Nur auf Docsity: Lade Abnormal Uterine Bleeding und mehr Übungen als PDF für Corporate Finance herunter!
Abnormal
Uterine
Bleeding
Here is a comprehensive educational resource on Abnormal Uterine Bleeding (AUB) , designed for advanced study in reproductive endocrinology and gynecology. It covers the core science, diagnostic workup, advanced hormonal evaluation, clinical case studies, and exam-style questions with detailed answers.
📘 Part 1 : Comprehensive Core Notes – Abnormal Uterine Bleeding (AUB)
1. Definition & Terminology
Abnormal uterine bleeding (AUB) refers to any variation from normal menstrual cycle parameters in terms of regularity, frequency, duration, or volume in a non-pregnant, reproductive-aged woman. The FIGO (International Federation of Gynecology and Obstetrics) PALM-COEIN classification system (2011, updated 2018) is the gold standard for categorizing causes. Normal menstrual parameters (FIGO):
- Regularity: Variation ≤ 7–9 days between cycles
- Duration: 4.5–8 days (average 5 days)
- Volume: 5–80 mL (subjective: no clots larger than a quarter, no flooding) Key AUB terminology:
- Heavy menstrual bleeding (HMB): Excessive menstrual blood loss that interferes with physical, emotional, social, or material quality of life. Previously called menorrhagia.
- Intermenstrual bleeding (IMB): Bleeding between regular cycles.
- Prolonged bleeding: Duration > 8 days.
- Frequent bleeding: Cycles < 24 days.
- Infrequent bleeding: Cycles > 38 days.
- Irregular bleeding: Cycle-to-cycle variation > 7–9 days in an individual.
- Postcoital bleeding (PCB): Bleeding after intercourse (often cervical cause).
- Postmenopausal bleeding (PMB): Bleeding after 12 months of amenorrhea in a woman of menopausal age.
2. The PALM-COEIN Classification System
This system divides causes of AUB into structural (PALM) and non-structural (COEIN) categories.
CategoryConditionKey FeaturesDiagnosis PPolypEndometrial or cervical polyp; often asymptomatic but can cause IMB or HMBSaline infusion sonography (SIS), hysteroscopy
AAdenomyosisEndometrial glands and stroma within myometrium; causes dysmenorrhea and HMBMRI or TVUS (myometrial cysts, thickening)
LLeiomyoma (fibroid)Submucosal (most likely to cause HMB), intramural, subserosalTVUS, SIS, MRI
MMalignancy / hyperplasiaEndometrial cancer or atypical hyperplasia (risk factors: age >45, obesity, unopposed estrogen)Endometrial biopsy or D&C
- Characterize bleeding: regularity, frequency, duration, volume (pads/tampons per day, clots, flooding).
- Cyclic vs. acyclic: Ovulatory bleeding is cyclical; anovulatory is irregular.
- Associated pain (dysmenorrhea suggests adenomyosis or fibroids).
- Postcoital bleeding (cervical cause).
- Risk factors for endometrial cancer: age ≥45, obesity (BMI >30), unopposed estrogen (PCOS, anovulation), tamoxifen use, Lynch syndrome.
- Bleeding disorder screening: HMB since menarche, postpartum hemorrhage, surgical bleeding, easy bruising, family history.
- Medications: anticoagulants, hormonal contraceptives, IUDs, tamoxifen.
- Pregnancy: always rule out.
- Physical Examination :
- Vital signs (hemodynamic stability).
- Pelvic exam: assess for cervical lesions, polyps, uterine size/shape, adnexal masses, tenderness.
- Signs of bleeding disorder: petechiae, ecchymoses.
- Signs of endocrinopathy: hirsutism, acanthosis nigricans (PCOS), thyromegaly, galactorrhea.
- Pregnancy Test : Urine or serum hCG in all reproductive-aged women.
- Complete Blood Count (CBC) : Assess for anemia (Hb, Hct) and thrombocytopenia.
B. Advanced Hormonal Evaluation (Based on Presentation)
Hormonal testing is essential when ovulatory dysfunction (O) is suspected or for evaluating endocrine causes.
TestOptimal TimingRationale & Interpretation | Serum progesterone | Mid-luteal (day 21 of 28-day cycle, or 7 days before expected menses) | >10 nmol/L (3 ng/mL) confirms ovulation; <10 suggests anovulation. | | TSH, free T4 | Any day | Hypothyroidism (↑TSH) causes anovulation and AUB. Hyperthyroidism can also cause oligomenorrhea. | | Prolactin | Fasting, morning | Hyperprolactinemia suppresses GnRH → anovulation. Exclude hypothyroidism first. | | FSH, LH, Estradiol (E2) | Cycle day 2–4 | FSH >10–15 suggests ovarian aging/perimenopause. LH/FSH >2–3 suggests PCOS. Low FSH/LH + low E2 suggests hypothalamic amenorrhea. | | Androgens (total/free testosterone, DHEA-S) | Cycle day 2–4 | Elevated in PCOS and NCAH (non- classic congenital adrenal hyperplasia). | | AMH | Any day | Low AMH (<1.0) indicates diminished ovarian reserve (perimenopause). High AMH (>4) suggests PCOS. | | 17-hydroxyprogesterone (17-OHP) | Follicular phase, morning | Screening for NCAH if hyperandrogenism and not PCOS. ACTH stimulation test if borderline. |
C. Imaging & Structural Evaluation
- Transvaginal ultrasound (TVUS) : First-line for all women with AUB. Evaluates endometrial thickness (ET), fibroids, polyps, adenomyosis, and ovarian pathology.
- Endometrial thickness <12 mm in premenopausal women is reassuring. In postmenopausal bleeding, ET >4 mm requires biopsy.
- Saline infusion sonography (SIS) or hysteroscopy : Gold standard for evaluating the endometrial cavity (polyps, submucosal fibroids, adhesions).
- Magnetic resonance imaging (MRI) : Reserved for complex cases (deep adenomyosis, multiple fibroids for surgical planning).
D. Endometrial Sampling (Indications)
- Age ≥45 with AUB (especially if persistent or new-onset).
- Age <45 with risk factors for endometrial cancer (obesity, PCOS, Lynch syndrome, unopposed estrogen).
- Failed medical therapy.
- Persistent intermenstrual or postmenopausal bleeding.
- FSH variable (often >10–20 IU/L, may be into menopausal range >40).
- AMH low (<1.0 ng/mL) or undetectable.
- Estradiol may be normal or intermittently high due to persistent follicles.
- Progesterone low or absent (anovulatory cycles common).
3. PCOS-Related AUB
- LH:FSH ratio >2–3 (often LH 10–20, FSH 4–6).
- Testosterone elevated (free testosterone >0.5 ng/dL typically).
- AMH >4.0 ng/mL.
- Oligo-ovulation leads to prolonged proliferative endometrium → irregular, heavy bleeding.
🏥 Part 4 : Clinical Case Studies
Case Study 1: Heavy Menstrual Bleeding from Menarche – Coagulopathy
History: A 19-year-old woman presents with heavy bleeding since her first period at age 12. She changes a super-plus tampon every 1–2 hours on days 2–3 of her cycle, passes large clots, and has flooding. She also has easy bruising and had prolonged bleeding after wisdom tooth extraction. No other medical problems. Physical exam: Normal; no pelvic tenderness. Normal vital signs. Workup:
- CBC: Hb 9.5 g/dL (moderate anemia), platelets normal.
- TSH, prolactin: normal.
- Transvaginal ultrasound: normal endometrial stripe, no fibroids or polyps.
- Coagulation studies: PT normal, PTT prolonged. Von Willebrand factor antigen: 18% (normal 50–200). Ristocetin cofactor: 20%. Factor VIII: 25%. Diagnosis: Von Willebrand disease (Type 1) presenting with heavy menstrual bleeding (AUB-C). Management:
- Hematology consultation.
- For acute bleeding: Tranexamic acid 1300 mg three times daily or desmopressin (DDAVP) nasal spray.
- Long-term: Combined oral contraceptive (regulates cycles and raises vWF levels) or levonorgestrel- releasing IUD (Mirena) – highly effective for HMB.
- Iron supplementation. Outcome: Mirena IUD placed; within 6 months, bleeding reduced to normal volumes, Hb normalized.
Case Study 2: Perimenopausal Anovulatory Bleeding
History: A 48-year-old woman with irregular cycles for 2 years now reports heavy bleeding for 10– 12 days every 3–4 weeks, requiring double protection. She has hot flashes and night sweats. No dysmenorrhea. BMI 32. Physical exam: Normal pelvic exam; uterus normal size. Workup:
- Pregnancy test: negative.
- CBC: Hb 10.2 g/dL.
- TSH: 1.8, prolactin: 12.
- FSH: 28 IU/L, AMH: 0.4 ng/mL.
- TVUS: Endometrial thickness 10 mm (normal for late proliferative), no focal lesions.
- Endometrial biopsy: proliferative endometrium (no hyperplasia or malignancy).
- Surgical: Hysteroscopic myomectomy (definitive, preserves uterus).
- Preoperative GnRH agonist (leuprolide) for 2–3 months to shrink fibroid and correct anemia.
- Alternative (if no desire for future fertility): Endometrial ablation or hysterectomy. Outcome: After leuprolide, Hb rose to 11.5; hysteroscopic myomectomy performed. Menses normalized postoperatively.
Case Study 4: Postmenopausal Bleeding – Endometrial Hyperplasia
History: A 62-year-old woman, G3P3, has had no periods for 12 years. She presents with painless vaginal spotting for 1 week. BMI 34. No hormone therapy. History of hypertension. Physical exam: Atrophic vaginal mucosa, no visible lesions. Uterus small, non-tender. Workup:
- TVUS: Endometrial thickness 8 mm (postmenopausal normal <4 mm).
- Endometrial biopsy: Complex endometrial hyperplasia with atypia (premalignant). Diagnosis: Endometrial hyperplasia with atypia (AUB-M – malignancy/hyperplasia). Management:
- Total hysterectomy with bilateral salpingo-oophorectomy (gold standard due to high risk of progression to cancer).
- No hormone therapy. Outcome: Final pathology confirmed complex atypical hyperplasia without carcinoma. Recovered uneventfully.
Case Study 5: Iatrogenic AUB from Anticoagulation
History: A 55-year-old woman with atrial fibrillation on warfarin presents with heavy, prolonged menses. She had regular cycles until 1 year ago; now in late perimenopause. She reports no other bleeding sites. Workup:
- INR: 3.2 (therapeutic range 2–3).
- TVUS: Endometrial thickness 6 mm, no structural lesion.
- Endometrial biopsy: atrophic (consistent with perimenopause). Diagnosis: Iatrogenic AUB due to anticoagulation (AUB-I) in the setting of perimenopause. Management:
- Tranexamic acid (contraindicated with warfarin? Use caution – increased thrombotic risk. Not recommended with anticoagulation).
- Levonorgestrel IUD (Mirena) – reduces menstrual blood loss without systemic hormones; safe with warfarin.
- Consider reducing warfarin target INR if clinically appropriate (cardiology consult).
- Iron supplementation. Outcome: Mirena IUD placed; bleeding reduced by 80% within 3 months.
📝 Part 5 : Exam-Style Questions & Answers
Multiple Choice Questions
Q1: A 42-year-old woman with BMI 38 and known PCOS presents with heavy, irregular bleeding for 6 months. She is not trying to conceive. Which of the following is the most appropriate initial treatment to control bleeding while addressing the underlying anovulation?
D) Recommend hysterectomy. > Answer: C > Explanation: At age 51 with persistent AUB and endometrial thickness >12 mm (or any thickness > mm in a postmenopausal woman), endometrial sampling is required to exclude hyperplasia or cancer. She is not yet postmenopausal (9 months amenorrhea), but guidelines favor biopsy for thickness > mm in perimenopause. Q4: A 35-year-old with a 5 cm intramural fibroid and heavy bleeding desires future pregnancy. Which treatment is most appropriate? A) Hysterectomy. B) Uterine artery embolization. C) Myomectomy (abdominal or hysteroscopic depending on location). D) Endometrial ablation. > Answer: C > Explanation: Myomectomy preserves fertility and reduces bleeding. Hysterectomy and endometrial ablation preclude pregnancy. Uterine artery embolization may compromise ovarian reserve and is not recommended for those desiring fertility. Q5: A 46-year-old woman reports intermenstrual spotting for 3 months. She is using no hormones. TVUS shows a 1.5 cm echogenic endometrial polyp. Endometrial biopsy is benign. What is the best management? A) Observation (most polyps are benign and may regress). B) Hysteroscopic polypectomy. C) Total hysterectomy. D) Oral progestins. > Answer: B
> Explanation: Symptomatic polyps (intermenstrual bleeding) should be removed hysteroscopically. Hysterectomy is excessive. Observation is acceptable if asymptomatic, but she has bleeding. Progestins do not treat polyps.
Short Answer Questions
- Q: List the four indications for endometrial biopsy in a woman with AUB. A: 1) Age ≥45 years. 2) Age <45 with risk factors for endometrial cancer (obesity, PCOS, unopposed estrogen, Lynch syndrome). 3) Failed medical therapy with persistent AUB. 4) Ultrasonographic endometrial thickness >12 mm (premenopausal) or >4 mm (postmenopausal).
- Q: What is the FIGO PALM-COEIN classification for a patient with anovulatory bleeding related to PCOS? A: AUB-O (ovulatory dysfunction).
- Q: How does the levonorgestrel-releasing IUD (Mirena) reduce heavy menstrual bleeding? A: It releases progestin locally, causing endometrial atrophy, suppression of proliferation, and reduction in prostaglandin synthesis, leading to a marked decrease in menstrual blood volume (up to 90 – 95% reduction).
- Q: A 22-year-old athlete with BMI 17 and secondary amenorrhea presents with 2 weeks of light spotting. Her FSH is 3 IU/L, LH 2 IU/L, estradiol 20 pg/mL. What is the diagnosis and most appropriate next step? A: Diagnosis: Hypothalamic amenorrhea (functional hypothalamic amenorrhea due to low energy availability). Next step: Rule out pregnancy, then address lifestyle (increase caloric intake, reduce exercise intensity). Hormonal workup is otherwise consistent. No immediate hormone therapy needed unless she desires bone protection.
- Q: Name three medications that can cause iatrogenic AUB. A: Anticoagulants (warfarin, apixaban), tamoxifen, hormonal contraceptives (especially during the first months or with progestin-only pills), and some antipsychotics (risperidone) that elevate prolactin.
AUB), please let me know.
