{"id":2605,"date":"2020-08-13T14:20:36","date_gmt":"2020-08-13T14:20:36","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=156"},"modified":"2021-05-09T20:49:50","modified_gmt":"2021-05-09T20:49:50","slug":"45-normal-and-abnormal-uterine-bleeding","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/45-normal-and-abnormal-uterine-bleeding\/","title":{"rendered":"45. Normal and Abnormal Uterine Bleeding"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/Im7csocMDcM\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Although the Image attached to this video suggests it is about Gonorrhea and Chlamydia, the video is really &#8220;Topic 45: Normal and Abnormal Bleeding.&#8221;<\/p>\n<p>Duration = 8:50<\/p>\n<input type='hidden' bg_collapse_expand='69e9b5a5a187a3051265452' value='69e9b5a5a187a3051265452'><input type='hidden' id='bg-show-more-text-69e9b5a5a187a3051265452' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b5a5a187a3051265452' value='Hide Transcript'><button id='bg-showmore-action-69e9b5a5a187a3051265452' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b5a5a187a3051265452' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 45 normal<br \/>\n00:03<br \/>\nand abnormal uterine bleeding abnormal<br \/>\n00:05<br \/>\nuterine bleeding is menstrual flow<br \/>\n00:07<br \/>\noutside of normal regularity frequency<br \/>\n00:09<br \/>\nvolume or duration in the United States<br \/>\n00:12<br \/>\nmore than 10 million women suffer from<br \/>\n00:14<br \/>\nabnormal uterine bleeding this common<br \/>\n00:16<br \/>\nmedical problem can adversely affect a<br \/>\n00:18<br \/>\nwoman&#8217;s daily activities and<br \/>\n00:19<br \/>\nresponsibilities with significant social<br \/>\n00:21<br \/>\nmedical sexual and emotional impacts<br \/>\n00:25<br \/>\nalthough abnormal uterine bleeding can<br \/>\n00:27<br \/>\naffect adolescents and women of<br \/>\n00:29<br \/>\nreproductive age the majority of cases<br \/>\n00:30<br \/>\noccur in the five to ten years prior to<br \/>\n00:32<br \/>\nmenopause abnormal uterine bleeding<br \/>\n00:34<br \/>\naccounts for more than 70% of all<br \/>\n00:36<br \/>\ngynecological consults for<br \/>\n00:38<br \/>\nperimenopausal and postmenopausal women<br \/>\n00:40<br \/>\nmeet dr. paul cohen obstetrician<br \/>\n00:44<br \/>\ngynecologist extraordinaire in this<br \/>\n00:46<br \/>\nvideo we will discuss normal menses and<br \/>\n00:48<br \/>\nhow dr. Palm Cohen can help women with<br \/>\n00:50<br \/>\nabnormal uterine bleeding the objectives<br \/>\n00:53<br \/>\nof this video are to define the normal<br \/>\n00:54<br \/>\nmenstrual cycle and describe its<br \/>\n00:56<br \/>\nendocrinology and physiology define<br \/>\n00:58<br \/>\nabnormal uterine bleeding or AUB define<br \/>\n01:01<br \/>\nthe pathophysiology and possible<br \/>\n01:03<br \/>\nideologies of AUB define the steps in<br \/>\n01:06<br \/>\nthe evaluation and management for AUB<br \/>\n01:08<br \/>\nand finally summarize the medical and<br \/>\n01:10<br \/>\nsurgical options for AUB let&#8217;s talk<br \/>\n01:12<br \/>\nabout the normal menstrual cycle it is<br \/>\n01:14<br \/>\npredictable and precisely regulated the<br \/>\n01:17<br \/>\ncycle lasts 21 to 35 days and remember<br \/>\n01:20<br \/>\nthis is the time between the first day<br \/>\n01:21<br \/>\nof one menses &#8211; the first day of the<br \/>\n01:23<br \/>\nnext menses the duration of menstrual<br \/>\n01:25<br \/>\nflow is four to six days with the loss<br \/>\n01:27<br \/>\nof approximately 30 CC&#8217;s of menstrual<br \/>\n01:29<br \/>\nblood let&#8217;s discuss the mechanics of how<br \/>\n01:31<br \/>\nthis cycle works so predictably here is<br \/>\n01:33<br \/>\na timeline starting with day one of<br \/>\n01:35<br \/>\nmenses and here is day 28 we&#8217;ll look at<br \/>\n01:37<br \/>\nGrenada tropen and hormone levels in<br \/>\n01:39<br \/>\nrelationship to ovarian and endometrial<br \/>\n01:41<br \/>\nchanges let&#8217;s look at the ovary first a<br \/>\n01:44<br \/>\nprimary follicle develops during the<br \/>\n01:46<br \/>\nfollicular phase and becomes the<br \/>\n01:48<br \/>\ndominant follicle we will label that<br \/>\n01:49<br \/>\nfollicle d this follicle secretes<br \/>\n01:52<br \/>\nincreasingly large amounts of estradiol<br \/>\n01:54<br \/>\nand you can see the estradiol levels<br \/>\n01:56<br \/>\nrising here during the follicular phase<br \/>\n01:59<br \/>\nLH levels increase and there is a surge<br \/>\n02:02<br \/>\non day 11 to 13 of the cycle this LH<br \/>\n02:06<br \/>\nsurge triggers ovulation so here you&#8217;ll<br \/>\n02:08<br \/>\nsee the dominant follicle now becoming<br \/>\n02:10<br \/>\nthe corpus luteum after ovulation<br \/>\n02:14<br \/>\nthis corpus luteum produces large<br \/>\n02:17<br \/>\namounts of progesterone and thus<br \/>\n02:19<br \/>\nprogesterone levels rise rapidly after<br \/>\n02:21<br \/>\novulation the progesterone has a<br \/>\n02:23<br \/>\nnegative feedback on the pituitary gland<br \/>\n02:24<br \/>\nthe corpus luteum also produces some<br \/>\n02:27<br \/>\nestrogen the uterine lining is<br \/>\n02:30<br \/>\nstimulated by the rising levels of<br \/>\n02:31<br \/>\nprogesterone to get ready for<br \/>\n02:33<br \/>\nimplantation and progesterone stimulates<br \/>\n02:35<br \/>\nthe endometrial lining to become<br \/>\n02:36<br \/>\nsecretory endometrium the endometrial<br \/>\n02:39<br \/>\nglands become tortuous and contain<br \/>\n02:41<br \/>\nsecretory material at the end of the<br \/>\n02:43<br \/>\nluteal phase serum concentrations of<br \/>\n02:45<br \/>\nestradiol progesterone and LH reach<br \/>\n02:47<br \/>\ntheir lowest levels in response these<br \/>\n02:49<br \/>\nlow levels FSH begins to rise in the<br \/>\n02:52<br \/>\nlate luteal phase before the onset of<br \/>\n02:54<br \/>\nmenstruation to recruit the next cohort<br \/>\n02:55<br \/>\nof follicles if conception does not<br \/>\n02:58<br \/>\noccur the corpus luteum envelopes<br \/>\n03:00<br \/>\nprogesterone and estrogen production<br \/>\n03:02<br \/>\ndeclines and menstruation occurs in<br \/>\n03:04<br \/>\nresponse to low estrogen and<br \/>\n03:05<br \/>\nprogesterone level during menstruation<br \/>\n03:07<br \/>\nthe entire endometrium is expelled and<br \/>\n03:10<br \/>\nonly the basal layer remains during the<br \/>\n03:12<br \/>\nfollicular phase the rise in estrogen<br \/>\n03:14<br \/>\nlevels stimulate endometrial cell growth<br \/>\n03:16<br \/>\nthe endometrial stroma thickens and the<br \/>\n03:18<br \/>\nendometrial glands become elongated to<br \/>\n03:20<br \/>\nform proliferative endometrium wow that<br \/>\n03:25<br \/>\nwas a lot of hardcore basic<br \/>\n03:26<br \/>\nendocrinology let&#8217;s move back to the<br \/>\n03:28<br \/>\nworld of clinical diagnosis historically<br \/>\n03:31<br \/>\nthere have been many terms used to<br \/>\n03:32<br \/>\ndescribe AUB such as Metro Raja or Meno<br \/>\n03:34<br \/>\nMetro Raja<br \/>\n03:35<br \/>\nhowever the acronym palm colon has been<br \/>\n03:38<br \/>\nintroduced to describe a UV that<br \/>\n03:39<br \/>\nreplaces these historical terms here is<br \/>\n03:42<br \/>\na clever cartoon illustration created by<br \/>\n03:44<br \/>\ndr. Asha Yousef that helps explain the<br \/>\n03:46<br \/>\npalm cone acronym here is our patient<br \/>\n03:49<br \/>\nand she has a uterus and an endometrial<br \/>\n03:53<br \/>\ncavity the pea of Palm colon stands for<br \/>\n03:57<br \/>\npolyps so the peas are in the<br \/>\n03:59<br \/>\nendometrial cavity the a stands for<br \/>\n04:01<br \/>\nadenomyosis and you can see that she has<br \/>\n04:04<br \/>\na globular and a large uterus<br \/>\n04:05<br \/>\ncharacteristic for adenomyosis the L<br \/>\n04:08<br \/>\nstands for a leiomyoma so I&#8217;m going to<br \/>\n04:10<br \/>\ndraw multiple leiomyoma in her uterus<br \/>\n04:14<br \/>\nthe M stands for malignancy and here we<br \/>\n04:17<br \/>\ncan see mean malignant Mouse&#8217;s the C<br \/>\n04:21<br \/>\nstands for coagulopathy and here you see<br \/>\n04:24<br \/>\na C<br \/>\n04:25<br \/>\nshaped liver the liver is making<br \/>\n04:29<br \/>\nmarkedly decreased coagulation factors<br \/>\n04:32<br \/>\nthe O stands for ovarian dysfunction so<br \/>\n04:36<br \/>\nhere is a sad-looking ovary and it&#8217;s a<br \/>\n04:38<br \/>\nsick over e to the e stands for<br \/>\n04:42<br \/>\nendometrial process most of these<br \/>\n04:44<br \/>\nprocesses are affected by estrogen the I<br \/>\n04:48<br \/>\nstands for iatrogenic so here is an<br \/>\n04:51<br \/>\ninjection of heparin the n stands for<br \/>\n04:56<br \/>\nnot yet classified the usual causes of a<br \/>\n05:00<br \/>\nUB vary over a woman&#8217;s lifetime for<br \/>\n05:03<br \/>\nadolescent women the most common cause<br \/>\n05:05<br \/>\nwill be ovulating ssin this is<br \/>\n05:07<br \/>\nspecifically from an ambulatory bleeding<br \/>\n05:09<br \/>\nfrom immaturity of the hpo axis regular<br \/>\n05:11<br \/>\nperiods are usually established within<br \/>\n05:13<br \/>\ntwo to three years of menarche<br \/>\n05:14<br \/>\nif an adolescent woman presents with<br \/>\n05:16<br \/>\nheavy periods it&#8217;s also important to<br \/>\n05:18<br \/>\nremember coagulation disorders such as<br \/>\n05:20<br \/>\nvon Willebrand&#8217;s disease for women of<br \/>\n05:22<br \/>\nreproductive age ovulatory dysfunction<br \/>\n05:24<br \/>\nis still a common cause of a UB and the<br \/>\n05:27<br \/>\nmost common cause of ovulate or E<br \/>\n05:28<br \/>\ndysfunction will be polycystic ovarian<br \/>\n05:30<br \/>\nsyndrome or PCOS PCOS affects 6% of all<br \/>\n05:33<br \/>\nwomen of reproductive age pregnancy and<br \/>\n05:36<br \/>\nrelated complications are a common cause<br \/>\n05:37<br \/>\nof a UB so don&#8217;t forget to check a<br \/>\n05:39<br \/>\npregnancy test<br \/>\n05:40<br \/>\nsexually transmitted diseases such as<br \/>\n05:42<br \/>\ngonorrhea and chlamydia can also cause<br \/>\n05:44<br \/>\nabnormal uterine bleeding perimenopausal<br \/>\n05:47<br \/>\nwomen have increased incidence of<br \/>\n05:48<br \/>\nanatomic sources such as polyps Edna<br \/>\n05:51<br \/>\nmeiosis leiomyomas or malignancy<br \/>\n05:53<br \/>\nanovulatory dysfunction is also a common<br \/>\n05:55<br \/>\ncause of a UB and perimenopausal woman<br \/>\n05:58<br \/>\nsecondary to declining ovarian function<br \/>\n06:00<br \/>\nlet&#8217;s move on to the evaluation of a UB<br \/>\n06:03<br \/>\nhow do we go about figuring out what is<br \/>\n06:05<br \/>\nthe potential cause for a patient&#8217;s a UB<br \/>\n06:07<br \/>\nwe need to start with a good history<br \/>\n06:10<br \/>\nfind out how heavy her periods are and<br \/>\n06:13<br \/>\nimportantly the pattern of bleeding the<br \/>\n06:15<br \/>\nfollowing scenes will illustrate dr.<br \/>\n06:17<br \/>\nPalm Cohen in action dr. Palm cone my<br \/>\n06:20<br \/>\nperiods are not predictable nor regular<br \/>\n06:22<br \/>\nthis may be of unit ory dysfunction this<br \/>\n06:26<br \/>\novulatory dysfunction could be secondary<br \/>\n06:28<br \/>\nto PCOS or perimenopausal and ovulation<br \/>\n06:30<br \/>\ndr. pan cone I am bleeding in between my<br \/>\n06:33<br \/>\nperiods this sounds like an in atomic<br \/>\n06:36<br \/>\nsource the anatomic source could be a<br \/>\n06:38<br \/>\nsub mucosal<br \/>\n06:39<br \/>\nhybrid or a uterine polyp dr. pan cone I<br \/>\n06:42<br \/>\nhave always had very heavy periods I<br \/>\n06:44<br \/>\nwonder if you have a coagulopathy the<br \/>\n06:47<br \/>\nmost common inherited coagulopathy would<br \/>\n06:49<br \/>\nbe von Willebrand&#8217;s disease don&#8217;t forget<br \/>\n06:51<br \/>\nto also ask about medical or herbal<br \/>\n06:53<br \/>\nremedies that she may be taking let&#8217;s<br \/>\n06:55<br \/>\nmove on to the physical exam look for<br \/>\n06:58<br \/>\nsigns of excessive weight gain signs of<br \/>\n07:00<br \/>\nPCOS such as hirsutism and acne think<br \/>\n07:03<br \/>\nabout signs of thyroid disease and signs<br \/>\n07:05<br \/>\nof insulin resistance physical exam<br \/>\n07:07<br \/>\nfindings suggestive of a bleeding<br \/>\n07:09<br \/>\ndisorder would include petechiae<br \/>\n07:10<br \/>\necchymosis skin pallor or swollen joints<br \/>\n07:13<br \/>\npelvic examination including bimanual<br \/>\n07:15<br \/>\nexamination should of course be<br \/>\n07:17<br \/>\nperformed to assess the size and contour<br \/>\n07:19<br \/>\nof the uterus when deciding upon<br \/>\n07:21<br \/>\ndiagnostic testing remember again that<br \/>\n07:23<br \/>\nwe are trying to determine the source of<br \/>\n07:24<br \/>\nthe AUB there should be a low index of<br \/>\n07:27<br \/>\nsuspicion to perform an endometrial<br \/>\n07:28<br \/>\nbiopsy to rule out endometrial<br \/>\n07:30<br \/>\nhyperplasia or endometrial cancer for<br \/>\n07:32<br \/>\nwomen over 40 or who have risk factors<br \/>\n07:34<br \/>\nsuch as obesity or diabetes laboratory<br \/>\n07:37<br \/>\nevaluation should include a complete<br \/>\n07:38<br \/>\nblood cell count to look for anemia and<br \/>\n07:40<br \/>\na TSH to rule out thyroid disease it&#8217;s<br \/>\n07:43<br \/>\nworth repeating here don&#8217;t forget to<br \/>\n07:45<br \/>\nevaluate for pregnancy in any<br \/>\n07:46<br \/>\nreproductive aged woman a pelvic<br \/>\n07:48<br \/>\nultrasound is usually the best<br \/>\n07:50<br \/>\nradiologic study for evaluation of the<br \/>\n07:52<br \/>\ngynecologic organs treatment will of<br \/>\n07:54<br \/>\ncourse depend on the etiology for her<br \/>\n07:56<br \/>\nAUB if an ambulatory bleeding is the<br \/>\n07:59<br \/>\nsource of her AUB then medical therapy<br \/>\n08:01<br \/>\nwith oral contraception or cyclic<br \/>\n08:02<br \/>\nprogesterone can be used a<br \/>\n08:04<br \/>\nlevonorgestrel iud is also an excellent<br \/>\n08:06<br \/>\ntreatment option for these women an<br \/>\n08:08<br \/>\nendometrial ablation is also an option<br \/>\n08:10<br \/>\nhowever endometrial hyperplasia has to<br \/>\n08:12<br \/>\nbe ruled out first with an endometrial<br \/>\n08:14<br \/>\nbiopsy if the source of the bleeding is<br \/>\n08:16<br \/>\nan anatomic one which is an endometrial<br \/>\n08:18<br \/>\npolyp or sub mucosal fibroid then she<br \/>\n08:20<br \/>\nmay need surgical management<br \/>\n08:22<br \/>\nhysterectomy is an option when<br \/>\n08:23<br \/>\nconservative medical and surgical<br \/>\n08:25<br \/>\noptions have been discussed and tried<br \/>\n08:26<br \/>\nthis concludes the ethical educational<br \/>\n08:29<br \/>\nvideo on normal and abnormal uterine<br \/>\n08:31<br \/>\nbleeding we have covered quite a bit<br \/>\n08:32<br \/>\nwith the normal menstrual cycle abnormal<br \/>\n08:34<br \/>\nuterine bleeding and the initial<br \/>\n08:36<br \/>\nevaluation and management steps for a UB<\/p>\n<p><\/div>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>Although the Image attached to this video suggests it is about Gonorrhea and Chlamydia, the video is really &#8220;Topic 45: Normal and Abnormal Bleeding.&#8221; Duration = 8:50<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":45,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2605","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2605","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=2605"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2605\/revisions"}],"predecessor-version":[{"id":2850,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2605\/revisions\/2850"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=2605"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}