45. Normal and Abnormal Uterine Bleeding

Although the Image attached to this video suggests it is about Gonorrhea and Chlamydia, the video is really “Topic 45: Normal and Abnormal Bleeding.”

Duration = 8:50

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


Introductory Women's HealthCare