Transcript 8th Edition APGO Objectives for Medical Students

8th Edition APGO Objectives
for Medical Students
Normal and Abnormal
Bleeding
Rationale
The occurrence of bleeding at times other
than expected menses is a common
event. Accurate diagnosis of abnormal
uterine bleeding is necessary for
appropriate management.
Objectives
The student will be able to:
 Describe endocrinology and physiology of the
normal menstrual cycle
 Distinguish abnormal uterine bleeding from
dysfunctional uterine bleeding
 List causes of abnormal uterine bleeding
 Evaluate and diagnose abnormal uterine
bleeding
 Describe therapeutic options
Normal Menstrual Cycle
Basic functional components
 Hypothalamic-pituitary unit
 Ovaries
 Uterus-endometrium
Normal Menstrual Cycle
Normal parameters
 Cycle interval 28 days + 7 days
 Duration of menstrual flow - 4-7 days
 Average blood loss - 30-45 mL
 Ovulatory bleeding is cyclic and
predictable
Normal Menstrual Cycle
Follicular phase (days 1-13)
 Rapid endometrial growth due to
stimulation by ovarian estrogen
 Regeneration in region of glandular
stumps
 Maximum thickness in late follicular
phase
Normal Menstrual Cycle
Luteal phase (days 14-28)
 Dependent upon ovulation (day 14) and
development of corpus luteum,
progesterone production
 Progesterone inhibits further
endometrial thickness
 Microvasculature becomes welldifferentiated (spiral arterioles)
Normal Menstrual Cycle
Menstrual phase

Fall in progesterone as corpus luteum
involutes

Vasoconstriction → ischemia and hemorrhage

Release of PGF2α

Hemostasis
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
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Platelet plugs
Vasoconstriction
Regeneration of functional layer (estrogen
stimulation)
Normal Menstrual Cycle
Hormonal changes
 LH peaks day 14
 FSH is slightly increased day 14 and
day 27-28
 Estradiol peaks day 12-13
 Progesterone peaks day 18-22, then
falls
 Inhibin increased in luteal phase
Normal Menstrual Cycle
Pathways of ovarian steroidogenesis
 ∆ 4 → Estradiol, testosterone
androstenedione
 ∆ 5 → Dehydroepiandrosterone;
Dihydrotestosterone
Abnormal uterine bleeding
Definition
 Excessive flow or prolonged bleeding
 Frequent bleeding episodes
 Prolonged intervals between bleeds
 Organic cause (structural or systemic) vs.
hormonal dysfunction
Abnormal uterine bleeding
Terminology
 Hypermenorrhea/menorrhagia
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Regular bleeding
Prolonged bleeding >7 days
Excessive bleeding >80 mL
Metrorrhagia - irregular bleeding at frequent
intervals
Polymenorrhea - regular uterine bleeding at
intervals <21 days
Intermenstrual - bleeding between regular and
identifiable periods
Oligomenorrhea - bleeding at intervals >40
days
Menorrhagia
Affects approximately 15% of adult women
Etiology - pathologic conditions
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Bleeding disorders
Leiomyomas
Adenomyosis
Thyroid dysfunction
Chronic endometritis
Endometrial polyps or hyperplasia
Estrogen-producing tumors Cervical or endometrial
cancer Intrauterine device Anovulation (dysfunctional
uterine bleeding)
Menorrhagia
Laboratory evaluation
 Urine pregnancy test
 CBC with platelets
 EMB (endometrial biopsy)
 Thyroid functions (TSH)
 Coagulation studies
 Pelvic sonography
Menorrhagia
Medical management
 Prostaglandin synthetase inhibitors
 Combination hormonal contraceptives
 Progestins
 Correct medical conditions
Menorrhagia
Surgical management
 D&C - if clinically indicated
 Myomectomy - if leiomyomata are cause
and fertility desired
 Hysteroscopy with lesion resection
 Endometrial ablation
 Hysterectomy
Intermenstrual bleeding
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Unpredictable
Generally associated with structural
abnormalities
Differential diagnosis
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Ovulatory (Mittelschmerz)
Inflammatory - endometritis
Structural
• Malignancy
• Leiomyomas
• Polyps

Iatrogenic
• Oral contraceptives
• Hormone Replacement Therapy (HRT)
Anovulatory (dysfunctional) uterine
bleeding
Etiology
 Obesity
 Adrenal hyperplasia
 Polycystic ovary syndrome (PCO) - increased
ovarian production of androgens, insulin
resistance, chronic anovulation
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Increased circulating androgens aromatized to E1
(estrone) providing negative feedback to pituitary
Low FSH (due to chronic elevation of estrogens) and
high LH - static levels do not trigger ovulation
Anovulatory (dysfunctional) uterine
bleeding
Etiology
 Obesity
 Adrenal hyperplasia
 Polycystic ovary syndrome (PCO) - increased ovarian
production of androgens, insulin resistance, chronic
anovulation


Increased circulating androgens aromatized to E1 (estrone)
providing negative feedback to pituitary
Low FSH (due to chronic elevation of estrogens) and high LH static levels do not trigger ovulation
Anovulatory (dysfunctional) uterine
bleeding
Laboratory evaluation
 Urine pregnancy test
 CBC with platelets
 DHEAS and testosterone, if symptoms of
hirsutism
 Endometrial biopsy (R/O neoplasia)
 Thyroid stimulating hormone (TSH)
Anovulatory (dysfunctional) uterine
bleeding
Medical management
 Combination hormonal contraceptives
 Progestins (cyclic or continuous)
 Weight reduction/exercises
 Metformin
References
Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology,
symptomatology, and management. Fertil Steril 36:433-445, 1981.
American College of Obstetricians and Gynecologists Practice Bulletin
#16, Surgical Alternatives to Hysterectomy in the Management of
Leiomyomas, ACOG: Washington, DC, May 2000.
Adapted from Association of Professors of Gynecology and Obstetrics
Medical Student Educational Objectives, 7th edition, copyright
1997
Clinical Case
Normal and Abnormal
Uterine Bleeding
Patient Presentation
41-year-old G2P0020 LMP=10 days ago presents with persistent
heavy vaginal bleeding. She denies dizziness, but complains of
feeling weak and fatigued. Her cycles have been heavy for a long
time, but seem to be worsening over the last several months. Her
cycles come every 28-35 days and she bleeds for 7-10 days. She
describes bad cramps, passing clots and using 2 boxes of maxi
pads each cycle. She is worried about losing her job if the bleeding
is not better controlled. She only gets designated break times from
the assembly line to use the bathroom. She takes Ibuprofen every
4-6 hours for cramps. She denies any bleeding disorders in the
family. She uses condoms for contraception. She also complains of
a pressure sensation and increased urinary frequency.
Allergies: None; Medications: Ibuprofen as needed
Patient Presentation
Ob-Gyn history Menarche 13/cycles 28-35 days/ 7-10 days.
Normal pap smears. History of Gonorrhea once and treated
1 elective termination at 16-years-old and 1 miscarriage at 10
weeks, about 2 years ago
Past medical history None
Past surgical history D & C for miscarriage; tonsils and adenoids as
a child
Social history Nonsmoker. Occasional alcohol. No drugs. Works at a
factory for machine parts assembly.
Family history Hypertension in mother and father. Mother had 1
miscarriage and 3 sons. Her brothers are healthy and one has
sickle trait. Her paternal grandfather died of lung cancer.
Patient presentation
ROS Negative, except as noted above.
Physical exam VS: BP=130/88; Pulse= 110; Respirations= 18; Ht=5’6’;
Wt=150 pounds
African-American women who appears pale and with bags under her eyes
HEENT: NC and AT
Lungs: clear to auscultation and percussion
CV: rapid rate, no murmurs
Breasts: Non-tender, no masses, no dimpling, retraction or discharge
Abdomen: Non-tender, No hepatomegaly, firm palpable mass in the lower
abdomen
Extremities: Non-tender, no edema, 2+/= DTRs bilaterally
Pelvic exam: Normal external genitalia; moist and pink vagina with rugae
and dark blood in the vault; cervix is non-tender, no lesions, and
nullipara; uterus is 16 weeks size, firm, mobile, non-tender; adnexae:
non-tender, no palpable masses
Patient presentation
Laboratory/studies
Hbg: 9.0, HCT: 27%
HCG: negative
TSH: 3.5 uIU/mL (Normal range: 0.4-4.0)
Prolactin: 19 ng/dl (Normal range <20)
PT/PTT: normal
Urinalysis: negative for infection
Endometrial biopsy: Proliferative endometrium
Pelvic Ultrasound: Multiple myomas (intramural and
submucosal in location), Normal ovaries
Diagnoses
Menorrhagia
 Anemia
 Leiomyomatous uterus
 Possible anovulation (when her cycles are
greater than or equal to 35 days)

Treatment
This patient was treated with GnRH analog for three months.
Her hemoglobin increased to 12. She had some minor
spotting during therapy. She complained of hot flushes and
irritability. Her follow-up examination at 2.5 months of therapy
showed a decrease in uterine size to 12-14 weeks size. Her
repeat ultrasound confirmed these findings. She was
counseled regarding medical management with oral
contraceptives, progestins or continued GnRH analog with
hormonal add-back. Given the presence of submucosal
myomas, it is likely that this treatment may not be effective in
the long run. However, she has had an optimal response
thus far.
Treatment
She was also counseled regarding surgical management.
If she is interested in maintaining her fertility, her
options include: hysteroscopic resection of submucosal
myomas only or abdominal myomectomy. If fertility is
not desired and she wants a definitive therapy, then a
hysterectomy is indicated. Risks and benefits for these
medications and surgeries were discussed. This patient
is at increased risk for requiring a blood transfusion if
the bleeding recurs and is heavy, or if the bleeding is
significant during surgery. She will think about her
options and decide over the next week.
Teaching points
1.
2.
Leiomyomas occur with a high prevalence of 25-50% of women
(Buttram and Reiter). They are more common in the AfricanAmerican population.
If this patient did not respond to the gonadotropin agonist therapy
and the bleeding worsened, she would have been a candidate
for high dose oral contraceptives, high-dose Premarin
intravenously or a D&C to control her bleeding. If none of these
options were effective, a uterine artery embolization or
hypogastric artery ligation could be options prior to hysterectomy.
In the near future, other medical therapies may become
standard. Currently, gonadotropin-releasing hormone
antagonists and progesterone antagonist mifepristone (RU 486)
are under investigation. Gene therapies may be developed as
we learn more about leiomyoma formation and growth.
Teaching points
3. After a myomectomy, the recurrence rate of
leiomyomas ranges from 27-51%. Approximately, 15%
require another operative procedure. The incidence of
re-operation is increased with multiple myomas (26%)
as opposed to a single myoma (11%).
4. It is important to rule out the other differential
diagnoses in women with leiomyomas, i.e. pregnancy
with possible incomplete abortion or ectopic, thyroid
disease, endometrial cancer, etc). These disorders are
also present in these women and we cannot assume
we have the correct diagnosis unless tested.