It isn't relevant to this discussion of Anatomy, DUB, and PCOS, but it is important to mention none-the-less-uterine bleeding may have nothing to do with _______at all
Uterine bleeding may have nothing to do with an abnormal uterus at all
______lesions are a common cause of uterine bleeding
structural lesions
Of the structural lesions, which type are most common?
Fibroids
There is a lot to know about structural lesions, but what are the 3 that we should focus on?
1. Adenomyosis
2. Fibroids
3. Polyps
FIBROIDS
Start Here
What is another name for fibroids?
Leiomyoma
What are fibroids/leiomyoma's?
They are benign growths of the myometrium
Fibroids/leiomyoma's are responsive to ______ and also______
Fibroids/leiomyomas are
estrogen responsive
and
non malignant
Patient with fibroids/leiomyoma may present as ______ or ______
As an
asymptomatic mass
or with
pain
Fibroids/leiomyoma may_______and cause what
They may
bleed
and cause anemia, or they may also cause
infertility
(implantation compromised)
How do you first make the diagnosis for fibroids/leiomyoma? However, what is the best test?
First make the
transvaginal ultrasound
. However, the best radiographic test is an
MRI
MRI is the most accurate test for firborids, so when should you do it?
Not often, because routine cases do not require it
Although often not needed, what is the best test for fibroids?
Hysteroscopy
Should you biopsy fibroids?
No, DON'T biopsy fibroids
Treatment for fibroids is dependent on what?
Tx is dependent on what mom wants
If mom has fibroids and wants children, what is the tx?
a
myomectomy
is performed to "scoop out" the fibroid
If mom has fibroids and DOESNT want children, what is the tx?
Perform a
total abdominal hysterectomy
If the fibroid is too large for surgery, then do what?
Give
leuprolide
(continuous) until the fibroids shrink, then go to surgery
Aside from surgery, what meds can you give pt with fibroids?
NSAIDS
OCP's
OK, SO HERE IS A
BRIEF SUMMARY OF FIBROIDS
OK
Describe the imaging for work up of potential fibroids
-Transvaginal US is the first test
-MRI is very accurate, very expensive, usually not done
-Hysteroscopy is best test, often not needed
NSAIDS for treating fibroids?
NSAIDS good for pain, not useful mono therapy
What is the first line medical therapy for fibroids?
OCP's
For fibroids, what is essentially identical to OCP's for tx purposes?
Levonorgestrel IUD: essentially the same as OCP's
What's tx is good for large fibroids?
GnRH Agonists (leuprolide).
GnRH agonists (leuprolide) used in the treatment of fibroids can have what SE?
It can induce menopause sxs and decrease bone density
What should you NOT use to treat fibroids?
Aromatase inhibitors: Don't use these
Antiprogestins Mifeprisrtone: uncertain
For fibroids, when do you do myomectomy vs hysterectomy?
Myomectomy if wants kids (low satisfaction)
Hysterectomy if doesn't want kids (high satisfaction)
ADENOMYOSIS
START HERE
What is adenomysosis?
A
symmetrical smoothed
uterus that's filled with normal uterine tissue; generally stromal and glandular epithelium
What is the classic form of adenomyosis?
Diffuse adenomyosis, is the one most often tested
When evaluating for adenomyosis, what will the physical exam reveal?
The physical exam will reveal am enlarged
smooth uterus
In general, the diagnostic tests and for adenomysosis is______
Essentially identical to fibroids., the goal being reduction in bleeding and pain
The only difference between adenomyosis and fibroids is that adenomomysis......
adenomyosis doesn't have a layer of connective tissue that easily defines the plane of adenomysosis, unlike fibroids which do. This makes the residual disease the cause of most tx failure.
POLYPS
Start Here
Polyps are a structural cause of vaginal bleeding, but don't present with_____
An abnormal physical exam
Polyps dont present with an abnormal physical exam, but aside from that, they present very similarly to?
Adenomyosis and Leiomyomas (fibroids)
What are the diagnostic tools for polyps?
Transvaginal
ultrasound
, saline infusion sonography, and
hysteroscopy
How to treat polyps?
Polyps should be surgically excised via hysteroscopic polypectomy
Don't treat polyps with?
NSAIDS, OCP's
ETIOLOGY OF UTERINE BLEEDING TABLE
START HERE
Mnemomic for remembering structural causes of uterine bleeding?
PALM
P
olyps
A
denomyosis
L
eiomyoma (fibroids)
M
alignancy, hyperplasia
Mnemonic for remembering non structural causes of uterine bleeding
COEIN
C
OAGULOPATHY
O
VULATORY DYSFXN
E
NDOMETRIAL
I
ATROGENIC
N
OT YET CLASSIFIED
ABNORMAL UTERINE BLEEDING
Start Here
Abnormal uterine bleeding is diagnosed how?
It is a
diagnosis of exclusion
AUB is a dx of exclusion, what do you order to rule out other things?
CBC, TSH, U/S, MRI, Prolactin, Hysteroscopy, etc
When can a women be diagnosed with dysfunctional uterine bleeding (DUB)?
Once all organic causes have been rules out, the women can be diagnosed with DUB
Abnormal uterine bleeding (AUB) vs dysfunctional uterine bleeding?
AUB may have various causes, some of them benign. When AUB is related to changes in hormones that directly affect the menstruation cycle, the condition is called dysfunctional uterine bleeding (DUB)
Most of dysfunctional uterine bleeding is caused by?
anovulation
What is anovulation?
It is when the ovaries do not release an oocyte during a menstruation cycle. Therefore, ovulation does not take place
If ovulation doesn't occur, what happens?
What isn't produced?
What happens to the endometrium?
If ovulation doesn't occur, progesterone isn't produced and the proliferative endometrium continues to grow until it outgrows its blood supply. Endometrial vessels become markedly dilated and unstable. Since they are dilated (prostaglandin effect), the bl
What are the three types of abnormal periods?
Meno, Metro, or menometrorrhagia
When are abnormal periods (meno, metro, menometrorrhagia) considered as being normal/not worrisome?
They are
normal
near
menarche
and
menopause
Even if there isn't diagnosed AUB, if there is
life threatening bleeding
tx with_______
Use
IV estrogen
(and taper to OCPs)
If there is life threatening vaginal bleeding and IV estrogen doesn't help, what should be your next step?
If the bleeding continues despite estrogen, surgical ligation or embolization of arteries may be required.
Ultimately, what is the curative treatment for life threatening vaginal bleeding?
Ultimately, a hysterectomy is curative
For most cases of abnormal uterine bleeding, treatment centers on?
NSAIDS
and
OCP
s
NSAIDS used in the treatment of abnormal uterine bleeding is a bit of a weird one because?
Weird, because generally they worsen bleeding by inhibiting platelets. But yet, NSAIDS can adequately treat AUB
NSAIDS are especially useful for treating AUB if started when?
Especially useful if started at the onset of menses
NSAIDS and OCP can be used for the treatment of AUB, but what is the best tx for chronic control?
For more chronic control,
OCP's
are the drug of choice
OCPs provide benefits for?
OCP's provide contraception, reduction in dysmenorrhea, and control bleeding
What are some other procedures that can also control bleeding?
endometrial ablation
or elective
TAH
(total and hysterectomy) (even if the bleeding isn't severe)
POLYCYSTIC OVARIAN SYNDROME
Start here
Polycystic ovarian syndrom is one particular cause of?
anovulation
Polycystic ovarian syndrome is one cause of anovulation, so what happens?
The ovary is replaced by
thousands of atretic follicles
.
So in polycystsic ovarian syndrom, the ovary is replaced by thousands of atretic follicles. What does this mean/result in?
These follicles cant produce progesterone, so they produce large amounts of estrogen. That's then converted to testerone
Ok, so these atretic follicles lead to large amounts of estrogen, which is converted to testosterone. What does this lead to?
This testosterone makes women
hirsute
. (excessive growth of facial or body hair)
So, for polycystic ovarian syndrome what should you look for in the patient?
Look for women who are
fat and hairy
, maybe with a deep voice, who has
irregular menses
and
trouble getting pregnant
Polycystic ovarian syndrome is a ____diagnosis
It is an endocrine diagnosis...so an ultrasound IS NOT required
Ultrasound isn't required for polycystic ovarian syndrome, but tests will still often show....?
an
ovarian ultrasound
with lots of little black circles, representing cysts
To make the diagnosis of polycystic ovarian syndrome, test question may show US, but what should you really use instead?
To make the diagnosis, instead use the
LH/FSH >3
, and make a metabolic diagnosis of diabetes (with the
2 hour glucose tolerance test
) and dyslipidemia.
So once again, what level will be elevated in polycystic ovarian syndrome?
Levels of testosterone will be elevated
For polycystic ovarian syndrome, should you obtain DHEAS level? Why or why not?
DHEAS is normal in PCOS and it isn't necessary to test if there is no evidence of virilization, but it is still often obtained to rule out other causes of hirsutism
What is the name of the criteria for the diagnosis of polycystic ovarian syndrome?
Rotterdam criteria*
What are the Rotterdam criteria for the diagnosis of polycystic ovarian syndrome, and how many do you need for the dx?
need 2/3
1)Oligo and/or anovulation
2)Clinical and or biochemical signs of hyperandrogegism
-Elevated DHEAS
-Elevated testosterone
-LH:FSH>3:1
3)Polycystic ovaries via ultrasound
Once polycystic ovarian syndrome is diagnosed, what is the mainstay therapy?
The mainstay therapy of polycystic ovarian syndrome is
OCP's
The mainstay treatment for polycystic ovarian syndrome is OCPs. What do they do?
They reset the axis and reduce anovulation
What else is involved in the treatment of polycystic ovarian syndrome?
metformin
to treat the diabetes
Metformin is involved in the treatment of polycystic ovarian syndrome. It treats the diabetes, but also helps to?
Reduce circulating androgens, making the effects of PCOS less severe.
OCP
s and
metformin
are the most common treatments for polycystic ovarian syndrome, but what is one other possible medication that you may see patients being put on?
spironolactone
Spironolactone occasionally used for polycystic ovarian syndrome, what does it do?
It's possible to see patients on spironolactone for its androgen receptor antagonism, further reducing the symptoms of hirsutism
If a women hoping to become pregnant, is diagnosed with polycystic ovarian syndrome, what is used to help facilitate the pregnancy.
clomiphene
or
pergonal
, which can induce ovulation
Clomiphene or pergonal can be used to induce ovulation for a polycystic ovarian syndrome hoping to become pregnant. However, what are the side effects?
The risk is multiple pregnancies
QUICK TABLES
Start Here
Dysfunctional Uterine Bleeding
ok
Path of DUB?
anovulation
.
No ovulation=no progesterone=estrogen only=proliferation
DUB is normal when?
NORMAL near menarche or near menopause
DUB, pt?
Bleeding that occurs without regular cycles
DUB, dx?
Diagnosis of exclusion, rule out everything with.....CBC, TSH, U/S, MRI, Prolactin, Hysterectomy, etc
DUB, tx?
------decrease stress
-------increase weight
OCPs-anemia
NSAIDS
DUB, f/u?
Very significant bleeding=IV estrogen
unresponsive to IV estrogen, TAH
POLYCYSTIC OVARIAN SYNDROME
Start Here
PCOS path?
Anovulation----->atretic follicles cant produce progesterone, so they produce large amounts of estrogen. Thats then converted to testosterone
PCOS, pt?
Hirsute= Fat + hairy
Deep voice
Anemia
Infertility
Endometrial cancer
PCOS, dx?
Dont do ultrasound
LH/FSH>3
Endocrine: Increased T, Normal DHEAS
DM-2 hour glucose test or A1c
PCOS, tx?
OCP's
Metformin
Clomiphene
It isn't relevant to this discussion of Anatomy, DUB, and PCOS, but it is important to mention none-the-less-uterine bleeding may have nothing to do with _______at all
Uterine bleeding may have nothing to do with an abnormal uterus at all
______lesions are a common cause of uterine bleeding
structural lesions
Of the structural lesions, which type are most common?
Fibroids
There is a lot to know about structural lesions, but what are the 3 that we should focus on?
1. Adenomyosis
2. Fibroids
3. Polyps
FIBROIDS
Start Here
What is another name for fibroids?
Leiomyoma
What are fibroids/leiomyoma's?
They are benign growths of the myometrium
Fibroids/leiomyoma's are responsive to ______ and also______
Fibroids/leiomyomas are
estrogen responsive
and
non malignant
Patient with fibroids/leiomyoma may present as ______ or ______
As an
asymptomatic mass
or with
pain
Fibroids/leiomyoma may_______and cause what
They may
bleed
and cause anemia, or they may also cause
infertility
(implantation compromised)
How do you first make the diagnosis for fibroids/leiomyoma? However, what is the best test?
First make the
transvaginal ultrasound
. However, the best radiographic test is an
MRI
MRI is the most accurate test for firborids, so when should you do it?
Not often, because routine cases do not require it
Although often not needed, what is the best test for fibroids?
Hysteroscopy
Should you biopsy fibroids?
No, DON'T biopsy fibroids
Treatment for fibroids is dependent on what?
Tx is dependent on what mom wants
If mom has fibroids and wants children, what is the tx?
a
myomectomy
is performed to "scoop out" the fibroid
If mom has fibroids and DOESNT want children, what is the tx?
Perform a
total abdominal hysterectomy
If the fibroid is too large for surgery, then do what?
Give
leuprolide
(continuous) until the fibroids shrink, then go to surgery
Aside from surgery, what meds can you give pt with fibroids?
NSAIDS
OCP's
OK, SO HERE IS A
BRIEF SUMMARY OF FIBROIDS
OK
Describe the imaging for work up of potential fibroids
-Transvaginal US is the first test
-MRI is very accurate, very expensive, usually not done
-Hysteroscopy is best test, often not needed
NSAIDS for treating fibroids?
NSAIDS good for pain, not useful mono therapy
What is the first line medical therapy for fibroids?
OCP's
For fibroids, what is essentially identical to OCP's for tx purposes?
Levonorgestrel IUD: essentially the same as OCP's
What's tx is good for large fibroids?
GnRH Agonists (leuprolide).
GnRH agonists (leuprolide) used in the treatment of fibroids can have what SE?
It can induce menopause sxs and decrease bone density
What should you NOT use to treat fibroids?
Aromatase inhibitors: Don't use these
Antiprogestins Mifeprisrtone: uncertain
For fibroids, when do you do myomectomy vs hysterectomy?
Myomectomy if wants kids (low satisfaction)
Hysterectomy if doesn't want kids (high satisfaction)
ADENOMYOSIS
START HERE
What is adenomysosis?
A
symmetrical smoothed
uterus that's filled with normal uterine tissue; generally stromal and glandular epithelium
What is the classic form of adenomyosis?
Diffuse adenomyosis, is the one most often tested
When evaluating for adenomyosis, what will the physical exam reveal?
The physical exam will reveal am enlarged
smooth uterus
In general, the diagnostic tests and for adenomysosis is______
Essentially identical to fibroids., the goal being reduction in bleeding and pain
The only difference between adenomyosis and fibroids is that adenomomysis......
adenomyosis doesn't have a layer of connective tissue that easily defines the plane of adenomysosis, unlike fibroids which do. This makes the residual disease the cause of most tx failure.
POLYPS
Start Here
Polyps are a structural cause of vaginal bleeding, but don't present with_____
An abnormal physical exam
Polyps dont present with an abnormal physical exam, but aside from that, they present very similarly to?
Adenomyosis and Leiomyomas (fibroids)
What are the diagnostic tools for polyps?
Transvaginal
ultrasound
, saline infusion sonography, and
hysteroscopy
How to treat polyps?
Polyps should be surgically excised via hysteroscopic polypectomy
Don't treat polyps with?
NSAIDS, OCP's
ETIOLOGY OF UTERINE BLEEDING TABLE
START HERE
Mnemomic for remembering structural causes of uterine bleeding?
PALM
P
olyps
A
denomyosis
L
eiomyoma (fibroids)
M
alignancy, hyperplasia
Mnemonic for remembering non structural causes of uterine bleeding
COEIN
C
OAGULOPATHY
O
VULATORY DYSFXN
E
NDOMETRIAL
I
ATROGENIC
N
OT YET CLASSIFIED
ABNORMAL UTERINE BLEEDING
Start Here
Abnormal uterine bleeding is diagnosed how?
It is a
diagnosis of exclusion
AUB is a dx of exclusion, what do you order to rule out other things?
CBC, TSH, U/S, MRI, Prolactin, Hysteroscopy, etc
When can a women be diagnosed with dysfunctional uterine bleeding (DUB)?
Once all organic causes have been rules out, the women can be diagnosed with DUB
Abnormal uterine bleeding (AUB) vs dysfunctional uterine bleeding?
AUB may have various causes, some of them benign. When AUB is related to changes in hormones that directly affect the menstruation cycle, the condition is called dysfunctional uterine bleeding (DUB)
Most of dysfunctional uterine bleeding is caused by?
anovulation
What is anovulation?
It is when the ovaries do not release an oocyte during a menstruation cycle. Therefore, ovulation does not take place
If ovulation doesn't occur, what happens?
What isn't produced?
What happens to the endometrium?
If ovulation doesn't occur, progesterone isn't produced and the proliferative endometrium continues to grow until it outgrows its blood supply. Endometrial vessels become markedly dilated and unstable. Since they are dilated (prostaglandin effect), the bl
What are the three types of abnormal periods?
Meno, Metro, or menometrorrhagia
When are abnormal periods (meno, metro, menometrorrhagia) considered as being normal/not worrisome?
They are
normal
near
menarche
and
menopause
Even if there isn't diagnosed AUB, if there is
life threatening bleeding
tx with_______
Use
IV estrogen
(and taper to OCPs)
If there is life threatening vaginal bleeding and IV estrogen doesn't help, what should be your next step?
If the bleeding continues despite estrogen, surgical ligation or embolization of arteries may be required.
Ultimately, what is the curative treatment for life threatening vaginal bleeding?
Ultimately, a hysterectomy is curative
For most cases of abnormal uterine bleeding, treatment centers on?
NSAIDS
and
OCP
s
NSAIDS used in the treatment of abnormal uterine bleeding is a bit of a weird one because?
Weird, because generally they worsen bleeding by inhibiting platelets. But yet, NSAIDS can adequately treat AUB
NSAIDS are especially useful for treating AUB if started when?
Especially useful if started at the onset of menses
NSAIDS and OCP can be used for the treatment of AUB, but what is the best tx for chronic control?
For more chronic control,
OCP's
are the drug of choice
OCPs provide benefits for?
OCP's provide contraception, reduction in dysmenorrhea, and control bleeding
What are some other procedures that can also control bleeding?
endometrial ablation
or elective
TAH
(total and hysterectomy) (even if the bleeding isn't severe)
POLYCYSTIC OVARIAN SYNDROME
Start here
Polycystic ovarian syndrom is one particular cause of?
anovulation
Polycystic ovarian syndrome is one cause of anovulation, so what happens?
The ovary is replaced by
thousands of atretic follicles
.
So in polycystsic ovarian syndrom, the ovary is replaced by thousands of atretic follicles. What does this mean/result in?
These follicles cant produce progesterone, so they produce large amounts of estrogen. That's then converted to testerone
Ok, so these atretic follicles lead to large amounts of estrogen, which is converted to testosterone. What does this lead to?
This testosterone makes women
hirsute
. (excessive growth of facial or body hair)
So, for polycystic ovarian syndrome what should you look for in the patient?
Look for women who are
fat and hairy
, maybe with a deep voice, who has
irregular menses
and
trouble getting pregnant
Polycystic ovarian syndrome is a ____diagnosis
It is an endocrine diagnosis...so an ultrasound IS NOT required
Ultrasound isn't required for polycystic ovarian syndrome, but tests will still often show....?
an
ovarian ultrasound
with lots of little black circles, representing cysts
To make the diagnosis of polycystic ovarian syndrome, test question may show US, but what should you really use instead?
To make the diagnosis, instead use the
LH/FSH >3
, and make a metabolic diagnosis of diabetes (with the
2 hour glucose tolerance test
) and dyslipidemia.
So once again, what level will be elevated in polycystic ovarian syndrome?
Levels of testosterone will be elevated
For polycystic ovarian syndrome, should you obtain DHEAS level? Why or why not?
DHEAS is normal in PCOS and it isn't necessary to test if there is no evidence of virilization, but it is still often obtained to rule out other causes of hirsutism
What is the name of the criteria for the diagnosis of polycystic ovarian syndrome?
Rotterdam criteria*
What are the Rotterdam criteria for the diagnosis of polycystic ovarian syndrome, and how many do you need for the dx?
need 2/3
1)Oligo and/or anovulation
2)Clinical and or biochemical signs of hyperandrogegism
-Elevated DHEAS
-Elevated testosterone
-LH:FSH>3:1
3)Polycystic ovaries via ultrasound
Once polycystic ovarian syndrome is diagnosed, what is the mainstay therapy?
The mainstay therapy of polycystic ovarian syndrome is
OCP's
The mainstay treatment for polycystic ovarian syndrome is OCPs. What do they do?
They reset the axis and reduce anovulation
What else is involved in the treatment of polycystic ovarian syndrome?
metformin
to treat the diabetes
Metformin is involved in the treatment of polycystic ovarian syndrome. It treats the diabetes, but also helps to?
Reduce circulating androgens, making the effects of PCOS less severe.
OCP
s and
metformin
are the most common treatments for polycystic ovarian syndrome, but what is one other possible medication that you may see patients being put on?
spironolactone
Spironolactone occasionally used for polycystic ovarian syndrome, what does it do?
It's possible to see patients on spironolactone for its androgen receptor antagonism, further reducing the symptoms of hirsutism
If a women hoping to become pregnant, is diagnosed with polycystic ovarian syndrome, what is used to help facilitate the pregnancy.
clomiphene
or
pergonal
, which can induce ovulation
Clomiphene or pergonal can be used to induce ovulation for a polycystic ovarian syndrome hoping to become pregnant. However, what are the side effects?
The risk is multiple pregnancies
QUICK TABLES
Start Here
Dysfunctional Uterine Bleeding
ok
Path of DUB?
anovulation
.
No ovulation=no progesterone=estrogen only=proliferation
DUB is normal when?
NORMAL near menarche or near menopause
DUB, pt?
Bleeding that occurs without regular cycles
DUB, dx?
Diagnosis of exclusion, rule out everything with.....CBC, TSH, U/S, MRI, Prolactin, Hysterectomy, etc
DUB, tx?
------decrease stress
-------increase weight
OCPs-anemia
NSAIDS
DUB, f/u?
Very significant bleeding=IV estrogen
unresponsive to IV estrogen, TAH
POLYCYSTIC OVARIAN SYNDROME
Start Here
PCOS path?
Anovulation----->atretic follicles cant produce progesterone, so they produce large amounts of estrogen. Thats then converted to testosterone
PCOS, pt?
Hirsute= Fat + hairy
Deep voice
Anemia
Infertility
Endometrial cancer
PCOS, dx?
Dont do ultrasound
LH/FSH>3
Endocrine: Increased T, Normal DHEAS
DM-2 hour glucose test or A1c
PCOS, tx?
OCP's
Metformin
Clomiphene