Abnormal Uterine Bleeding in Gynaecology clerking MBBS

 Important History

- History of presenting illness

o Last menstrual period

o Menses frequency, regularity, duration, volume of flow,

any blood clot, flooding

o Intermenstrual and post-coital bleeding

o Since when?

o Abdominal mass: rapidly increasing in size?, compressive

sx

- Associated symptoms

o Symptoms of anemia

o Pain (abdominal, pelvic, dyspareunia)

o Dysmenorrhea

o Vaginal discharge; colour, odour, amount

o Abdominal and bladder symptoms

o Symptoms of bleeding tendency

o Symptoms of endocrine disorder

o Affect toward daily activities

- Gynae hx

o Current contraception

o History of sexually transmitted infections (STIs)

o PAP smear history

- Obs hx

o The number of pregnancy and mode of delivery; previous

caesarean section

- PMH: Liver disease, Thyroid disease, Anemia

- Drug: Blood thinner, OCP

- FH: Malignancy, endocrine disorder, coagulopathy

- Social: Tobacco, alcohol, and drug uses; occupation; impact of

symptoms on quality of life, Concern?

Physical Examination

- General – cachexia, pallor, hirsutism, insulin resistance

signs

- Vital signs, BMI

- Signs of endocrine disorders

o Examination of the thyroid for enlargement or

tenderness

o Excessive or abnormal hair growth patterns,

clitoromegaly, acne that could indicate

hyperandrogenism

o Moon facies, abnormal fat distribution, striae that could

indicate Cushing's

- Signs of coagulopathies; bruising or petechiae

- Abdominal exam to palpate for any pelvic or abdominal

masses

o (Site, Size (gravid uterus), Tenderness, Margin,

Surface, Consistency, Mobility, Get below or not)Complete examination by:

- Speculum examination: Lesion at the external genitalia,

growth or lesion in the vagina, cervical growth or discharge,

prolapse fibroid / polyp.

- Bimanual : Differentiate between uterine or ovarian

mass,adnexal mass, POD tenderness

- Digital Rectal Examination: to look for any PR bleed

Script presentation (Althea’s) & Discussion

Uterine:

My patient is young/elderly conscious and alert. She is lying comfortably with one

pillow, she had small body frame and hydration status is fair. She is not tachypnic

with respiratory rate of 20 breath/min. She is pale with clinical Hb of about

8g/dl. There is/no evidence of cachexic or jaundice. There is/no evidence of

lymphanedopathy. On hand examination, the CRT is less than 2 secs, palmar pallor,

and the pulse rate is 90 beats/min regular rhythm, good volume.

On inspection, there is well healed transverse suprapubic scar/midline

infraumbilical scar measuring 15cm, with no evidence of incisional hernia. The

lower part of the abdomen is slightly distended. There is no dilated vein or visible

peristalsis noted.

On palpation, the abdomen is soft and non tender. There is mass palpable at

suprapubic area measuring 7x5cm located centrally and extending to the right.

The mass can get above but cannot get below and it mobile right to left but

cannot move up and down. The mass is about 16 week gravid uterus. There is no

inguinal node felt. The liver and spleen are not palpable and kidneys are not

ballotable.

On percussion, the shifting dullness is negative suggestive of no ascites. On

auscultation, the bowel sound is heard and it is normal. There is no bruit heard.

I would like to complete my examination by performing speculum examination and

bimanual examination to assess the vulva, vagina, cervix, uterus adnexa and the

mass- to determine the origin of the mass either from uterus or ovary

Ovarian:

On general examination, patient is comfortable not in pain, cachexic, pale and

jaundiced. There is cervical lymphadenopathy (left Virchow node)

The abdomen is mildly distended, the umbilicus is centrally located and inverted.

There was no dilated vein or visible peristalsis.

There is mass palpable at suprapubic area measuring 7x5cm located centrally and

extending to the right. The mass can get above and also can get below and it

mobile up and down but cannot move right and left. The mass is about 16 week

gravid uterus

The shifting dullness is positive suggestive of ascites

I would like to complete my examination with speculum examination and bimanual

examination in order to assess the origin of the mass

Investigation

Blood

- Urine pregnancy test

- Full blood count (Hb, WCC, platelet)

- Thyroid function test

- Coagulation profile

- FBC: anemia (lethargy)

- LFT: liver metastasis (For Mass)

- RP: compressive effect to ureters (obstruction / renal

failure)Imaging

- Transvaginal or/and transabdominal ultrasound:

(endometrial thickness, uterus size and shape, fibroids,

adenomyosis, ovarian anomalies)

o ET: premenopausal

▪ Menstrual phase 2-4mm

• Early proliferative phase 5-7mm

• Late proliferative phase 11mm

• Secretory phase 7-16mm

# so need to ask last menses before doing US to check

for ET (identify the phase)

Uterine Features Ovarian Features

● uterine size, shape

● Endometrial thickness (ET)

○ <4mm cancer less likely

ca

○ >4mm (rule out Ca-

require further

evaluation)

● uterine margin

(irregularity)

● any mass in uterus:

○ Size

○ multiple/single

○ solid/cystic

○ Hyperechoic/hypoechoic

● Presence of metastases

● Size >10cm

● Solid vs cystic nature

● Uniloculated vs Multiloculated

● Papillary projections (>3mm)

● Poorly defined margins

● Bilaterality

● Presence of free fluid

(Ascites)

● Extraovarian disease -

peritoneal thickening, omental

deposits

● Doppler - vascularized vs

avascular

- CT TAP: if suspect malignancy & to rule out metastasis

- Pipelle Hysteroscopy

o Endometrial biopsy

o Indication:

▪ PMB

▪ HMB >45 years old

▪ HMB with IMB

▪ Risk factor of endometrial pathology

Management

General: AUB

Medical Minimally Invasive Major Surgery

- Antifibrinolytics

- Progestins

- Estrogen +

progestins (OCP)

- GnRH agonists

- Anti-progestational

agents

- Intrauterine

device (IUD)

- Endometrial

ablation

- D&C

- Myomectomy

- Hysterectomy

1. I would like to manage this patient as inpatient/outpatient

2. Acute/immediate management

- ABC are secured & stable

- Insert 2 large bore branula to anticipate further bleeding

- Take blood for investigation

- Start fluid resuscitation if there is hypotensive due to blood loss

- Pain relief: analgesia

3. Observation

- BP/ pulse rate (tachycardia are signs of hypovolemic shock

secondary to blood loss

- Pad chart monitoring

- Input output chartFibroid

Non-hormonal - Tranexamic acid

- Mefenamic acid

- NSAIDs

Hormonal - OCP

- LNG IUS

- GnRH analogue

- Danazol

- SPRM

Surgical - Myomectomy

- Hysterectomy

Radiological - Uterine artery embolization

- High intensity focussed ultrasound

- Asymptomatic: reassurance & 6 monthly f/up

- HMB, anaemic, want to conceive: tranexamic acid + Fe

supplement

- Compressive sx want to conceive: GnRH agonist w/

myomectomy

- Subfertility want to conceive: fertility workup, if normal

offer myomectomy

Adenomyosis

- Medical

o Non hormonal: NSAIDs reduce severity of

dysmenorrhea & pelvic pain

o Hormonal

- Surgical

Hysterectomy The definitive treatment for adenomyosis

Only way to remove diffuse adenomyosis & preferred

way to remove focal adenomyoma except where future

pregnancy is desired

Uterine-

sparing

resection

Can be considered in women with extensive

adenomyosis who are actively pursuing pregnancy

Associated with improvement of pain and menorrhagia

and reduction in uterine volume

Can use hormonal agents, such as GnRH agonists and

the LNG IUD, to help prevent recurrence and control

symptoms

Risk: Uterine rupture in the following pregnancy

Endometrial Hyperplasia

W/o

atypia

Conservative

- Observation alone w/ f/up endometrial biopsy

- Informed the risk progressing to endometrial cancer is <5% over 20

years & majority of cases will regress spontaneously during f/up

- Lifestyle modification: Obesity (Weight reduction)

- Reassess HRT: change to less estrogen

Pharmaco

- Progestogens for minimum 6/12

o Oral: medroxyprogesterone 10-20mg/day or norethisterone

10-15mg/day

- LNG-IUS is 1st line as has higher ds regression & more favourable

bleeding profile, less side effects

Surgical: Hysterectomy

- Not 1st line as progestogen therapy induce histological and

symptomatic remission

- Indicated in those not wanting to preserve fertility when:

o Progression to atypical hyperplasia

o No histological regression despite 12 months treatment

o Relapse after completing progestogen treatmento Persistence bleeding sx

o Decline endometrial surveillance & compliance to medication

W/

atypia

Surgical

• TAHBSO: 1st line treatment

• Progression to cancer

Endo Ca

Stage I TAHBSO*

Stage II Wertheim/Radical hysterectomy (spread to

cervival)

Stage III Surgical debulking or radiotherapy first followed

by surgery

Stage IV Chemoradiotherapy

Discussion on Uterine Mass & HMB

1) how do you ix if it is leiyomyosarcoma?

- Rapidly increasing in size (clinical)

- MRI

2) How to do bimanual examination? – use to confirm the

origin of mass

- My left hand is place on the abdomen to hold the mass. My

right index and middle finger will be placed inside the vagina,

touching the cervix. I will push the mass towards the

xiphisternum. If the cervix move away from my right fingers,

most likely the mass is uterine in origin and my ddx is ovarian

mass which has adhere to uterus.

- If the cervix remain static, most likely the mass is from

ovary and my ddx is a pedunculated uterine fibroid

3) How to differentiate ovarian & uterine mass?

Uterine mass Ovarian mass

• Center

• Arising from suprapubic

• Unable to get below the mass

• Center or side

• Able to get below the

mass

4) Common side effect of danazol?

- androgenic effect

5) Mechanism of Uterine artery embolization?

- Embolization of both uterine arteries under radiological

guidance

- injection of polyvinyl alcohol particles into uterine artery n

branches that supply fibroid & reducing the blood supply

- can reduce intra-op bleeding

- periop cx: infection, bleeding, hematoma at femoral artery,

allergy

- Uncertain subsequent reproductive fx

- Post-embolization: fever, pain, n&v

6) How to do bimanual examination?7) Fibroid Vs Adenomyosis

Discussion on Endometrial cancer

1) Premalignant lesion = endometrial hyperplasia (simple,

complex and atypia)

2) Management of simple and complex endo hyperplasia

- Progesterone therapy 3 month → repeat hysteroscopy and

biopsy → if regress, continued therapy for 3-6 month and

surveillance TVS → if persistent, high dose depo-povera for

3 months or hysterectomy

3) Management of atypia endo hyperplasia

- Hysterectomy because higher risk to dev endo CA. If pt

refused or unfit, give high dose progesterone, endo sampling

6 monthly and long term surveillance

4) How to manage endometrial cancer?

- Explore risk factor

- TVS finding > 4mm (abnormal in postmenopausal woman) → do

pipelle (endometrial biopsy) → confirmed CA, do staging for

management and prognosis (MRI pelvis for T and N, CT TAP

for M)

5) How many type of endometrial CA?

- Type I = endometrioid adenocarcinoma, due to estrogen

(endometrioid and mucinous tumor)

- Type II = serous papillary cancer, not related to estrogen

associated with atrophic endometrium (serous and clear cell

tumor)

6) What type of ovarian tumor that can cause PMB and

development of endometrial CA?

- Estrogen secreting tumor which is granulosa-thecal tumor (a

sex cord stromal tumor)

Discussion on Ovarian Mass

1) What is your diagnosis?

- young pt = ovarian cyst, endometrioma, teratoma,

hydrosalpinx, pyosalpinx, tubo-ovarian abscess

- elderly pt = ovarian cancer

2) What is tumor marker you want to do?

- CA-125 = epithelial ovarian CA (serous)

- CA 19-9 = epithelial ovarian CA (mucinous)

- Inhibin = granulosa cell tumors

- hCG = choriocarcinoma, dysgerminoma

- AFP = yolk sac tumor, teratoma

3) Difference b/w ascites and ovarian mass?

Ascites Ovarian cyst

• Resonant

anteriorly &

dullness in flanks

• Fluid thrill positive

• Shifting dullness

positive

• Dullness anteriorly &

resonant in flanks

• Fluid thrill positive

• Shifting dullnes

negative4) Benign Vs malignant Ovarian mass?