AUB: Diagnostic Evaluation and Case Study – Gynecology | Lecturio


[Music] let’s now talk about the diagnostic evaluation of abnormal uterine bleeding first you want to ask them what the age of menarche was and if they’ve already had menopause when that was again the average age for menarche is 12 well it’s 51.4 for menopause then you want to ask them their menstrual bleeding patterns do they have all ago materia Pali materia amenorrhea you want to make sure that’s clearly documented in your medical record then you want to ask them about the severity of bleeding do they pass clots do they ruin their nightgown at night do they have to change their pants at work which can be very embarrassing and very distressing for many women do they have pain with their periods this is sometimes called dysmenorrhea you want to ask about the character the severity and in what they do at home to treat the pain then you want to ask them about medical conditions do they have hypothyroidism are they on any medications that could send their blood then you want to ask about surgical history recall you want to ask if they’ve had any bleeding after a surgery or postoperatively ask them about any medications they could be using sometimes patients are treating themselves with things that can actually increase bleeding such as certain non-fda-approved medicinals and supplements then you want to ask them if they have any signs and symptoms of a possible hemostatic disorder such as von Willebrand disease then on physical exam you should do a detailed general physical exam but especially you should do a detailed gynecologic exam first look externally to see if they’re a lesions on the vulva then a speculum exam with a pap smear needs to be done if it is required and she’s due for her pap smear we talked about pap smears in another lecture and then a bimanual exam needs to occur so that you can feel the cervix make sure that it feels normal it should feel like the tip of your nose and then you should also do a bimanual to see how large the uterus is and usually we express that in terms of weeks does she have a 20-week sized uterus that be an indication that she has fibroids or adenomyosis or a combination so in terms of laboratory tests what we want to do is a pregnancy test first and foremost to rule it out sometimes we need to do blood and urine depending on the clinical scenario a CBC or a complete blood count is important to make sure the patient does not already have anemia then based on the history we should do targeted screening for bleeding disorders only when indicated a TSH should also be checked to make sure the patient is not hypothyroid and in the patients who are younger especially a chlamydia test need to be done to rule out chlamydia trachomatis in terms of the diagnostic tests we review this a little bit before but again a saline infusion so no history goofy is very important and it can show us a polyp or a fibroid or any other lesion that could be causing the bleeding a transvaginal ultrasound is also helpful as we can actually measure the size of the uterus and MRI is sometimes helpful especially when you have a large uterus that can be either caused by leiomyomas or adenomyosis and lastly hysteroscopy where we insert a small camera through the vagina into the cervix and into the uterus to actually visualize any pathology that could be there the other things that we can do in the office especially in the perimenopausal or postmenopausal woman over forty-five is to do an endometrial biopsy well that sounds really painful it’s just a straw that provides gentle suction to allow us to take some of the endometrium to sample it usually this is done in several passes to make sure that we have enough tissue to send to pathology again in the office we can do a hysteroscopy directed endometrial sampling but this is usually not done because the pipe L is usually sufficient pipe L is another term for endometrial biopsy so a UB management really depends on the etiology first you have to determine what type of a EB you think the patient has and then evaluate her with a good general physical exam a GYN exam after obtaining a very thorough history then you can manage based on the etiology so if a patient comes into the emergency room with acute bleeding this is important to remember you can stop acute heavy bleeding with 25 milligrams of conjugated equine IV estrogen and this would help and sometimes these patients are taken to the operating room for dilation and curettage to actually take some of this endometrium away so that the bleeding is less this is normally only given to a young healthy patient who has no other medical comorbidities which would be a contraindication to estrogen let’s remember some things now about AUB don’t forget to check for foreign bodies and young girls the most common foreign body that you’ll recover is toilet tissue fibroids are very common especially in women of African descent so you might get a case with a woman who is of African or Caribbean or african-american descent don’t forget to remember fibroids thyroid abnormalities are also a possibility with severe AUB and a TSH should always be checked in these patients also in the young girl’s platelet dysfunction is the most common coagulopathy and don’t forget to ask about a history of bleeding after surgery or with brushing your teeth or after cutting yourself these things will be helpful to delineate this diagnosis let’s now review some cases of AUB here we have a 25 year old g-zero with a BMI of 45 who presents the emergency room with an extremely heavy period her last period was 6 months ago that should be a red flag you should have a period every month her exam is notable for hirsutism hmm she has a high BMI and hirsutism what does this sound like what’s your differential diagnosis PCOS should be your most likely given the fact that it’s very common she has an elevated BMI most PCOS patients are obese and they also have to have some type of hyper androgen emia which leads to hirsutism oftentimes but you should not forget to rule out pregnancy fibroids infection coagulopathy and thyroid abnormalities especially in obese patient who may have thyroid abnormalities let’s now review another case of AUB here we have a 65 year old woman who presents to you she’s a g2 p10 one one who underwent menopause at 52 years of age just a year after the normal average she now presents with onset of vaginal bleeding her only medications include calcium and vitamin D so she’s pretty healthy what’s in your differential diagnosis I’ll wait while you think about that so the first thing that you should think about new differentials should be atrophic bleeding so she can have a little bleeding from her vagina due to atrophy which means that after to estrogen it stops being made the vagina can become smaller atrophic and some can sometimes bleed with penetration or just by itself also the line of the endometrium can also bleed because it’s thinned and sometimes that can cause spontaneous bleeding these patients are also at risk for endometrial cancer while this patient seems normal and healthy the very obese patient has unopposed estrogen because of peripheral aromatization that occurs in the adipocytes that estrogen does affect the line of the endometrium and that can lead to endometrial cancer polycystic ovarian syndrome patients during their reproductive years can also be at risk for endometrial cancer and their postmenopausal years also these patients are older and they can be on blood thinners for cardiovascular reasons thank you for listening and I hope you do well in your exam [Music] you

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