[Music]
hi
now we're gonna discuss abnormal uterine
bleeding
this is abbreviated AUB so you'll hear
me say that over and over again during
the lecture abnormal uterine bleeding or
a UB was traditionally called mini Rajah
the research standard for mental blood
loss was greater than 80 milliliters
however on average women men straight
about 25 to 30 milliliters Metro Raja
was leading in between periods so again
recall menorrhagia was heavy bleeding
Metro Raja was bleeding in between your
normal scheduled period
poly materia is bleeding that occurs
more often than every 21 days and that's
just really annoying all ago men area is
when your period doesn't come as often
as it should all ago men area is less
than every 35 days so as you can
probably imagine the normal period is
between 21 and 35 days and length
between the time you bleed to the next
cycle let's talk now about a UB
classification this is a newer
classification and it starts with a UB
au b h mb which is heavy menstrual
bleeding which was formerly referred to
as mini raja interventional bleeding
which was formerly referred to as Metro
Raja and there's different causes so if
we look at structural causes the first
thing that you see in the new
classification system is a u BP a UB P
stands for polyp and the polyp can cause
any one of you above bleeding
abnormalities a UB a stands for
adenomyosis which is a common cause of
chronic pelvic pain and there is another
lecture that you can refer to about
chronic pelvic pain then there's a UB L
which is leiomyoma or fibroid as it's
traditionally called within leiomyoma or
a ub l you'll see here that you can have
a sub
coastal myoma which is in within the
cavity and that is abbreviated AUB l sm
for sub mucosal or you can have an other
myoma and that's a ub - l au for another
myoma will review myomas shortly then
the M under palm of the palm coin system
which is the new system is malignancy or
hyperplasia and this is referred to as a
ub - m you may see this in a chart once
you start on your clinical rotations now
let's look at non structural causes
coagulopathy a UBC is one avila tori
dysfunction meaning you probably have a
legume in area or au bo and de metrio
causes so there's something wrong with
the endometrium like endometritis this
is a ube
or iatrogenic a ubi which means we're
giving the patients something that
causes them to have more bleeding than
they normally should okay let's now
discuss some specifics about the
structural causes of a UB here we have
au BP as you remember that stands for
polyp endometrial polyps are an
overgrowth of cells that are usually
benign and present with bleeding but
usually they can be asymptomatic however
if a patient says you know I have a
history of bleeding in between periods
that is interventional bleeding or metro
Rajah you could consider polyps as a
diagnosis well how do we diagnose polyps
well the best way is to do a sailing and
few sonogram and here you can see an
ultrasound followed by an ultrasound
with saline infusion so we actually use
a catheter which we put saline through
using a syringe and we're able to
actually open the walls of the uterus
and see if there's any pathology if you
stuck a camera directly into the uterus
you would see via hysteroscopy polyps
that look like this in the last picture
you can see it's nice and pink
it looks like the normal endometrium is
just an overgrowth
let's talk about the risk factors for
developing polyps obesity which is very
common in the u.s. hypertension which
goes along with obesity diabetes which
also correlates with diabetes with
hypertension and obesity and advancing
age
recall that tamoxifen usage is
associated with polyp development so a
lot of women who've had breast cancer
this Estrin receptor positive will be on
tamoxifen let's now talk about
adenomyosis a UVA adenomyosis was
formerly turned in Demetrios as' interna
which in some ways was an interesting
name because endometriosis which is
covered in another lecture chronic
pelvic pain is actually the presence of
stroma and glandular tissue that should
normally be normally being in the
metrium inside the actual myometrium of
the uterus
classically an atom ionic uterus is
large boggy globular and usually these
patients suffer from chronic pelvic pain
let's now discuss abnormal uterine
bleeding due to lay oh my omus this is a
UBL uterine leiomyomas are also called
myomas or fibroids they are usually
benign and come from one single cell
actually undergoing expansion into a
large tumor they're unlikely to be
cancerous but less than 1% are reported
to be so more than 80% of African
Americans actually have leiomyomas and
more than 70% of Caucasian or European
descendant Americans also have glioma so
they're very very common and it actually
increases as time goes on in the
reproductive lifespan there are lots of
detail specifics about leiomyomas and so
if you're in a rush you might want to
skip through this and go on to the other
causes of AUB but I'll review this now
you can see here that african-american
versus Caucasian women have a three-fold
increase of having fibroids the age of
diagnosis in ass
Americans tend to be three to five years
younger and the severity that means the
pain the pressure that they may be
experiencing or the bleeding such as the
AUB that we're discussing as a five-fold
increase fibroid growth at older ages
has actually increased seven to eight
fold the risk of having a myomectomy
which is a surgery where we remove the
fibroids is a six-fold increase and
their risk of hysterectomy is a two to
threefold increase so you can see here
that african-americans have a higher
incidence and also suffer more from
fibroids here this is a pathology slide
of a smooth muscles tumor which is what
you would see with leiomyomas remember
that most of them are benign but we
still need to check the pathology to
make sure that's true this is a lovely
diagram that shows where leiomyomas can
occur there have been abnormal locations
such as on the bow but they usually
occur within the uterus their location
differs by how we describe them rather
we describe them differently based on
their location so you can see here that
a fibroid that's inside the uterus and
the lining is called a sub mucosal
fibroid a fibroid that's within the
muscle of the uterus is called an
intramural fibroid a fibroid that's kind
of just hanging whether it be a sub
mucosal or subsea Roesel is a bit tongue
culated fibroid sub serosa means it's
just under the tissue that lines the
outside of the uterus depending on their
location they can cause bleeding pain
and pressure in the patient this is a
view of a uterus at laparoscopy which is
a minimally invasive surgery where we
look in with a small camera usually
through the belly button you can see
here this uterus is distorted by the
presence of fibroids this patient is
likely going to be undergoing a
laparoscopic myomectomy they can be open
or abdominal myomectomy x' as well or a
history of scopic myomectomy
let's now move on to a UBC coagulopathy
these again these next following a UB
slides will be non structural causes
approximately 20% of patients who are
adolescent with a UB will have an
underlying coagulopathy so remember on
your exam to check for the presence of
abnormalities in their bleeding times or
potentially platelet function disorders
von Willebrand disease or other
coagulation factor issues usually these
patients have some type of history that
they will give you the initial screening
though should include questions that
specifically pinpoint these historical
issues so you want to ask them did you
have heavy menstrual bleeding since the
beginning of your periods that's
referred to as menarche
so if they report either a postpartum
hemorrhage or asserted leading or
bleeding associated with dental work
that should be a clue that they may have
a coagulopathy if they report one of
those but two of these which is bruising
over one or two times per month
epistaxis switches nose bleeding one or
two times a month frequent gum bleeding
one or two times a month or even once a
month and family history of bleeding you
should be concerned so again one of the
first category and two of the second
category makes you think that there
could be a UBC or coagulopathy let's
talk now about a UB o ovulatory
anovulatory cycles result in a range of
disorders amenorrhea means you have no
menstrual period but you then can have a
period which can be irregular and very
heavy because you're not shedding as you
should every month the most common cause
is due to polycystic ovarian syndrome
there's another lecture about PCOS or
polycystic ovarian syndrome that you can
look at to explain more let's now review
a ube
endometrial this classification refers
to endometrial causes of course we
discuss endometritis which is very
common in young
who may be susceptible or have STI s
let's now review the final
classification one of the final
classifications which is a ubi our
iatrogenic which means we have as
healthcare providers have actually
caused the AUB
through some type of medication whether
it be contraceptives that cause
breakthrough bleeding or irregular
bleeding with a levonorgestrel iud for
the first three to six months or
anticoagulants or antipsychotics
chemotherapy which decreases the overall
clotting ability or spironolactone which
is a medication that we talked about in
the hirsutism lecture or drugs related
to dopamine metabolism such as
antidepressants and antipsychotics
[Music]