Abnormal uterine bleeding
?? ??: 21-35? ??. (?? ? 2-5?? 21-45? ??)
???? ???? DUB, dysfunctional uterine bleeding
Without anatomic lesion, ?? ??? ???? ??? ??.
?? ???? ? unopposed E ? ???? ???; ?? ??? ??? ??? ??.
P withdrawal? ?? ??. ? ? E breakthrough, E withdrawal, P breakthrough ??? ??.
??? E? ?? ??? P? ??? ??? ??? ?? ??.
- ????
- Pregnancy-related
- ???(myoma, endometrial polyp)
- ???(Halban, ?? ?? ??)
| NSAID | ??? 30-50% ?? |
| Hormone | ??? ?? ?? ? ?? ??? ??? ?? ?? ?? Combined OC: ??? ?? ??? ?? ? ?? ?? ? ? ??? ??? ?? Progestin: OC? ???? E? ??? ?. ?? ???? ?? ??. |
| Surgical | D&C or ?? ??? |
?? ? 70%? endometrial atrophy ??. HRT 20% > Endometrial polyp/hyperplasia/cancer
Endometrial polyp
- Well-circumscribed collection of endometrial tissue within uterine wall. May contain smooth muscle cells.
- Can arise as a side effect of tamoxifen, which has anti-estrogenic effects on the breast but weak pro-estrogenic effects on the endometrium.
- Bleeding between regular, monthly menstrual cycles.
Hypothyroidism
?circulating thyroxin ? ?TRH ? ?prolactin ? ?FSH, LH ? anovulation and AUB
Management
- Acute heavy bleeding
- High-dose estrogen IV – stabilizes the endometrial lining and typically stops bleeding within 1 hour. Transition to combined OC or add progestin when bleeding stabilized.
- If estrogen is contraindicated, can give high-dose progestin therapy alone.
- If bleeding is not controlled within 12-24 hours, a D&C is often indicated.
- Ovulatory bleeding (menorrhagia)
- NSAIDs to ?blood loss.
- Tranexamic acid can be given for 5 days during menses.
- Anovulatory bleeding
- Progestin for 10 days to stimulate withdrawal bleeding
- If medical management fails
- D&C
- Hysteroscopy
- Uterine artery embolization if fibroids are the cause of menorrhagia
- Hysterectomy or endometrial ablation
Pelvic masses
Vulvar disease
Bartholin cyst dilation
- Etiology
- Inflammation and obstruction of gland
- Usually occurs in women of reproductive age
- Clinical presentation
- Unilateral, painful cystic lesion at the lower vestibule adjacent to the vaginal canal
- Management
- Asymptomatic: observation and expectant management
- Symptomatic: incision and drainage ? placement of a Word caatheter
- Recurrent: marsupialization
Condyloma
C131 Sexually Transmitted Infections: Overview and Clinical Approach
Squamous hyperplasia
=hypertrophic dystrophy
Lichen sclerosus
=atrophic dystrophy. m/c, ?? ? ?? ??.
Pruritic, white
Thinning of the epidermis and fibrosis (sclerosis) of the dermis & perianal thickening with fissure.
Presents as a white patch (leukoplakia) with parchment-like vulvar skin.
Possible autoimmune etiology.
Benign, but associated with a slightly increased risk for SCC
? topical steroid (clobetasol)
Lichen simplex chronicus
= Lichen planus (?)
Characterized by hyperplasia of the vulvar squamous epithelium
Pruritic, glassy, bright red-purple lesions with overlying white reticular lines “Wickham striae”
Presents as leukoplakia with thick, leathery vulvar skin
Associated with chronic irritation and scratching
Benign; no increased risk of SCC.
Depigmentation
=leukoderma or vitiligo. ???: trauma, ?? ??, radiation scarring
Hyperkeratosis
By ?? ??.
Pediatric
P25 Gynecologic Problems of Childhood
Vaginal disease
Adenosis
Focal persistence of columnar epithelium in the upper 1/3 of the vagina
Increased incidence in females who were exposed to diethylstilbestrol (DES) in utero
Other malignant diseases…
C36 Cervical and Vaginal Cancer
Prepubertal age group
Abnormal bleeding
- Maternal withdrawal of estrogen (m/c cause in neonatal period)
- Following delivery, the neonatal endometrium may slough off, causing self-limited, mucoid, vaginal bleeding.
- Typically occurs within the first 2 weeks of life and may last for several dyas. Lasts <1 week
- Examination otherwise normal.
- The bleeding is self-limited, and no treatment is required.
Pelvic masses
Vulvar conditions
Neonatal vulvar conditions
Childhood vulvar conditions
Labial adhesion
D/t low estrogen production inflammation from poor hygiene, infection (eg, vaginitis), irritation (eg, diaper rash) or trauma (eg, straddle injury) also contributes to the development of adhesions.
Partial adhesions are often asymptomatic. Some may experience vaginal pain or pulling.
Asymptomatic adhesions require no treatment, topical estrogen is first-line therapy for those with symptoms.
Vaginal conditions
Adolescent age group
Abnormal Bleeding
Immature HPA axis
- Pathophysiology
- Anovulation ? heavy, irregular menstrual bleeding
- Clinical presentation
- Thick endometrial s tripe, otherwise normal.
- Management
- High-dose oral contraceptive
- To stabilize endometrium and stop the acute bleeding.
- Mainly by estrogen. Progestins are not as effective as estrogen.
High-dose GnRH- Create a hypoestrogenic state. Do not work quickly enough to stop bleeding.
- Not recommended for adolescents d/t decreased BMD caused by prolonged use.
- High-dose oral contraceptive
Pelvic masses
Vulvar conditions
Vaginal conditions
Reproductive-Age Group
Abnormal bleeding
Differential diagnosis
Pelvic masses
Diagnosis
- Pregnancy test
- TVUS
- Benign-looking
- Observation and repeat exam in 6 weeks
- Give OCS if functional
- Malignant-looking
- 8cm, Multiloculations, Septum, Papillae, Ascites, Blood flow?, Irregular surface, Fixed, Solid, Bilateral
- ???? ?? ?? ?? ??? ???. Aspiration? ?? ??!
- Postmenopausal
- ??? TOC. ??? ?? ?? ?? ??
- No Sx, <5cm, unilocular thin-walled cyst, nl CA-125
- Benign-looking
- CA-125
- High false positive (eg, ?? 1?, endometriosis, adenomyosis, Mens, ?? ovarian cyst) ? used only as a marker for progression and recurrence.
- In postmenopausal women,
Functional ovarian cyst
- Follicular cyst
- m/c. Freqeuntly torsion. normally disappear within 4-8weeks.
- Corpus luteum cyts
- US: simple-appearing ovarian cyst with normal Doppler flow
- Disappear with menorrhea. But massive bleeding may uccur if ruptured. DDx with ectopic!
- Theca lutein cyst
- Usually with High LH or hCG (e.g. H-mole). Usually regress spontaneously.
| Pregnancy | Teratoma-m/c. ????? ?? ??? ??? ??! |
| Torsion | ???? 1st trimester? 2/3? ??. ? laparoscopic detorsion ± cystectomy |
| Rupture |
esp. often in functional cyst. ? Dx: TVUSG, culdocentesis ? Tx: Surgery when severe anemia, suspicious of hemoperitoneum. (otherwise, just f/u) |
Vulvar conditions
Vaginal conditions
- Retained foreign body—tampon, pessary
- Ulcerations—tampon-induced, lichen planus, herpes simplex infection
- Malignancy—cervical, vaginal
Postmenopausal Age Group
Abnormal bleeding
All patients with PMB require endometrial evaluation
(endometrial biopsy or transvaginal ultrasound)
- Low estrogen levels
- Diminished blood flow & decreased collagen and glycogen production
- Vaginal pH ?5 b/c ?glycogen production reducees normal vaginal lactobacilli activity
- Loss of epithelial elasticity and subsequent atrophy
Pelvic masses
Vulvar conditions
Urogenital atrophy
- Decreased collagen, elasticity, and blood flow in the bladder trigone and urethra (which are estrogen-sensitive tissues)
- ? urogenital atrophy ? induce urgency incontinence
- Decreased glycogen content
- Loss of vaginal lactobacilli and an elevated vaginal pH ? increase the risk of recurrent UTIs.
- Thin, easily denuded vulvovaginal epithelium ? dysuria
- Management
- 1st line: nonhormonal moisturizers and lubricants
- Vaginal estrogen is indicated in patients with no symptom. relief or in those with severe symptoms.
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