Abnormal Uterine Bleeding
Abnormal uterine bleeding (AUB), often known as heavy, protracted, or recurrent menstrual-like bleeding, is a kind of abnormal uterine bleeding. Can be acute or chronic (lasting more than six months) Instead of dysfunctional uterine bleeding (DUB), the International Federation of Gynaecology and Obstetrics (FIGO) now refers to AUB. EPIDEMIOLOGY Women who are adolescent or perimenopausal are more frequently afflicted. Incidence In any given year, 5% of women in reproductive age will visit a doctor for AUB. Prevalence AUB affects 3–30% of reproductive-age women. PATHOPHYSIOLOGY AND AETIOLOGY 90% of AUB is caused by anovulatory cycles, which are typically brought on by an underdeveloped hypothalamic-pituitary-ovarian (HPO) axis in adolescents. The acronym PALM-COEIN was created to remember AUB in women of reproductive age. PALM stands for Polyp, Adenomyosis, Leiomyoma, and Malignancy and/or Hyperplasia (structural causes) COEIN (nonstructural causes): Coagulopathy, Iatrogenic, Endometrial, Ovulatory problems, and Coagulopathy is currently unclassified. 20% of people who experience severe menstrual bleeding also suffer from a bleeding condition. The two most typical: Blood clotting issues and thrombocytopenia - Conditions that affect ovulation PCOS, eating problems, prolactinoma, hypothyroidism, hyperparathyroidism, and thyroid disorders - Drugs (iatrogenic factors) Blood thinners, steroids, oestrogen receptor antagonists like tamoxifen, hormonal contraceptives like copper IUDs, first-generation antipsychotic drugs, postmenopausal hormone replacement therapy, and antiemetics like metoclopramide and domperidone Ectopic pregnancy, threatened or unfinished abortions, hydatidiform moles, upper genital tract infections, advanced or fulminant liver disease, chronic renal disease, nutritional deficiencies, inflammatory bowel disease, excessive weight gain, and increased exercise are some additional causes of AUB not listed in PALM-COEIN. Genetics-Unknown but may include hereditary hemostasis diseases Age, usually >40 years old; obesity; PCOS; diabetes mellitus; nulliparity; early menarche or late menopause (>55 years of age); chronic anovulation or infertility; history of breast cancer or endometrial hyperplasia; use of tamoxifen; family history of gynecologic, breast, or colon cancer; thyroid disease are all risk factors for endometrial cancer. DURATIONAL PREVENTION There is no specific prevention for AUB COMMONLY ASSOCIATED CONDITIONS. Endometrial polyps, adenomyosis, leiomyoma, endometrial cancer, coagulopathy, PCOS, thyroid issues, malnutrition (eating disorders), hyperprolactinemia, ovarian follicle decline (perimenopause), pregnancy, and endometriosis are some of the conditions that can affect the uterus. DISEASE HISTORY Menstrual history, including the start, severity (measured by pad/tampon use, the presence and size of clots), and timing of bleeding (unpredictable or episodic) for the previous six months; also determine menopausal status. Association with additional factors, such as coitus, contraception, and weight gain or loss Review of systems (excluding symptoms of pregnancy, bleeding disorders, stress, exercise, recent weight change, vision changes, headaches, galactorrhea) Gynecologic history: gravidity and parity, STI history, prior Pap smear findings ALERT Any bleeding that occurs more than a year following the previous menstrual period is referred to as postmenopausal bleeding; malignancy must always be ruled out. MEDICAL ANALYSIS Body mass index, pallor, vital signs, faults in the visual field (pituitary lesion), vaginal discharge, hirsutism or acne, goitre, galactorrhea, purpura, and ecchymosis are all things to look out for. Pelvic exam: Tanner stage, foreign bodies, irregularities in the uterus, ruling out rectal or urinary tract bleeding, Pap test, and tests for STIs (1)[C] Child Safety Considerations Children who are premenarchal and have vaginal bleeding should be examined for foreign objects, symptoms of physical or sexual abuse, potential infections, and early signs of puberty. Initial Tests (lab, imaging) Diagnostic Tests & Interpretation For acute heavy/hemorrhagic bleeding, a type and cross should be acquired in all patients. A partial thromboplastin time (PTT), prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level should be obtained if a disorder of hemostasis is suspected; if abnormal, von Willebrand factor, ristocetin cofactor assay, and factor VIII should also be obtained. - STI testing, KOH preparation, follicle-stimulating hormone (FSH), prolactin level, and vaginitis panel – 17- Testosterone and/or dehydroepiandrosterone sulphate (DHEA-S) if PCOS is suspected. - Hydroxyprogesterone if congenital adrenal hyperplasia is detected. TVUS in postmenopausal AUB: Postmenopausal endometrial thickness (ET) 4 mm does not necessitate endometrial sample unless bleeding is continual or recurrent, but ET >4 mm should warrant further investigation. - Negative predictive value (NPV) for excluding endometrial cancer at 99.6% for ET 5 mm (2) - Postmenopausal women who discover an endometrial measurement of >4 mm incidentally should not be evaluated; nonetheless, a risk factor assessment based on each person is appropriate. In premenopausal women with AUB, TVUS, sonohysterography, and hysteroscopy may all be equally successful at spotting intrauterine disease. Tests in the Future & Special Considerations Prior to performing an endometrial biopsy (EMB), it is advisable to begin medical treatment in females under the age of 35 if there is a low risk of uterine anatomic/histologic abnormalities or adenomyosis. Other/Diagnostic Procedures If you are older than 21 years, get a Pap test to check for cervical cancer (1).[C] EMB - Women over 45 with AUB to rule out cancer or premalignancy - Postmenopausal women with ET 4 mm - Women between the ages of 18 and 45 with AUB, a history of unopposed oestrogen, and unsuccessful medical management - Women of any age without risk factors if imaging results show abnormalities (1) - If known, perform on or after day 18 of the cycle; secretory endometrium verifies ovulation. Hysteroscopy with targeted biopsy is recommended in cases of suspected intrauterine lesions and negative EMB; the NPV for endometrial cancer in these cases is 99.5%. Interpretation of Tests A Pap smear may show cervicitis-related inflammation or cancer. Anovulation is typically indicated by proliferative or dyssynchronous endometrium in EMBs, but endometrial cancer or simple or complicated hyperplasia can also be present. NSAIDs (naproxen sodium 500 mg BID, mefenamic acid 500 mg TID, and ibuprofen 600 to 1,200 mg/day) Decreases amount of blood loss and pain compared to placebo "Surgical" techniques (including LNG-IUD) are typically preferable to medical approaches for long-term control First Line: MEDICATION Acute, urgent, nonovulatory bleeding: Conjugated equine oestrogen (Premarin) 25 mg IV every four hours (maximum six doses) stops bleeding in 72% of people in eight hours; 2.5 mg Premarin given orally every six hours should cease bleeding in 12 to 24 hours.[A]. TXA 1.3 g PO or 10 mg/kg IV (maximum dose of 600 mg) If there is no improvement after two to four Premarin doses, or sooner if bleeding is more than one pad per hour, do an intrauterine tamponade by filling a 26F foley bulb with 30 mL saline (1). Then switch to an oral contraceptive pill (OCP) or progestin for cycle regulation. Acute, nonemergent, nonovulatory bleeding is stopped in 88% of women by monophasic combination OCPs with 35 g of oestrogen TID for 7 days. Non-acute, nonovulatory bleeding can be stopped in 76% of women in 3 days with medroxyprogesterone acetate 20 mg PO TID for 7 days (3)[A]. Levonorgestrel IUD (Mirena) is the most efficient type of progesterone delivery, reducing blood loss by 71% to 95%, and is not less successful than surgical treatment. Medroxyprogesterone acetate (Provera), 10 mg/day for 5–10 days per month, is a progestin. Progesterone is taken daily for 21 days per cycle, which greatly reduces blood loss. - OCPs: 20 to 35 g of daily oestrogen plus progesterone (pay special attention to anovulatory females under the age of 18 who are not yet engaged in sexual activity). - TXA 1.0-1.5 g PO 3 times per day; refrain from administering to patients with hypercoagulable conditions. If there are any contraindications to using oestrogen, including those for smoking in women over 35 (relative contraindication), a history of DVT, migraines with aura, or suspicion of endometrial hyperplasia or cancer. Precautions: If medical treatment proves unsuccessful, additional investigation and surgical intervention should be considered. – When using high dose oestrogen therapy, take DVT prevention into consideration. Next Line Gonadotropin-releasing hormone (GnRH) agonists include Elagolix 300 mg BID and Leuprolide (various dosages and durations of action). Danazol (200 to 400 mg/day for a maximum of 9 months), while more effective than NSAIDs, was constrained by androgenic side effects and cost; it has since been replaced by GnRH agonists. Add-back therapy (1 mg estradiol/0.5 mg norethindrone acetate once a day) is now FDA-approved for heavy menstrual bleeding caused by uterine fibroids in premenopausal women. Clomifene (Clomid) or metformin, either alone or in combination, for PCOS patients who want to ovulate and become pregnant QUESTIONS FOR REFERENCE Consult a paediatric gynaecologist or endocrinologist if a child's vaginal bleeding does not have an obvious reason. Additional treatments include antiemetics when using high doses of oestrogen or progesterone, iron supplementation if anaemia (usually iron deficiency) is found, and ulipristal acetate 5 mg or 10 mg (selective progesterone receptor modulator), which has been found to be effective but is currently being suspended while being assessed for a potential severe liver injury. SURGICAL AND OTHER PROCEDURE Endometrial ablation, which is less expensive than hysterectomy and is associated with high patient satisfaction; this is a permanent procedure and should be avoided in patients who desire continued fertility. Hysterectomy in cases of endometrial cancer, if medical therapy fails, or if other uterine pathology is found. If bleeding is unresponsive to medicine or fibroids have been diagnosed, uterine artery embolisation CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING Significant bleeding that results in acute anaemia and hemodynamic instability; restore volume with crystalloid and blood as needed in cases of acute bleeding. To estimate and keep track of the quantity of bleeding, pad counts and clot sizes can be helpful. Hemodynamic stability and management of vaginal bleeding are the conditions for discharge. CONTINUING CARE AFTERCARE RECOMMENDATIONS Once the patient is stable following acute care, a follow-up evaluation in 4 to 6 months is advised for additional assessment. patient observation Menstrual diaries should be kept by women on OCPs or oestrogen to track bleeding patterns and how they relate to treatment. No limitations on diet, albeit a 5% weight loss can trigger ovulation in women with PCOS-related anovulation. The majority of anovulatory cycles can be treated with medicinal therapy and do not need surgical intervention, however the prognosis varies with the pathophysiologic process. COMPLICATIONS Anaemia due to a lack of iron and mood disorders
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