Gynecology Book

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Abnormal Uterine BleedingAka: Dysfunctional Uterine Bleeding, Vaginal Bleeding

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  1. See Also
    1. Oral Contraceptive-Related Uterine Bleeding Management
    2. Lower GI Bleed
    3. Hematuria
  2. Epidemiology
    1. Lifetime risk of Menorrhagia: 33%
    2. Women with Menorrhagia who consult their doctors: 20%
    3. Women who have at least one endometrial sampling: 15%
    4. Women who have Hysterectomy by age 40 years: 10%
    5. Number of hysterectomies for Menorrhagia: 200,000/year
  3. Causes
    1. See Abnormal Uterine Bleeding Causes
  4. Types of Abnormal Uterine Bleeding
    1. Anovulatory Bleeding (90%)
      1. Unopposed Estrogen (Progesterone deficiency)
    2. Ovulatory Bleeding (10%)
      1. Inappropriate endometrial response to normal cycle
      2. Shortened or prolonged life span of corpus luteum
      3. Abnormal Estrogen : Progesterone ratio (low Estrogen)
  5. Symptoms
    1. Anovulatory Bleeding
      1. Change in Amount and Frequency of bleeding
        1. Low Levels of Unopposed Estradiol or Estrogens
          1. Lighter and Less Frequent Menses
        2. High Levels of Unopposed Estradiol or Estrogens
          1. Prolonged periods of Amenorrhea
          2. Heavy Withdrawal Bleeding
      2. Lack of premenstrual signs
        1. Progesterone absent: no bloating or Breast Pain
    2. Ovulatory Bleeding
      1. Change in Amount of bleeding, normal cycle intervals
        1. Menorrhagia (over 80 ml per cycle)
        2. Prolonged bleeding (7 days or more per cycle)
      2. Premenstrual Symptoms are present
  6. Evaluation: History
    1. Red Flags suggestive of pathology
      1. Post-coital Bleeding (Cervical Cancer)
      2. Perimenopause, postmenopausal patient (Malignancy)
        1. See Postmenopausal Bleeding
    2. Pelvic Pain
      1. See Uterine Bleeding in Pregnancy
      2. Consider Pelvic Inflammatory Disease
      3. Consider trauma (e.g. sexual abuse)
    3. Pregnancy Symptoms
    4. Bleeding Disorder
    5. Endocrinopathy
      1. Hypothyroidism and Hyperthyroidism symptoms
      2. Hyperandrogenism (e.g. PCOS)
      3. Hyperprolactinemia (e.g. Galactorrhea)
  7. Labs
    1. Initial testing
      1. Urine Pregnancy Test (bHCG)
      2. Pap Smear
      3. Chlamydia screen
      4. Thyroid Stimulating Hormone (TSH)
      5. Serum Prolactin
      6. Complete Blood Count (CBC) with platelets
      7. Consider ureaplamsa culture
    2. Additional Testing to Consider
      1. Glucose to Insulin Ratio
      2. Hyperandrogenism labs
      3. Coagulation studies
        1. ProTime (PT)
        2. Partial Thromboplastin Time (PTT)
        3. Bleeding Time (Von Willebrand's Disease suspected)
  8. Diagnostics: Evaluation over age 35 years
    1. Combination approach may be best
      1. Endometrial Cancer screening
        1. Endometrial Biopsy or
        2. Dilatation and Curretage
      2. Structural evalutaion
        1. Transvaginal Ultrasound or
        2. Hysteroscopy
    2. Non-Invasive investigation
      1. Transvaginal Ultrasound
        1. Consider Endometrial Biopsy for stripe >5 mm
        2. Cancer is very unlikely if stripe <3 mm
        3. Saline infusion improves sensitivity
          1. False positive rate is increased
      2. Endometrial Biopsy
        1. See Endometrial Biopsy for efficacy
        2. Sensitive and specific for Endometrial Cancer
          1. Misses endometrial polyps
        3. Insufficient samples are common (no glandular cell)
          1. Requires other study (non-diagnostic)
    3. Invasive procedures (performed by gynecology)
      1. Dilatation and Curettage
        1. No significant advantage over Endometrial Biopsy
      2. Hysteroscopy
        1. Insufflation with carbon dioxide or warmed saline
          1. Risk of tumor dissemination
        2. Flexible 3 mm hysteroscope (Same size as Pipelle)
        3. Improves diagnosis with D&C and Endometrial Biopsy
          1. Identifies most structural lesions (e.g. polyps)
  9. Evaluation Protocols
    1. See Anovulatory Bleeding
    2. See Ovulatory Bleeding
    3. See Postmenopausal Bleeding
  10. Reference
    1. Nelson (1997), Fam Prac Recert 19(8):14
  11. Resources: Patient Education
    1. Information from your Family Doctor
      1. http://www.familydoctor.org/handouts/470.html

Metrorrhagia (C0025874)

Definition (MSH)Abnormal uterine bleeding that is not related to MENSTRUATION, usually in females without regular MENSTRUAL CYCLE. The irregular and unpredictable bleeding usually comes from a dysfunctional ENDOMETRIUM.
ConceptsPathologic Function (T046)
ICD9626.6
BasqueHILEROKOARTEKO ODOLJARIOA ETA ZIKLOKO BESTE ZENBAIT NAHASTE
DanishIntermenst blodn og an cyklusforst
DutchIntermenstrueel bloedverlies
EnglishBleeding Between Periods, BLEEDING BREAKTHROUGH, BLEEDING INTERMENSTRUAL, Bleeding on the pill, Bleeding unrelated to menstrual cycle, Breakthrough bleeding, DYSFUNCTIONAL UTERINE BLEEDING, Dysfunctional Uterine Bleedings, Dysfunctional uterine haemorrhage, Dysfunctional uterine hemorrhage, Intermenstrual bleeding, Irreg.intermenst.bleed., Irregular intermenstrual bleeding, METRORRHAGIA, Spotting, SPOTTING BETWEEN MENSES, Spotting between periods
FinnishVALIVUOTO
FrenchSaignement intermenstruel
Germanintermenstruelle Blutung
Hungariankozti verzes
ItalianSanguinamento intermestruale
Spanishhemorragia intercurrente, Hemorragia intermenstrual, metrorragia, pérdidas entre períodos menstruales, perdidas entre periodos menstruales, sangrado intermenstrual, sangrado intermenstrual anormal, sangrado uterino disfuncional, sangrando no relacionado con el ciclo menstrual
SwedishINTERMENSTRUELL BLODNING
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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