AUB

• Primary dysmenorrhea


  Menstrual pain without underlying gynecological condition linked to prostaglandin production in uterine lining with onset in adolescents in first few years of menarche
• Secondary dysmenorrhea


  Menstrual pain from underlying reproductive disorder; caused by PID, endometriosis, fibroids, adenomyosis, IUDs, onset post 25 years old
• Membranous dysmenorrhea


  Rare dysmenorrhea where the endometrial lining is a single piece or a membrane
• Dysmenorrhea workup


  1. Pelvic US to rule out secondary causes

  2. Cultures to rule out infectious causes of PID
• Dysmenorrhea treatment


  1. NSAIDs, COC if primary

  2. Treat underlying cause if secondary
• Abnormal uterine bleeding (AUB)

  Includes due to pregnancy, systemic disease or cancer; consider complication of pregnancy
• AUB workup


  1. Pap test

  2. Cervicitis testing

  3. Pelvic US (intrauterine polyps/adnexal mass)

  4. Endometrial biopsy

  5. Hysteroscopy
• Common causes for AUB

  • Heavy (Submucous myomas, adenomyosis, IUDs, endometrial hyperplasias, malignant tumors, unclassified)
  • Low (Hymenal or cervical stenosis, Asherman’s syndrome; use of COC)
  • Intermenstrual (ovulatory bleeding, endometrial polyps, endometrial and cervical carcinomas, exogenous estrogen administration)
  • Menometrorrhagia (anything that causes intermenstrual bleeding; tumors or complications of pregnancy)
  • Oligomenorrhea (pregnancy, endocrine causes, excessive weight loss, low body weight, estrogen secreting tumors)
  • Contact bleeding/postcoital (cervical eversion, cervical polyps, cervical or vaginal infection, atopic vaginitis)
• Endometriosis


  A condition where endometrial tissue grows outside the uterus
• Risk factors for endometriosis

  • Retrograde menstruation
  • Family history
  • Nulliparity
  • Early menarche
  • Late menopause
  • Heavy bleeding in menstruation
  • Shorter cycles
• Protective factors for endometriosis

  • Regular exercise over 4 hours a week
  • Higher parity
  • Longer duration of lactation
• It takes 4-7 years from symptom onset to diagnosis of endometriosis
• Diagnosis of endometriosis


  Endometrioma visualized as a homogenous hypoechoic ovarian cyst on TVUS; palpated on bimanual exam; powder burn on MRI; gold standard is laparoscopy showing lesions with biopsy
• Characteristics of lesions in endometriosis

  • Irregularly shaped reddish/reddish-blue lesions
  • Nodular
  • Cysts
  • Fibrous adhesions
• Management options for endometriosis

  • NSAIDs
  • Progestins
  • COC
  • Surgical excision
• Endometrial cancer


  A type of cancer that begins in the lining of the uterus
• Risk factors for endometrial cancer

  • Excess estrogen
  • Endometrial hyperplasia
  • Gene mutations (PIK3CA, CTNNB1, PTEN, ARID1A, KRAS)
  • Estrogen dependence from endometrial poly/atrophy
  • Tp53 gene mutations
• Clinical features of endometrial cancer

  • Painless postmenopausal bleeding
  • Abnormal menstruation
  • Lower abdominal pain
  • Unusual vaginal discharge
  • Pelvic cramping
  • Dyspareunia
• Diagnosis of endometrial cancer

  • TVUS (endometrium >5mm thick in postmenopausal women; if hyperplasia, biopsy); CT scan looking for metastasis
• Management options for endometrial cancer

  • Surgery
  • Avoiding tamoxifen or exogenous estrogen
  • Managing weight, metabolic syndrome, and diabetes
• Protective factors for endometrial cancer

  • Pregnancy
  • Breastfeeding
  • Hormonal contraceptives
  • Weight loss
  • Physical activity
• Uterine fibroids


  Firm, round tumors formed from myometrial smooth muscle cells
• Pathophysiology of uterine fibroids

  • Hormonally sensitive
  • Increase cyclically with menstruation
  • Regress post-menopause
• Risk factors for uterine fibroids

  • Increased age
  • African American ethnicity
  • First-degree relative
  • Early menarche (<10 years)
  • Late menopause
  • Obesity
  • Prenatal exposure to DES
• Protective factors for uterine fibroids

  • Smoking
  • Exercise
  • Increased parity
  • Late menarche/Early menopause
  • Oral contraceptives
• Clinical features of uterine fibroids

  • Abnormal uterine bleeding (AUB)
  • Heavy menstrual bleeding (HMB)
  • Dysmenorrhea
  • Dyspareunia with deep penetration
  • Pelvic pressure
  • Infertility
  • Recurrent pregnancy loss
  • Mass effect
• Physical examination findings for uterine fibroids

  Lumpy, cobblestone uterus on palpation; enlarged, irregular-shaped, nontender uterus
• Types of uterine fibroids

  • Intramural
  • Submucosal
  • Subserosal
  • Cervical
• Diagnosis of uterine fibroids

  • MRI determines fibroid type
  • TVUS helps visualize
• Management options for uterine fibroids

  • Depends on symptoms; GnRH agonists
  • Endometrial atrophy inducement
  • Menstrual suppression
  • Pain management