ETIOLOGIES
You should consider this etiology when a patient presents with INTERMENSTRUAL BLEEDING?
Polyps-cervical and endometrial
For the Levonorgestrol IUD, it can take as long as __- ___ months to see stability in the bleeding pattern
6-12m
These are the first lab tests to do when evaluating AUB in addition to a pelvic exam with bimanual and PAP if not uptodate.
Pregnancy Test and CBC
This is the number 1 symptom of uterine cancer-present in 90% of women with this cancer?
POSTMENOPAUSAL BLEEDING...Dr.Howell describes as "watery"
For AUB in premenopausal or perimenopausal women without an identifiable cause, this is recommended first line treatment and is as effective as hysterectomy.
Mirena IUD, change every 5y
Patients with prolonged menses, painful menses, pelvic pain may have this condition where the uterine lining grows into the muscular layer-seen on ultrasound?
Adenomyosis
For Birth Control Pills (CHCs, POPs), Rings and Patches, this is how long it takes to see a stable bleeding pattern: ____months
3m
These other labs can be useful if history supports their differentials-provide at least 4 responses
TSH, Prolactin, Estradiol, Testosterone or DHEA, clotting tests-PT,PTT, von Willebrand, hematology referral
This is the most likely cause of PMB?
vaginal or endometrial atrophy
For women trying to get pregnant, these two medications are reasonable to try for heavy menstrual bleeding
NSAIDs or TXA
This benign cause of painful, prolonged and heavy menstrual periods can also be found on ultrasound and sometimes on exam such as a unilateral uterine mass?
Leiomyoma (Fibroid)
23 y/o patient who had Mirena placed 6m ago now with irregular bleeding. Work up neg-IUD in place, preg test neg, this is how you could treat her: (first line and second line)
Naproxen 500mg BID x 5 days and if that fails, Estradiol 2mg daily x 2-6weeks if no contraindications
This is the first imaging test to obtain with AUB in most patients
TVUS-consider transabdominal u/s if never sexually active
You should obtain follow up testing for potmenopausal patients presenting with PMB and endometrial thickness (stripe) of how much?
5mm or greater needs further diagnostic testing
This is a contraindication to TXA
History of thrombosis-DVT/PE etc
What history would prompt you to consider a coagulopathy?
Heavy menses since menarche, hx of postpartum or surgical hemorrhages or bleeding with dental work, or at least 2 of the following: 1-2 episodes of bruising per month, 1-2 episodes of epistaxis/month, family hx of bleeding disorder or frequent gum bleeding
A 19 y/o F has had Nexplanon for 6m and has had irregular bleeding. This is the recommended treatment, if no contraindications
Daily OCPs if no contraindications with 20-30mg of Ethinyl Estradiol for 2-6 weeks but may require continued use; also option for NSAID x 5-10d or oral estrogen or patch alone
This is the first test to pursue in a PREMENOPAUSAL woman over 45 years old as well as younger women with risk factors for endometrial cancer who is experiencing AUB.
Endometrial Biopsy (note endometrial stripe on u/s is not useful in premenopause)
These are risk factors for endometrial cancer-give at least 5
Unopposed estrogen use, Obesity, Diabetes, early menarche (before age 12), late menopause (after age 55), nulliparity, PCOS, family history of endometrial ca, thyroid disease, Tamoxifen use
This is how you could dose CHCs for acute AUB in a hemodynamically stable patient
1 monophasic pill TID x 7 days, containing 35mcg of ethinyl estradiol, if no estrogen contraindications
Consider this differential for Ovulatory Dysfunction as causes for possible AUB-provide 4 differentials
Endocrinopathies, PCOS, Hyperprolactinemia, Hypothyroidism, Anorexia, Stress, Extreme Exercise (ie female athlete triad-low energy, amenorrhea, reduced bone density)
In patients experiencing AUB on CHCs, you can increase the dose of this component of the CHC pill to improve bleeding
Estrogen component-ie max is 35mg ethinyl estradiol
You can perform either of these tests FIRST in evaluating POSTMENOPAUSAL women with Bleeding
TVUS OR Endometrial Biopsy
True or false: Endometrial cancer is on the rise in North America
True
For acute bleeding and hemodynamically stable and estrogen contraindicated, progestin can be used this way
norethindrone 5mg TID x 7 days
A 24 y/o F w/pmh of GAD, Essential Tremor, has regular intervals for her menses but they are heavy and often painful. Labs and TVUS are normal and she has no symptoms concerning for coagulopathy. The patient takes the following medications: Sertraline 100mg, Propranolol 40mg po BID, and melatonin. In addition to considering endometrial infection and endometriosis, what medication or supplement could be impacting her bleeding?
Sertraline (SSRIs)
A 28 y/o F is taking Sprintec (norgestimate 0.25mg /ethinyl estradiol 35mcg) and continues to experience heavy bleeding on during the placebo week. She is otherwise happy with the OCP as a form of birth control. This is a prescribing strategy you can use to reduce her bleeding.
Skip placebo week and take active hormone continuously-may experience some intermenstrual spotting-->give a 5-7day hormone free every few months
What is your next step in a PMB case with endometrial stripe 5mm or greater?
Endometrial biopsy vs referral for hysteroscopy/D+C
True or False: The death rate from endometrial cancer is the same for all races in North America
False, Black women are twice as likely to die from endometrial cancer despite improved reduction in disparities for cervical and breast cancers ?genetics?more aggressive cancers?
For acute bleeding and hemodynamically unstable treat with this:
IV estrogen