal and Abnormal Bleeding. Define the normal menstrual cycle and describe its endocrinology and physiology Define abnormal uterine bleeding - PowerPoint PPT Presentation
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Normal and AbnormalUterine Bleeding
UNC School of MedicineObstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Normal and Abnormal Bleeding
Define the normal menstrual cycle and describe its endocrinology and physiology
Define abnormal uterine bleeding Describe the pathophysiology and identify etiologies of
abnormal uterine bleeding Discuss the steps in evaluation of abnormal uterine
bleeding Explain medical and surgical management options for
patients with abnormal uterine bleeding Counsel patients about management options for abnormal
uterine bleeding
Normal Menstrual Cycle
Basic functional components Hypothalamic-pituitary unit Ovaries Uterus-endometrium
Normal Menstrual Cycle
Proliferative (Follicular) Phase: Days 1-13 Rise in FSH stimulates maturation of ovarian follicle Follicles secrete estrogen as they mature Estrogen stimulates proliferation of the endometrial lining Endometrium reaches maximum thickness in late follicular phase Level of estrogen peaks on day 12-13, stimulating LH surge on day 14 LH surge stimulates ovulation
Normal Menstrual Cycle
Secretory (Luteal) Phase: Days 14-28 After ovulation, FSH and LH cause follicle to transform into corpus luteum Corpus luteum produces progesterone which maintains endometrial lining Microvasculature becomes well-differentiated (spiral arterioles) In absence of fertilization the corpus luteum involutes Fall in progesterone triggers menstruation (endometrial sloughing)
Normal Menstrual Cycle
Normal parameters: Cycle interval: 24 – 35 days Menses: 4 – 7 days Blood loss: 30 – 45 mL
Ovulatory bleeding is cyclic and predictable
Normal Menstrual Cycle
Bleeding that is outside the normal parameters of the menstrual cycle (volume, duration, or interval)
Abnormal Uterine Bleeding (AUB): Polymenorrhea: regular cycle interval < 24 days Oligomenorrhea: regular cycle interval > 40 days Menorrhagia: regular blood loss > 80 mL or menses > 7 days Metrorrhagia: irregular bleeding Menometrorrhagia: heavy and irregular bleeding
Abnormal Uterine Bleeding: Definition
Iatrogenic Exogenous estrogen Intrauterine device (IUD) Heparin, Coumadin
Systemic Hepatic disease Thyroid disease Hyperprolactinemia Renal failure Other Anovulation (DUB)
AUB: Etiology
Trauma Cervical laceration Foreign body
Organic Pregnancy complication Uterine leiomyoma Adenomyosis Endometrial polyp Endometrial hyperplasia Malignancy (cervix, uterus)
Dyscrasias Von Willebrand’s Disease Thrombocytopenia
History Detailed menstrual history (volume, duration, intervals) Symptoms associated with ovulation
e.g. breast tenderness, bloating, mood changes Associated symptoms
e.g. dysmenorrhea, post-coital bleeding, galactorrhea, hirsutism Weight changes Medical history and medications
Pelvic Exam Cervical and vaginal lesions Size, shape of uterus
AUB: Evaluation
Laboratory Urine pregnancy test CBC with platelets Coagulation studies Thyroid studies (TSH, T4) Prolactin
Diagnostic Procedures Pap smear Endometrial biopsy (EMB) Transvaginal ultrasound Hysteroscopy Saline-infusion sonography (SIS)
AUB: Evaluation
Directed at treating the underlying pathology with relief of volume and duration of menses
Medical management NSAID’s Combination hormonal contraceptives (e.g. OCP’s, vaginal ring, patch) Levonorgestrel IUD (Mirena) GnRH agonists (e.g. Lupron) Correct medical condition
AUB: Management (Medical)
Surgical management Endometrial ablation D&C - IF clinically indicated Myomectomy – IF leiomyomata and fertility desired Hysteroscopic resection – IF polyp, submucous myoma Hysterectomy (TAH, TVH, or TLH)
AUB: Management (Surgical)
Abnormal uterine bleeding with no attributable underlying illness or pathology Diagnosis of exclusion! Must exclude all other causes of AUB
Dysfunctional Uterine Bleeding: Definition
Anovulation Polycystic ovary syndrome (PCOS) Obesity Adrenal hyperplasia Luteal phase defect (rare)
DUB: Etiology
Polycystic ovary syndrome (PCOS) Increased circulating androgens aromatize to estrone (E1) Constant, noncyclic, unopposed level of estrogen stimulates growth and
development of the endometrium Estrogen provides feedback to pituitary, resulting in low FSH and high LH Static levels of LH trigger chronic anovulation Without ovulation, progesterone-induced changes do not occur Endometrium outgrows blood supply and sloughs at irregular times in
unpredictable amounts (usually frequent and heavy)
DUB: PCOS
DUB: Etiology
22 44 66 88 1010 28281212 1414 1616 1818 24242020 2222 2626
Menses
Estrogen
Progesterone
Ovulatory Cycle
DUB/Anovulation
Estrogen
Pelvic Exam Cervical and vaginal lesions Size, shape of uterus
Laboratory evaluation Urine pregnancy test CBC with platelets Coagulation studies Thyroid studies (TSH, T4) DHEAS and testosterone, if symptoms of hirsutism Prolactin
Procedures Endometrial biopsy (R/O neoplasia) Transvaginal ultrasound (R/O anatomic lesions)
DUB: Evaluation
Massive Intractable Bleeding Conjugated Estrogens 25 mg IV
Continued Management after Massive Bleeding Conjugated Estrogens 2.5 mg po daily x 25 days Medroxyprogesterone acetate 10 mg for the last 10 days Allow 5-7 days for withdrawal bleed Administer Mirena IUD
DUB: Management (Medical)
Management of Moderate Menometrorrhagia1. Estrogen-Progestin Combination
Conjugated Estrogen 1.25 mg po daily x 25 days + Medroxyprogesterone acetate 10 mg po for last 10 days
OCP x 21 days, with 7 day withdrawal
2. Cyclic Progestin Medroxyprogesterone acetate 10 mg po daily x 10-15 days ea. month Norethindrone acetate 5 mg po daily x 10-15 days ea. month 5 – 7 days menstrual withdrawal should follow cessation ea. month
3. Mirena IUD
DUB: Management (Medical)
Patients who do not respond to medical therapy Patients who do not desire future pregnancies
Management: Endometrial ablation Hysterectomy
DUB: Management (Surgical)
Bottom Line Concepts Abnormal menstruation is one of the most common problems dealt
with in the gynecologic clinic. Understanding of the physiology and endocrinology of the menstrual
cycle is imperative in a thorough evaluation and management of AUB. It is important to rule out unsuspected pregnancies and endometrial
cancer in the evaluation of AUB. Irregular bleeding that is unrelated to anatomic lesions of the uterus is
referred to as dysfunctional uterine bleeding (DUB/anovulatory). Before DUB can be diagnosed, anatomic causes including neoplasia
should be excluded. The primary goal of treatment of DUB is to ensure regular shedding of
the endometrium and consequent regulation of menses. In AUB from other causes it is important to correct underlying
pathology and decrease volume and duration of menses.
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 45 (p96-97).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 35 (p315-319).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 33 (p368-370).