Daily Exam Question - GYN

By drwall
April 2, 2014

Which of the following is least likely included as part of the initial evaluation of abnormal uterine bleeding?

A. Transvaginal U/S

B. Pregnancy test

C. TSH

D. Complete blood count

E. MRI

Answer: E - MRI

Menstrual flow outside of normal volume, duration, regularity, or frequency is considered abnormal uterine bleeding (AUB).  The duration of normal menstrual flow is generally 5 days, and the normal menstrual cycle typically lasts between 21 days and 35 days.  In an effort to create a universally accepted system of nomenclature to describe uterine bleeding abnormalities in reproductive-aged women, a new classification system (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), known by the acronym PALM–COEIN, was introduced in 2011 by the International Federation of Gynecology and Obstetrics (FIGO). The American College of Obstetricians and Gynecologists supports the adoption of the PALM–COEIN nomenclature system developed by FIGO to standardize the terminology used to describe AUB.

The PALM–COEIN system classifies uterine bleeding abnormalities by bleeding pattern as well as by etiology. The overarching term AUB is paired with descriptive terms to denote bleeding patterns associated with AUB, such as heavy menstrual bleeding (instead of menorrhagia) and intermenstrual bleeding (instead of metrorrhagia). Abnormal uterine bleeding is further classified by one (or more) letter qualifiers that indicate its etiology or etiologies.. The term dysfunctional uterine bleeding––often used synonymously with AUB in the literature to indicate AUB for which there was no systemic or locally definable structural cause––is not part of the PALM–COEIN system, and discontinuation of its use is recommended.

P - Polyp

A - Adenomyosis

L - Leiomyoma

M - Malignancy and hyperplasia

C - Coagulopathy

O - Ovulatory dysfunction

E - Endometrial

I - Iatrogenic

N - Not yet classified

Figure 2 from the document is good - I can’t cut and paste it well on my mac.

Box 2. Diagnostic Evaluation of Abnormal Uterine Bleeding

Medical History

  • Age of menarche and menopause
  • Menstrual bleeding patterns
  • Severity of bleeding (clots or flooding)
  • Pain (severity and treatment)
  • Medical conditions
  • Surgical history
  • Use of medications
  • Symptoms and signs of possible hemostatic disorder

Physical Examination

  • General physical
  • Pelvic Examination

—External

—Speculum with Pap test, if needed*

—Bimanual

Laboratory Tests

  • Pregnancy test (blood or urine)
  • Complete blood count
  • Targeted screening for bleeding disorders (when indicated)†
  • Thyroid-stimulating hormone level
  • Chlamydia trachomatis

Available Diagnostic or Imaging Tests (when indicated)

  • Saline infusion sonohysterography
  • Transvaginal ultrasonography
  • Magnetic resonance imaging
  • Hysteroscopy

Available Tissue Sampling Methods (when indicated)

  • Office endometrial biopsy
  • Hysteroscopy directed endometrial sampling (office or operating room)

In a patient without enhanced risk of endometrial hyperplasia, neoplasia, or structural abnormalities, such as adolescents, a trial of therapy is appropriate. For those at increased risk, such as patients with genetic risk factors for endometrial cancer, patients older than 45 years, or patients whose prolonged anovulatory cycles are associated with unopposed estrogen, initiation of therapy is appropriate after a complete diagnostic evaluation has been completed (see Fig. 2). Persistent bleeding despite therapy requires further evaluation. An appropriate trial of therapy will depend on the cause of the abnormal bleeding, the risks and benefits of the therapy, the costs to the patient, and the patient’s own desire. Many causes of abnormal bleeding are amenable to medical management with nonsteroidal anti-inflammatory drugs, progestins, combination oral contraceptives, a levonorgestrel intrauterine device, or tranexamic acid. For anatomic causes of abnormal uterine bleeding, such as uterine myomas or polyps, surgery may be indicated. Endometrial ablation and resection are minimally invasive surgical options to control bleeding in women who have completed childbearing.

Prolog GYN and Surgery 7th edition, question #40:

Abnormal uterine bleeding in nonpregnant women can be categorized as chronic, acute, and intermittent.  Chronic abnormal uterine bleeding can be defined as bleeding from the uterine endometrium that is abnormal in volume, regularity, or timing, and has been present for most of the past 6 months.  The most common form of noncyclic uterine bleeding, anovulatory bleeding, is defined as noncyclic menstrual blood flow that may range in volume from spotty to excessive.  It originates from the uterine endometrium and is not attributed to an anatomic lesion, and is caused by anovulatory sex steroid production.  In anovulation, a corpus luteum is not formed, serum progesterone production remains low and estrogen production persists.  Estrogen stimulates endometrial proliferation and, without adequate progesterone levels, leads to unpredictable desynchronized sloughing of the endometrial lining.  Differential dx for anovulation includes hyperandrogenic anovulation (PCOS/CAH, and androgen secreting tumors), hypothalamic dysfunction (anorexia), hyperprolactinemia, hypothyroidism, primary pituitary disease, ovarian insufficiency, and iatrogenic (radiation/chemotherapy hx).

Laboratory evaluation should include a pregnancy test and TSH measurement.  Endometrial sampling is indicated for all pts with AUB over the age of 45 and for patients younger than 45 with a history of unopposed estrogen exposure (obese women/PCOS), hx of failed medical management, and those with persistent AUB.  The treatment of choice of AUB is medical therapy.

Daily Exam Question - Written/MOC

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