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Gyne - Case 05 Abnormal Uterine Bleeding
Gyne - Case 05 Abnormal Uterine Bleeding
Gyne - Case 05 Abnormal Uterine Bleeding
A woman may have mid-cycle bleeding that will last for only a When do you expect this to be normal?
few hours and will only stain the underwear. This will come
st
Post-menarcheal: 1 2 – 3 years after menarche
every month & will be notice on day 14-15 of the cycle. Cause: Immaturity of the HPO Axis
Book: Also failure of + feedback of Estradiol to cause LH surge
This is mid-cycle bleeding or termed: OVULATORY BLEEDING
Pre-menopausal: about age 45 – 46 may have irregular
What is the cause? Why does a woman bleed at the time she is menstruation indicating anovulation
ovulating? Cause: Start of ovarian failure, the follicles in the ovaries
In ovulation, there is mechanical extrusion of the egg that are already depleted
will cause bleeding inside the peritoneal cavity and will o Female: depletion of follicles
NOT cause bleeding thru the vagina. That bleeding inside o Male: can manufacture the sperm every 72 days
the peritoneum is termed as OVULATORY PAIN or
MITTELSCHMERZ What would be the main cause? What is absent in the patient?
Absence of Progesterone & Corpus Luteum
Some patient would think they are recently ovulating In TVS, you will be able to see only the thickened
because of a pain on one side of the pelvis. endometrium because of the proliferation of the
O
endometrium 2 to the continuous effect of estrogen & on
Day 20 you will not be able to see the presence of the
During this time Estrogen will rise, but just before corpus luteum
ovulation there will be a fall in Estrogen. And it is the fall
of this Estrogen that will trigger the LH surge to cause Book:
ovulation. This will be responsible for the little stains in Anovulatory: Continuous estradiol production without
underwear known as the KLEINE-REGAL SIGN corpus luteum formation & progesterone production
Continuous proliferation Outgrow BS Necrosis
2. MENORRHAGIA (HYPERMENORRHEA)
AKA Heavy Menstrual Bleeding (HMB) (> 7 days) Other causes of anovulatory:
Regular intervals PCOS
Problem: Amount of the flow (> 80 mL) Hypothalamic dysfunction
Hypothyroidism
Hyperprolactinemia (> 20 ng/mL)
Cushing’s Syndrome
TX When a woman is in the reproductive age group with AUB -
To have menstruation: ALWAYS R/O ACCIDENTS OF PREGNANCY
1. Progesterone
Supplement: 2nd half of the cycle 2. Infection of the Upper Genital Tract
If a woman ovulates on day 14 or 15 of the cycle, by day What is Puerperium?
15- 16 we expect her to produce her own progesterone so The state of a woman during childbirth or immediately
supplement after supposedly the day I should expect her thereafter, approximate 6-week period lasting from
to ovulate childbirth to the return of normal uterine size
Give her cyclic progesterone (Between Day 16 - 25)
3. Endometritis
To have pregnancy: ENDOMETRITIS following delivery patient may have
2. Ovulatory Drugs delayed post-partum hemorrhage after infection
Make her ovulate to produce her own progesterone Prolonged Menstruation
If she ovulates from the dominant follicle there will be More commonly: Episodic inter-menstrual spotting, Pre-
ovulation, that follicle per ovulation that took place will mentrual spotting
now be converted to corpus luteum which is destined to
produce her own progesterone. 4. Malignancies:
Drugs: Clomiphene Citrate Considered if in elderly age group except when thinking of
cervical cancer because these malignancies may range
To make her menstruation regular: from vagina (not common), can be cervical or uterine
3. OCP
To supplement a deficient hormonal status of the patient Book:
Endometrial & Cervical Ca > Vagina, vulva, fallopian tube
To simply stop the bleeding: Estrogen producing ovarian tumors,
4. Danazol, GnRH agonist Granulosa Theca Cell Tumors – Excessive uterine bleeding
Danazol is a testosterone derivative; if patient stops
bleeding there is no DUB. Cervical Ca
Symptom: bleeding every now and then
Ovulatory Dysfunctional Bleeding Profile/ Risk Factors: Early coitarche, several male partner,
Normal, Regular, periodic, predictable cycles multipara, infection with HPV
No demonstrable reproductive organ disorder DX: Speculum Exam
Pattern: Menorrhagia (HMB) How is bleeding related to contact? Post-coital Bleeding
That is why for a young girl (Age 14 – 15) presenting with AUB Remember:
while you would like to think this is anovulatory DUB because In pathogenesis of Ovulatory DUB, this is all because of an
she is post-menarcheal – ALWAYS R/O BLOOD DYSCRASIA increase in prostaglandin. That’s why a woman bleeds
Unless indicated by clinical signs: petechiae or ecchymosis more, there is NO organic cause but it is simply because
of prostaglandin which is responsible for myometrial
Reproductive Tract Disorders contraction
1. Accidents of pregnancy
Abortion 8. Iatrogenic Causes:
Ectopic pregnancy Oral & injectable steroids for contraception, HRT,
Gestational Trophoblastic Disease (any woman who has dysmenorrhea, hirsutism, acne, or endometriosis
had a recent pregnancy) Tranquilizers & other psychotropic drugs may interfere
Eclampsia? NO - not unless it causes to an abruption with the NT responsible for hypothalamic hormones
placenta
You will only be able to arrive at these organic causes of Hysteroscopy
bleeding after pelvic examination or even after doing an - Copy “Scope” meaning endoscopic examination under
ancillary procedure. minimally invasive surgery directly visualizing the
endometrial cavity
Principle: If you demonstrated an organic cause, the treatment Advantage: the moment a pathology can be seen, you can
is towards that organic cause (If it is a polyp take out the polyp) convert from diagnostic to an operative & therapeutic
procedure
DX:
Order of Ruling out: D&C
1. R/o systemic cause to dx reproductive tract disorder Dilatation & Curettage
2. R/o organic cause to diagnose DUB Tagalog: “RASPA”
Both diagnostic (GYN) & therapeutic (OB)
Β hCG – To rule out accidents of pregnancy
O
360 of uterine cavity is sampled
Blood Count & Coagulation profile – To rule out systemic
Endometrial Biopsy
TVS Take only representative samples
Best route to examine reproductive tract Advantage: do not have to dilate the cervix which is
Possible Dx: Submucous Myoma, Polycystic Ovaries painful
NOT PCOS, a syndrome is something a clinician will make a An office procedure which can be done in the clinic
diagnosis of. PCOS will be made up of Oligomenorrhea,
Hyperandrogenism & Polycystic Ovaries Fractional D & C
Practically not used anymore
Can be able to see an abnormal lining of the uterus & Divide the uterus into 2: Endometrial & Endocervix
thickened endometrium which may mean endometrial Objective: to find out especially if working diagnosis in
polyp, submucous myoma, endometrial hyperplasia, or endometrial cancer is confine to the body or involve both
endometrial Ca body & cervix.
If clinically you suspect it might be a polyp due to
presentation in the history of intermenstrual bleeding Note: Gold standard is no longer Fractional D & C, you can just
instead a TVS, request for SIS. do endometrial biopsy.
HSG Book
Primarily for the patency of the tubes SHG: to rule out an intracavitary lesion before ascribing
the diagnosis to ovulatory DUB
Endometrial Biopsy (> 8 mm), if obtained at the onset of
bleeding will show secretory changes (For age: >35, long
history of excessive bleeding)
CASE 5
36 year old G1P1 (1011) consulted because of prolonged and profuse menses for the past 4 cycles. She claimed that her menstrual
cycles lasted for 10 days consuming 4 overnight pads per day. Her usual menses lasted for 4 days and she consumes about 3
regular pads per day. PPE: BP – 110/70 PR: 90/min; pale palpebral conjunctiva; Speculum: cervix is pink, smooth with minimal
bleeding per os: IE: cervix – firm, long, closed; uterus – normal in size, anteverted; adnexa – no masses & tenderness.
Result: All are normal except for ↓ Hgb due to bleeding for 4 So this patient may simply need that use of Prostaglandin
months. Inhibitors, NSAIDS, or supplement it with hemostatics to
address the problem of HMB
2. Rule out ORGANIC reproductive tract disorder cause:
Polyp? Remember the patient has HMB, not inter-
menstrual bleeding
Foreign Body? Nothing in the history
Pregnancy: do β hCG
Malignancies:
Cervix is clean: R/o cervical cancer
No mass in adnexa: R/o possible ovarian malignancy
TVS Result:
Proliferative endometrium, normal size uterus & ovaries