Dysfunctional Uterine Bleeding (DUB)
If the pregnancy test is negative, there are no anatomic causes for bleeding and coagulopathy is ruled out, then the diagnosis of hormonal imbalance should be considered. The classic history is that of bleeding that is unpredictable in amount, duration and frequency without cramping occurring.
Mechanism. The most common cause of DUB is anovulation. Anovulation results in unop-posed estrogen. With unopposed estrogen, there is continuous stimulation of the endometrium with no secretory phase.
An estrogen dominant endometrium is structurally unstable as it increasingly thickens. With inadequate structural support, it eventually undergoes random, disorderly, and unpredictable breakdown resulting in estrogen breakthrough bleeding.
Diagnosis. Anovulatory cycles can usually be diagnosed from a history of irregular, unpre-dictable bleeding. Bleeding is usually without cramping since there is no PG release to cause myometrial contractions. Cervical mucus will be clear, thin and watery reflecting the estrogen dominant environment. Basal-body temperature (BBT) chart will not show a midcycle tem-perature rise due to the absence of the thermogenic effect of progesterone. Endometrial biopsy will show a proliferative endometrium.
GYN Triad
Endometrial Polyp or Submucosal Leiomyoma
• Predictable vaginal bleeding with intermenstrual bleeding
• 33-year-old woman
• Normal height and weight
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USMLE Step 2 l Gynecology
GYN Triad
Abnormal Uterine Bleeding
PALM-COEIN Classification
(FIGO 2011)
Visualizable by inspection or imaging:
P: Polyps (AUB-P)
A: Adenomyosis (AUB-A)
• Leiomyoma (AUB-L)
• Malignancy (AUB-M)
Needs further workup:
C: Coagulopathy (AUB-C)
• Ovulatory disorders
(AUB-O)
E: Endometrial (AUB-E)
I: Iatrogenic (AU B-1)
N: Not yet classified (AUB-N)
GYN Triad
Imperforate Hymen
• Primary amenorrhea
• (+) breasts and uterus
• Normal height and weight
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Progesterone trial involves administering progestin to stabilize the endometrium, stop the bleeding and prevent random breakdown. When the progestin is stopped, spiral arteriolar spasm results in PG release, necrosis, and an orderly shedding of the endometrium. A positive progesterone trial confirms a clinical diagnosis of anovulation. A negative progesterone trial rules out anovulation.
Correctable causes of anovulation. Anovulation can be secondary to other medical conditions.It is important to identify and correct a reversible cause of anovulation if present.
• Hypothyroidism is a common cause of anovulation, diagnosed by a low TSH and treated with thyroid replacement.
• Hyperprolactinemia, diagnosed by a serum prolactin test. An elevated prolactin inhibits GnRH by increasing dopamine. Treatment depends on the cause of the elevated prolactin.
Progestin management. Treatment involves replacing the hormone which is lacking (proges-terone or progestin). These methods help regulate the menstrual flow and prevent endometrial hyperplasia, but do not reestablish normal ovulation.
• Cyclic MPA. Medroxyprogesterone acetate can be administered for the last 7 to 10 days of each cycle.
• Oral contraceptive pills (OCs). Estrogen-progestin oral contraceptives are often used for convenience. The important ingredient however, is the progestin not the estrogen.
• Progestin intrauterine system (LNG-IUS). The levonorgestrel lUS (Mirena or Skyla) delivers the progestin directly to the endometrium. This treatment can significantly decreasing menstrual blood loss.
Other managements. If progestin management is not successful in controlling blood loss, thefollowing generic methods have been successful:
• NSAIDs can decrease dysmenorrheal, improve clotting and reduce menstrual bloodloss. They are administered for only 5 days of the cycle and can be used and can be combined with OCs.
• Tranexamic acid (Lysteda) works by inhibiting fibrinolysis by plasmin. It is contrain-dicated with history of DVT, PE or CVA, and not recommended with E+P steroids.
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• Endometrial ablation procedure destroys the endometrium by heat, cold or micro-waves. It leads to a iatrogenic Asherman syndrome and minimal or no menstrual blood loss. Fertility will be affected.
• Hysterectomy (removal of the uterus) is a last resort and performed only after allother therapies have been unsuccessful.
PRIMARY AMENORRHEA
A 16-year-old girl presents with her mother, complaining she has never had a menstrual period. All of her friends have menstruated, and the mother is concerned about her daughter’s lack of menstruation. On examination she seems to be well-nourished, with adult breast development and pubic hair present. Pelvic examination reveals a rudimentary vagina. No uterus is palpable on rectal examination.
Definition. Amenorrhea means absence of menstrual bleeding. Primary means that menstrualbleeding has never occurred.
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Chapter 11 l Menstrual Abnormalities
Diagnosis. Primary amenorrhea is diagnosed with absence of menses at age 14 without sec-ondary sexual development or age 16 with secondary sexual development.
Etiology. The origins of primary amenorrhea can be multiple. The two main categoriesof etiology are anatomic (e.g., vaginal agenesis/septum, imperforate hymen, or Müllerian agenesis) or hormonal (e.g., complete androgen insensitivity, gonadal dysgenesis [Turner syn-drome], or hypothalamic-pituitary insufficiency).
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