Normal and Abnormal Uterine Bleeding

00:00
APGO educational topic number 45 normal
00:03
and abnormal uterine bleeding abnormal
00:05
uterine bleeding is menstrual flow
00:07
outside of normal regularity frequency
00:09
volume or duration in the United States
00:12
more than 10 million women suffer from
00:14
abnormal uterine bleeding this common
00:16
medical problem can adversely affect a
00:18
woman’s daily activities and
00:19
responsibilities with significant social
00:21
medical sexual and emotional impacts
00:25
although abnormal uterine bleeding can
00:27
affect adolescents and women of
00:29
reproductive age the majority of cases
00:30
occur in the five to ten years prior to
00:32
menopause abnormal uterine bleeding
00:34
accounts for more than 70% of all
00:36
gynecological consults for
00:38
perimenopausal and postmenopausal women
00:40
meet dr. paul cohen obstetrician
00:44
gynecologist extraordinaire in this
00:46
video we will discuss normal menses and
00:48
how dr. Palm Cohen can help women with
00:50
abnormal uterine bleeding the objectives
00:53
of this video are to define the normal
00:54
menstrual cycle and describe its
00:56
endocrinology and physiology define
00:58
abnormal uterine bleeding or AUB define
01:01
the pathophysiology and possible
01:03
ideologies of AUB define the steps in
01:06
the evaluation and management for AUB
01:08
and finally summarize the medical and
01:10
surgical options for AUB let’s talk
01:12
about the normal menstrual cycle it is
01:14
predictable and precisely regulated the
01:17
cycle lasts 21 to 35 days and remember
01:20
this is the time between the first day
01:21
of one menses – the first day of the
01:23
next menses the duration of menstrual
01:25
flow is four to six days with the loss
01:27
of approximately 30 CC’s of menstrual
01:29
blood let’s discuss the mechanics of how
01:31
this cycle works so predictably here is
01:33
a timeline starting with day one of
01:35
menses and here is day 28 we’ll look at
01:37
Grenada tropen and hormone levels in
01:39
relationship to ovarian and endometrial
01:41
changes let’s look at the ovary first a
01:44
primary follicle develops during the
01:46
follicular phase and becomes the
01:48
dominant follicle we will label that
01:49
follicle d this follicle secretes
01:52
increasingly large amounts of estradiol
01:54
and you can see the estradiol levels
01:56
rising here during the follicular phase
01:59
LH levels increase and there is a surge
02:02
on day 11 to 13 of the cycle this LH
02:06
surge triggers ovulation so here you’ll
02:08
see the dominant follicle now becoming
02:10
the corpus luteum after ovulation
02:14
this corpus luteum produces large
02:17
amounts of progesterone and thus
02:19
progesterone levels rise rapidly after
02:21
ovulation the progesterone has a
02:23
negative feedback on the pituitary gland
02:24
the corpus luteum also produces some
02:27
estrogen the uterine lining is
02:30
stimulated by the rising levels of
02:31
progesterone to get ready for
02:33
implantation and progesterone stimulates
02:35
the endometrial lining to become
02:36
secretory endometrium the endometrial
02:39
glands become tortuous and contain
02:41
secretory material at the end of the
02:43
luteal phase serum concentrations of
02:45
estradiol progesterone and LH reach
02:47
their lowest levels in response these
02:49
low levels FSH begins to rise in the
02:52
late luteal phase before the onset of
02:54
menstruation to recruit the next cohort
02:55
of follicles if conception does not
02:58
occur the corpus luteum envelopes
03:00
progesterone and estrogen production
03:02
declines and menstruation occurs in
03:04
response to low estrogen and
03:05
progesterone level during menstruation
03:07
the entire endometrium is expelled and
03:10
only the basal layer remains during the
03:12
follicular phase the rise in estrogen
03:14
levels stimulate endometrial cell growth
03:16
the endometrial stroma thickens and the
03:18
endometrial glands become elongated to
03:20
form proliferative endometrium wow that
03:25
was a lot of hardcore basic
03:26
endocrinology let’s move back to the
03:28
world of clinical diagnosis historically
03:31
there have been many terms used to
03:32
describe AUB such as Metro Raja or Meno
03:34
Metro Raja
03:35
however the acronym palm colon has been
03:38
introduced to describe a UV that
03:39
replaces these historical terms here is
03:42
a clever cartoon illustration created by
03:44
dr. Asha Yousef that helps explain the
03:46
palm cone acronym here is our patient
03:49
and she has a uterus and an endometrial
03:53
cavity the pea of Palm colon stands for
03:57
polyps so the peas are in the
03:59
endometrial cavity the a stands for
04:01
adenomyosis and you can see that she has
04:04
a globular and a large uterus
04:05
characteristic for adenomyosis the L
04:08
stands for a leiomyoma so I’m going to
04:10
draw multiple leiomyoma in her uterus
04:14
the M stands for malignancy and here we
04:17
can see mean malignant Mouse’s the C
04:21
stands for coagulopathy and here you see
04:24
a C
04:25
shaped liver the liver is making
04:29
markedly decreased coagulation factors
04:32
the O stands for ovarian dysfunction so
04:36
here is a sad-looking ovary and it’s a
04:38
sick over e to the e stands for
04:42
endometrial process most of these
04:44
processes are affected by estrogen the I
04:48
stands for iatrogenic so here is an
04:51
injection of heparin the n stands for
04:56
not yet classified the usual causes of a
05:00
UB vary over a woman’s lifetime for
05:03
adolescent women the most common cause
05:05
will be ovulating ssin this is
05:07
specifically from an ambulatory bleeding
05:09
from immaturity of the hpo axis regular
05:11
periods are usually established within
05:13
two to three years of menarche
05:14
if an adolescent woman presents with
05:16
heavy periods it’s also important to
05:18
remember coagulation disorders such as
05:20
von Willebrand’s disease for women of
05:22
reproductive age ovulatory dysfunction
05:24
is still a common cause of a UB and the
05:27
most common cause of ovulate or E
05:28
dysfunction will be polycystic ovarian
05:30
syndrome or PCOS PCOS affects 6% of all
05:33
women of reproductive age pregnancy and
05:36
related complications are a common cause
05:37
of a UB so don’t forget to check a
05:39
pregnancy test
05:40
sexually transmitted diseases such as
05:42
gonorrhea and chlamydia can also cause
05:44
abnormal uterine bleeding perimenopausal
05:47
women have increased incidence of
05:48
anatomic sources such as polyps Edna
05:51
meiosis leiomyomas or malignancy
05:53
anovulatory dysfunction is also a common
05:55
cause of a UB and perimenopausal woman
05:58
secondary to declining ovarian function
06:00
let’s move on to the evaluation of a UB
06:03
how do we go about figuring out what is
06:05
the potential cause for a patient’s a UB
06:07
we need to start with a good history
06:10
find out how heavy her periods are and
06:13
importantly the pattern of bleeding the
06:15
following scenes will illustrate dr.
06:17
Palm Cohen in action dr. Palm cone my
06:20
periods are not predictable nor regular
06:22
this may be of unit ory dysfunction this
06:26
ovulatory dysfunction could be secondary
06:28
to PCOS or perimenopausal and ovulation
06:30
dr. pan cone I am bleeding in between my
06:33
periods this sounds like an in atomic
06:36
source the anatomic source could be a
06:38
sub mucosal
06:39
hybrid or a uterine polyp dr. pan cone I
06:42
have always had very heavy periods I
06:44
wonder if you have a coagulopathy the
06:47
most common inherited coagulopathy would
06:49
be von Willebrand’s disease don’t forget
06:51
to also ask about medical or herbal
06:53
remedies that she may be taking let’s
06:55
move on to the physical exam look for
06:58
signs of excessive weight gain signs of
07:00
PCOS such as hirsutism and acne think
07:03
about signs of thyroid disease and signs
07:05
of insulin resistance physical exam
07:07
findings suggestive of a bleeding
07:09
disorder would include petechiae
07:10
ecchymosis skin pallor or swollen joints
07:13
pelvic examination including bimanual
07:15
examination should of course be
07:17
performed to assess the size and contour
07:19
of the uterus when deciding upon
07:21
diagnostic testing remember again that
07:23
we are trying to determine the source of
07:24
the AUB there should be a low index of
07:27
suspicion to perform an endometrial
07:28
biopsy to rule out endometrial
07:30
hyperplasia or endometrial cancer for
07:32
women over 40 or who have risk factors
07:34
such as obesity or diabetes laboratory
07:37
evaluation should include a complete
07:38
blood cell count to look for anemia and
07:40
a TSH to rule out thyroid disease it’s
07:43
worth repeating here don’t forget to
07:45
evaluate for pregnancy in any
07:46
reproductive aged woman a pelvic
07:48
ultrasound is usually the best
07:50
radiologic study for evaluation of the
07:52
gynecologic organs treatment will of
07:54
course depend on the etiology for her
07:56
AUB if an ambulatory bleeding is the
07:59
source of her AUB then medical therapy
08:01
with oral contraception or cyclic
08:02
progesterone can be used a
08:04
levonorgestrel iud is also an excellent
08:06
treatment option for these women an
08:08
endometrial ablation is also an option
08:10
however endometrial hyperplasia has to
08:12
be ruled out first with an endometrial
08:14
biopsy if the source of the bleeding is
08:16
an anatomic one which is an endometrial
08:18
polyp or sub mucosal fibroid then she
08:20
may need surgical management
08:22
hysterectomy is an option when
08:23
conservative medical and surgical
08:25
options have been discussed and tried
08:26
this concludes the ethical educational
08:29
video on normal and abnormal uterine
08:31
bleeding we have covered quite a bit
08:32
with the normal menstrual cycle abnormal
08:34
uterine bleeding and the initial
08:36
evaluation and management steps for a UB