Miscellaneous
Physiology
PALM or COEIN
Diagnosis
Treatment
100
"PALM-COEIN" stands for these 9 common etiologies of AUB:
What are: polyps, adenomyosis, leiomyoma, malignancy, hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified?
100
This layer of the endometrium lines the uterine cavity, is very hormonally responsive, and ultimately sloughs during menstruation
What is the functionalis layer? The basalis layer lies beneath the functionalis, is in direct contact with the myometrium, and is less hormonally responsive.
100
Etiology bleeding associated with heavy menses, h/o post-partum hemorrhage, frequent epistaxis
What is COEIN (coagulopathy)
100
These are routine tests (name at least 5) involved in the workup for abnormal uterine bleeding in a 50 yo female
What are: pregnancy test, TSH, Prolactin, EMB, TVUS/SIS, CBC
100
Progestins improve heavy menstrual bleeding by this mechanism
What is stabilizing the endometrial lining, restricting growth (antagonizing estrogen). A progesterone withdrawal can also allow for organized sloughing.
200
Vulvovaginitis, malignancy, trauma, abuse, and foreign bodies are the most common causes of vaginal bleeding in this age group
What is childhood? ADOLESCENT: anovulation, coagulation defects, pregnancy, STD’s, sexual abuse. REPRODUCTIVE AGE: pregnancy, STD’s, leiomyoma, polyps. PERIMENOPAUSE: anovulation, benign/malignant neoplasms. MENOPAUSE: atrophy, polyps, endometrial hyperplasia/carcinoma.
200
Blood is supplied to the uterus mainly by the uterine and ovarian arteries which are branches of these arteries, respectively.
What is the hypogastric (internal iliac) and the aorta. Uterine/ovarian a. --> arcuarte arteries (myometrium) --> radial arteries --> basal/spiral arteries --> sub epithelial capillary plexus
200
Etiology of PCOS bleeding
What is COEIN (nonstructural, anovulatory bleeding) +100 points if team said BOTH; PCOS also increases risk of hyperplasia/malignancy (PALM,)
200
An endometrial stripe in a postmenopausal women of this thickness ( mm) can be used to virtually rule out cancer
What is 4mm or less
200
Lupron treatment is usually limited to 6 months for this reason
What is bone loss
300
Bleeding per cervix is common with these infections (name at least 3)
What is N.gon., C.trach, HSV, trichomoniasis
300
Thyroid dysfunction can cause AUB likely by this mechanism
What is H-P-O axis/anovulation. +300 if team mentions decreased coagulation factors seen in some hypothyroid pts.
300
Etiology of hypothyroid bleeding
What is COEIN (anovulatory bleeding)
300
To biopsy or not to biopsy? Per ACOG, a pt younger than 45 yrs should receive an EMB if she meets these 3 criteria
What is persistent AUB, failed medical management, h/o unopposed estrogen exposure
300
Conjugated equine estrogen (Premarin) can be given for acute menorrhagia at this dosage
What is 25mg IV q4hrs (for 12-24 hrs) or 2.5 mg po QID.
400
Pt’s with a Mirena IUD can be counseled about the bleeding profile in this way
What is… breakthrough bleeding can be expected for around 6 months, followed by amenorrhea in most women. Occasional spotting is common. NSAIDS are first line for breakthrough bleeding and often improve it within 3 months
400
This is the mechanism by which anovulation causes irregular bleeding
What is unopposed estrogen. In the absence of ovulation, a corpus luteum does not develop and the ovary fails to secrete progesterone. This results in continual endometrial proliferation without progesterone-withdrawal-induced shedding and bleeding. The clinical result is bleeding that is noncyclic, unpredictable, and inconsistent in volume. The endometrium that develops in the milieu of unopposed estrogen is fragile, vascular, and lacking sufficient stromal support. As one area of bleeding begins to heal, another area begins to slough, which results in erratic bleeding patterns.
400
Etiology of bleeding associated with bilateral hemianopsia and galactorrhea
What is COEIN (anovulatory bleeding, hyperprolactinemia, pituitary adenoma)
400
DAILY DOUBLE Chronic blood loss causes this type of anemia, and is associated with these lab findings (please list at least 5)
What is Iron deficiency anemia. Low Hgb, low Hct, Low MCV, Low MCH, low MCHC, low ferritin, low serum iron, high TIBC.
400
NSAIDS may improve heavy menstrual bleeding by this mechanism
What is downregulation of prostaglandins. Note: chronic NSAID use can eventually inhibit platelet function and cause the opposite effect.
500
These are the phases of the menstrual cycle pictured, respectively
What is proliferative, secretory, menstrual
500
At the end of a menstrual cycle, progesterone levels drop and cause the release of these factors that are responsible for the breakdown of the stroma integrity
What are matrix metalloproteinases.
500
Etiology of bleeding associated with abnormal saline-infused-sonogram results
What is PALM (structural-polyps, fibroid, malignancy)
500
These findings can distinguish polyps from fibroids on Doppler Ultrasound
What is number of feeding vessels. Polyps usually have only one arterial feeding vessel, while fibroids generally receive blood from several vessels within myometrium
500
Being color-blind is a contraindication for the usage of what drug used to treat acute AUB?
What is Tranexamic acid. Mech of action: antifibrinolysis. TA reversibly blocks binding sites on plasminogen  decreased plasmin  decreased fibrinolysis  fibrin stays intact, bleeding prevented. Theoretical increased risk of VTE, use with caution.
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