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clinical

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Abnormal Genital Tract Bleeding

Annekathryn

Goodman,

MD

Assistant

Professor

of Obstetrics,

Gynecology,

and

Reproductive

Biology

 

Harvard

Medical

School

 

Associate

Director,

Division

of Gynecologic

Oncology

Massachusetts

Boston,

General

Hospital

Massachusetts

The etiology of abnormal

ondary to anatomic

cies, and systemic illness. Appropriate workup is guided by age-related differential diagnoses for abnor- mal bleeding. Modern diagnostic tools can quickly focus the evaluation and allow timely intervention.

can be sec- malignan-

genital

tract bleeding

genital

encompasses

a wide range

of disorders

that

changes

of the female

tract, infection,

endocrinologic

disorders,

Most abnormal

genital

tract bleeding

is uterine

bleeding,

which

is one of the most common

gynecologic

problems

that health

care providers

will face.

It accounts for

approximately

15% of office

visits and

25% of gynecologic operations. Abnormal uterine bleeding in reproductive-age

bleeding at abnormal

average menstrual cycle length and duration

blood loss of 35cc (1). Any bleeding should be considered abnormal in premenarchal girls and in post- menopausal women except for those with predictable withdrawal bleeding taking hormone replacement therapy. This article will review the categories of abnormal genital tract bleeding and the diagnostic tools needed to establish the correct diagnosis. Common clinical cases will be presented to illustrate the

presenting symptoms, differential

with an average

women is defined

as

The

or unexpected

times or by excessive flow

of flow

at the time of an expected menses.

is 28 days and 4 days, respectively,

diagnoses,

workup,

treatment,

and long-term

follow-up.

CLASSIFICATION

GENITALTRACT

OF ABNORMAL BLEEDING

Table I lists the various causes of abnormal

tract bleeding.

bleeding

examination

genital

Although

the majority

of abnormal

comes from the uterus, a careful physical

will

rule out~vulvar, vaginal,

and cer-

(DUB).

tion or oligo-ovulation

and results in bleeding

ing and quantity. DUB is a diagnosis of exclusion after more serious pathology has been ruled out.

DUB

is defined

as that caused by anovula-

(2).

It is erratic

that is irregular

in nature

in both

tim-

vical pathology.

EVALUATION

OF PATIENTS

WITH

ABNORMAL

GENITALTRACT

BLEEDING

Initial evaluation must include a detailed history.

Important information

of the bleeding,

includes timing

and nature

the precipitating

factors, the

 

Terminology

for uterine bleeding

is listed

in

patient’s sexual history, and associated symptoms, such as pain, fever, or changes in bowel or bladder function. A menstrual calendar diary can be help- ful in determining if the bleeding is ovulatory or

“&bk

II.

The pathogenesis

of abnormal

uterine

anovulatory. The patient’s medical history and the

bleeding may be divided into 2 general categories:

organic causes and dysfunctional uterine bleeding

medications

ing pattern. It is equally important to determine

she is taking may influence her bleed-

uterine bleeding medications ing pattern. It is equally important to determine she is taking may influence

clinical CORNERSTONE

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clinical CORNERSTONE . OFFICE GYNECOLOGY n Vol. 3 No. I General Category Specific Conditions Anatomic
clinical CORNERSTONE . OFFICE GYNECOLOGY n Vol. 3 No. I General Category Specific Conditions Anatomic

General

Category

Specific

Conditions

Anatomic

Atrophic

endometrium

Leiomyomas

 

Polyps (cervical,

uterine)

Adenomyosis

Endometriosis

Intrauterine

devices

Infection

Cervicitis

Vaginitis

Endometritis

 

Oophoritis

Endocrine

Anovulatory

bleeding

Polycystic

ovaries

Thyroid

disease

Exogenous

hormones

 

-Oral

contraceptives

-Progestin-only

contraceptives

 

-Hormone

replacement

therapy

-Tamoxifen

 

Malignancies

Cervical

cancer

Endometrial

hyperplasia

 

Endometrial

cancer

Vaginal

cancer

Vulvar

cancer

Endometrial

stimulation

by estrogen-producing

ovarian

neoplasm

Metastatic

disease (leukemia,

gastrointestinal

cancers)

Systemic

Coagulopathies

Liver

disease

Sepsis

Trauma

Sexual

assault

Pelvic fracture

 

Hymenal

tear after first tampon

use or first vaginal

intercourse

Pregnancy

Spontaneous

miscarriage

Incomplete,

threatened,

or missed abortion

 

Ectopic

pregnancy

Complication of therapeutic abortion Gestational trophoblastic disease

of therapeutic abortion Gestational trophoblastic disease what nonprescription patient use of aspirin and Ginkgo

what nonprescription

patient

use of aspirin and Ginkgo biloba can cause easy

bruisability

drugs and herbal mixtures

the

may be taking.

For instance, the combined

a role in menorrhagia genital tract bleeding

(3).

and may play

Causes of abnormal

can be stratified by age. Prepubertal girls can develop abnormal bleeding. In newborn girls, this

can be secondary to placental estrogen stimulation of the endometrium. In girls <9 years of age, the most common causes are trauma, intravaginal for- eign bodies, vulvovaginitis, and urethral prolapse (4). The possibility of sexual abuse must also be considered. Precocious puberty should be consid- ered if the development of secondary sexual char-

abuse must also be considered. Precocious puberty should be consid- ered if the development of secondary

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dir&d CORNERSTONE m OFFICE GYNECOLOGY = Vol. 3 No. I Term Definition Menorrhagia Excessive bleeding at
dir&d CORNERSTONE m OFFICE GYNECOLOGY = Vol. 3 No. I Term Definition Menorrhagia Excessive bleeding at

Term

Definition

Menorrhagia

Excessive bleeding

at regular

intervals

Menometrorrhagia

Excessive bleeding

during

and between

menses

Intermenstrual

bleeding

Bleeding between menses

Polymenorrhea

Bleeding at <21-day intervals

Postmenopausal

bleeding

Bleeding occurring >l year after menopause

bleeding Bleeding occurring >l year after menopause a c t e r i s t i

acteristics has occurred; benign and malignant menopausal bleeding have cancer, this incidence ovarian and adrenal tumors must be ruled out. increases with age (7,X). The most common cause

Primary lower genital tract neoplasms, such as of bleeding in this age-group is vaginal or endome-

sarcoma botryoides, are rare.

trial atrophy

(9).

Abnormal

bleeding

in adolescence is most

commonly

lack of maturation of the pituitary-hypothalamic axis (2). Pregnancy must always be ruled out even

in the absence of a reported history of sexual activ- ity. Infection and hematologic abnormalities make up the remainder of cases in this age-group.

Malignancies

due to DUB,

which

is secondary to the

are rare.

women have a wide range

of reasons for abnormal bleeding. Pregnancy and

malignancy

tions. Anatomic alterations, such as fibroids,

endometriosis, and adenomyosis, can cause signifi-

cant bleeding

and other endocrinopathies, such as thyroid disor-

ders and hyperprolactinemia, should be considered.

Other categories include infection abnormalities (5).

Reproductive-age

are the most common

in this age-group.

serious condi-

DUB is common,

and hematologic

Perimenopause

is defined

as the

5- to

lo-

year period prior to complete amenorrhea. Ovarian

function wanes and anovulatory

mon (6). Anatomic alterations and an increasing

incidence of endometrial

endometrial hyperplasia, and cancers, become

important

pathology, such as polyps,

bleeding

is com-

causes of abnormal

is defined

bleeding. as the time period

Menopause

after 1 full year of amenorrhea. Any bleeding

should be considered

should determine

appropriate time on a cyclic hormone replacement regimen. While overall 10% of women with post-

abnormal.

A careful history occurs at the

if the bleeding

DIAGNOSTIC

TOOLS

TableIII lists the various tools that can establish the appropriate diagnosis for a woman with abnor- mal genital tract bleeding.

Examination

A careful physical examination of the external and

internal female genital tract is mandatory.

nosis and treatment

out a pelvic examination. Small children can be examined while they are sitting in their parent’s lap. However, it may be necessary to perform an exami- nation under anesthesia with the use of a hystero- scope. Examination under anesthesia may also be necessary for an adult woman who has vaginismus and cannot be evaluated adequately in the office. Vaginismus, the involuntary spasm and closure of the vaginal wall, can occur secondary to deep psy- chologic distress resulting from a history of abuse

A diag-

with-

plan cannot be developed

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clinical CORNERSTONE

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clinical CORNERSTONE . OFFICE GYNECOLOGY 1 Vol.3 No. I Physical examination Office examination Examination under
clinical CORNERSTONE . OFFICE GYNECOLOGY 1 Vol.3 No. I Physical examination Office examination Examination under
clinical CORNERSTONE . OFFICE GYNECOLOGY 1 Vol.3 No. I Physical examination Office examination Examination under

Physical

examination

Office examination Examination under anesthesia

Biopsy

Hysteroscopy Papanicolaou’s test Vulvar biopsy (dermatologic punch)

Cervical biopsy Endometrial biopsy Dilation and curettage

Laboratory

testing

Human chorionic gonadotropin Complete blood count Coagulation profile

 

Follicle-stimulating hormone Luteinizing hormone Thyroid function tests

Prolactin

Testosterone

Dehydroepiandrosterone sulfate Vaginal culture, wet prep Chlamydia, herpes, HIV testing

Radiology

Ultrasound

Sonohysterogram

Magnetic resonance imaging

Ultrasound Sonohysterogram Magnetic resonance imaging or secondary to a pathologic condition, such as infection,

or secondary to a pathologic condition, such as infection, traumatic lacerations, or neoplasms. With the woman in lithotomy position, the external skin, vulvar appendages, urethra, hymen, and perianal region are carefully inspected. The

focus of the examination is to determine the bleed-

ing site. A speculum

and the walls of the vagina

inspected. Vaginal lesions can be easily missed in a multiparous woman with redundant vaginal tis- sue. A large Graves’ speculum can help retract redundant vaginal tissue. A condom with the tip cut off can be slipped over a speculum to retract

the vaginal walls and allow better visualization

the cervix.

in a woman with an atrophic vagina and narrowing

is then placed in the vagina

and the cervix are

of

Conversely,

lesions may not be obvious

of the vaginal apex. A short course of estrogen

vaginal

other day for 2 weeks) can reduce the discomfort

cream (1 g applied intravaginally

every

from atrophy and allow better visualization in the postmenopausal woman. Digital palpation of all sides of the vagina is crucial to fully evaluate the vagina and the cervix.

woman. Digital palpation of all sides of the vagina is crucial to fully evaluate the vagina

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clinical CORNERSTONE

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R N E R S T O N E . OFFICE GYNECOLOGY m Vol. 3 No.
R N E R S T O N E . OFFICE GYNECOLOGY m Vol. 3 No.

Name

Manufacturer

Pipelle

Unimar

Vabra aspirator

Berkeley

Novak

curette

Milex

Tis-u-trap

Milex

Z-sampler

Zinnanti

Randall

curette

Cooper

Explora

Milex

Biopsy

Ah lesions should be biopsied. A vulvar lesion is amenable to a dermatologic punch biopsy after the injection of intradermal lidocaine. Papanicolaou’s (Pap) tests can be taken of the vagina and cervix.

However, the false-negative rate for Pap testscan range from 10% to 25% and is increased in the presence of

severe inflammation

visible vaginal and cervical lesions should be biopsied even in the setting of a negative Pap test.

in

or bleeding (10). Therefore, all

biopsy can be performed

An endometrial

the office or more completely in the operating

room during a dilation and curettage (D&C) (11).

All women

with a history of polycystic ovary syndrome (PCOS), infertility, anovulation, or a family

of endometrial cancer should be considered for endometrial biopsy. Many different office endome-

trial biopsy instruments are available (Table IV).

>40 years of age and younger

women

history

All instruments

use a suction mechanism

to sample

the endometrial

lining.

Except for the Tis-u-trap,

which has an inner diameter ranging from 1.8 mm

to 4.0 mm, the office instruments have inner diam- eters of 2.6 mm to 3.2 mm. Antibiotic prophylaxis

is indicated

valves, but is not required in patients with valvular prolapse with benign murmurs. Complications are rare. The most common is uterine perforation with

an incidence of

develop a transient vasovagal reaction after manip- ulation of the cervix. The indications to proceed to

a D&C under

discomfort, severe cervical stenosis, inadequate tis- sue sampling in the office, and a high suspicion of malignancy but a negative office biopsy. D&Cs are usually coupled with hysteroscopy.

for patients with prosthetic

heart

0.1% to 0.2%. Patients can also

general anesthesia include patient

The endometrial

cavity can be visualized

by either office

Hysteroscopy is superior to all other diagnostic

tools in the evaluation (12) and can directly

for a directed biopsy. This tool can be used to

evaluate submucosal fibroids, polyps, and rule in or

out a hyperplastic Complications

tion and infection. Hyponatremia can occur if hypotonic distension media is used and a fluid deficit occurs. The decision to refer to a gyne- cologist for this procedure will be based on the patient’s history, symptoms, and other diagnostic testing (see Case 3).

or malignant

or intraoperative

hysteroscopy.

pathology

of intrauterine

visualize a lesion and allow

endometrial

lesion.

are rare but include uterine perfora-

Laboratory

Testing

All women of reproductive age should have a preg- nancy test. A complete blood count can be useful

in assessing the volume and duration of the bleed-

ing.

manifestations, such as easy bruising and nose and

gum bleeding, a coagulation profile should be checked. Many authorities recommend a coagula- tion panel in teenage girls with bleeding that is heavy enough to require hospitalization. The

If the woman has other associated bleeding

girls with bleeding that is heavy enough to require hospitalization. The If the woman has other

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gonadotropins, follicle-stimulating hormone (FSH),

and

diagnosis of PCOS-women with this condition

have higher mean concentrations

levels of FSH or an LH:FSH

luteinizing

hormone

(LH) can be helpful

of LH

but

in the

low or

low-normal

compared with normal women (13). FSH and LH

are rarely useful to evaluate the perimenopausal state

as these hormones are secreted in a pulsatile manner

and the levels change throughout

Women with PCOS may also have associated hir-

sutism and mildly increased androgen levels, such as

testosterone and dehydroepiandrosterone

(DHEAS) (13). Serum testosterone and DHEAS

should be ordered in women with oligomenorrhea

and

els should trigger a search for a testosterone-secret- ing ovarian or adrenal tumor. Thyroid disorders are

ratio >2.5

the day (6).

sulfate

hirsutism.

Extreme elevations of androgen lev-

abnormalities, such as polyps, fibroids, or endome-

trial neoplastic changes, is low-ranging

to 96%. TVUS has a high false-positive rate in women receiving tamoxifen. The majority of patients taking tamoxifen who develop endometrial pathology will have abnormal bleeding. Screening

in the asymptomatic tamoxifen user is controversial, but these women should be screened either by

from 88%

TVUS

stenosis, present with a difficult office examination,

or have additional risk factors for endometrial cancer such as a family history. TVUS cannot distinguish

between a thickened endometrial

dometrial edema, which is a common benign finding

in tamoxifen

distort the uterine cavity making endometrial

or sonohysterogram

if they have cervical

stripe and suben-

users. Fibroids and large polyps can

stripe

measurements inaccurate. TVUS and transabdomi-

very common

in young women and can contribute

to

nal ultrasound are useful for imaging fibroids.

an anovulatory

state. Less commonly,

prolactin-

TVUS is usually unable to identify fibroids smaller

secreting pituitary adenomas will cause anovulation

 

than 2 cm. TVUS can be a useful adjunct in the

and galactorrhea.

Visual field defects can develop

evaluation

of abnormal bleeding when an office

with large tumors.

Serum prolactin

and thyroid-

biopsy shows scant tissue. An abnormal

ultrasound

stimulating hormone levels should be ordered only

finding would

necessitate a follow-up

D&C

with

in

patients with recurrent episodes of DUB.

 

hysteroscopy.

In the premenopausal

woman,

TVUS

 

A wet prep should be performed

if

there

is a

gives additional

information

about fibroids and

vaginal discharge. Chlamydia trachomatis and her-

pes simplex virus cultures should be considered

a woman has cervicitis.

sometimes cause vaginal bleeding from severe irri- tation Human immunodeficiency testing should

always be considered

and

if

Candidal

infections

can

in women with intractable

(14).

recurrent

yeast infections

Radiology

A transvaginal ultrasound (TVUS) can evaluate the

endometrial stripe. A thickness of less than 4 mm is

normal in a postmenopausal

evaluation

because it will fluctuate with the menstrual cycle. Thenormal endometrial thickness varies during the

menstrual

mm during the proliferative

during the secretory phase. Postmenopausally, the upper limit of normal increases by approximately 2 mm if the patient is taking unopposed estrogen replacement therapy with tamoxifen. The diagnostic sensitivity of TVUS for differentiating intracavitary

is less useful in premenopausal

woman (7). The stripe

women

during

menses, 4 to 8

phase, and 7 to

14 mm

cycle:

1 to 4 mm

adnexal abnormalities but is less relevant for infor- mation about the endometrial stripe.

30

or sonohysterog-

raphy can increase information about the endome- trial cavity (15). This technique involves the infu- sion of saline into the endometrial cavity followed by a TVUS. Sonohysterography can rule out lesions in the presence of tamoxifen-induced subendometrial edema, distinguish polyps from endometrial hyperplasias, and detect small intra- cavitary lesions. It cannot distinguish between polyps and submucosal fibroids.

Saline infusion

sonography

clinical

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clinical CORNERSTONE . OFFICE GYNECOLOGY 1 Vol. 3 No. I Magnetic used to distinguish resonance imaging

Magnetic used to distinguish

resonance imaging

leiomyomas

(MRI)

from ovarian

can be

the intervention is to rebuild the lining with high- dose estrogen as described. The brand of OCP and

pathology (16). It can also be helpful in preopera-

the dosage are not important.

The number

of pills

tive planning of myomectomies

by distinguishing

can be titrated by symptoms.

For patients who

between

subserosal, intramural,

and submucosal

need >2 pills a day, an antiemetic may be neces-

locations.

MRI

is also the only nonoperative

diag-

sary. With normal

and mature secondary sexual

nostic tool for detecting adenomyosis, a benign

glandular

cause significant

infiltration

of the myometrium

that can

bleeding

and pelvic pain.

CASE

STUDIES

Case 1

A

daily heavy vaginal bleeding

of menarche

year since then, all very heavy and lasting 2 weeks. She denied sexual activity. She had no other med- ical problems and did not take any medicines. She had no history of gastrointestinal symptoms, uri- nary problems, easy bruising, or dysmenorrhea.

17-year-old

presented with a 2-month

was age 13.

with clots.

history of

Her onset

a

She had 2 to 3 periods

characteristics

vention is needed. She will start ovulating in the

next few years.

endocrinologic concerns.

and normal

anatomy, no other inter-

fertility

and

There are no long-term

Case 2

The patient was a 42-year-old G2P2 woman who

developed increasing menorrhagia over the past 12

months.

cycles every 28 days that

length. In the year prior to presentation, she devel-

oped “flooding”

ods with

time. She then continued to bleed for another week. She had severe dysmenorrhea with aching down her legs and in the base of her spine. She

She had a history of normal

clots

during

were

4 to

the first

menstrual 6 days in

3 days of her peri-

3 pads at a

and the need to use 2 to

Workup: She was a pale-appearing teenager in no

denied intermenstrual or postcoital bleeding. Her

acute distress. She had normal and mature (Tanner

husband had a vasectomy.

She had no medical

 

stage V) breast and external genitalia development.

problems,

no bleeding

diathesis,

and took

no

There were no lesions, evidence of trauma, or

medicines.

abnormal anatomy. Laboratory data: urine human chorionic gonadotropin (hCG) negative, hemoglo-

Workup: Her general examination was normal.

 

bin 6, normal white blood count and differential, normal coagulation profile.

There were no vulvar, vaginal, or cervical lesions. On bimanual examination she had a 20-week size

Treatment: She was given iron supplements and

She was instructed

to take 2 OCPs daily until completing

pack. She then immediately started on the second OCP pack, one pill daily, without an intervening

period. She had a normal withdrawal

has been maintained on OCPs since then with no

further bleeding.

oral contraceptive

pills (OCP).

the first

bleed.

She

Comment: This is a classic case of DUB secondary

to

itary-hypothalamic axis. The history of menorrha-

gia, oligomenorrhea,

leads to the diagnosis without

testing. The patient had an exhausted endometrium secondary to excessive bleeding. The first step in

anovulatory

bleeding

from an immature

pitu-

and lack of dysmenorrhea

the need for other

midline

On rectal exam, the mass was impacted

pelvis and externally

Pap test and endometrial

Laboratory data: hCG negative, hemoglobin 7. A pelvic ultrasound showed the mass to be her uterus with multiple fibroids. Both ovaries were normal. There was no evidence of hydronephrosis.

mass that was inseparable

compressing

from her uterus.

in the

her rectum.

Her

biopsy were normal.

Treatment: The patient was given iron replacement and stool softeners. The various options for the management of symptomatic fibroids were present- ed: close observation, myomectomy, or hysterecto- my. Other options included use of a gonadotropin- releasing hormone (G&H) agonist to temporarily shrink the fibroids by putting her into pseudo- menopause. A newer technique of arterial emboli-

agonist to temporarily shrink the fibroids by putting her into pseudo- menopause. A newer technique of

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zation of the fibroids was also discussed. The

in the vagina.

On bimanual

examination,

the

patient chose to take a GnRH agonist for 3 months

uterus and adnexa were not palpated

secondary to

while she considered her options. She decided to

her obesity. A Pap test was

normal.

An office

undergo an abdominal hysterectomy with preserva-

endometrial

biopsy showed scant tissue and some

tion of her ovaries.

Now

at 1 year out from surgery,

fragments

of crowded

endometrial

glands with

she has no gynecologic complaints, normal sexual

function, and normal ovarian function.

Comment: Menorrhagia secondary to the distor-

tion of the uterine cavity causes heavy and pro-

longed menses.

performed

because the uterus is unable to contract down on the open venous sinuses in the zona basalis of the endometrium. Adenomyosis may also be a consid- eration. This is a structural problem and hormonal intervention will not help. GnRH agonists help by shutting down the pituitary-hypothalamic axis and preventing menses. This is only a temporary solu- tion because long-term use of GnRH agonists can cause osteoporosis. Asymptomatic fibroids can be managed by observation alone. Indications for intervention include anemia from menorrhagia,

hydronephrosis secondary to ureteral compression, pain secondary to mass effect. The gold standard is operative intervention. Myomectomy is an option for women who have not completed their child- bearing or who wish to preserve their uterus.

Arterial

causes infarction and shrinkage of the fibroid. Immediate side effects include pain and fever.

An endometrial

biopsy

should be

to rule out other causes. This occurs

embolization

is a newer procedure

that

complex atypical hyperplasia. Laboratory tests showed hemoglobin at 8.5. A pelvic ultrasound

showed a 4-mm endometrial

erogeneity

operating room and underwent a D&C and hys-

teroscopy. Her endometrial lining was atrophic except near the right tubal ostia where there was a shaggy 3-mm lesion. Pathology showed a grade 1

endometrioid

complex hyperplasia.

abdominal hysterectomy and bilateral salpingo- oophorectomy. The tumor was confined to the endometrium. She is alive without evidence of recurrence at 5 years.

stripe with slight het- She was taken to the

at the fundus.

adenocarcinoma

in a background

of

She was treated with a total

Comment:

menopausal bleeding.

only showed a premalignant

lesion was not ruled out by the office biopsy.

mm endometrial

matic postmenopausal woman, but cancers can still

be seen with this finding.

heterogeneous

had a sonohysterogram,

small polypoid

cer. In the presence of abnormal

This woman presented with post-

Although

her office biopsy

lesion, a malignant

A 4-

stripe is normal in an asympto-

The clue here was the

change seen in the stripe.

If she had

it would have revealed a

with the can-

however,

lesion that correlated

bleeding,

Preliminary

studies are promising

but long-term

a normal endometrial stripe is not completely reas-

follow-up

is needed (17).

suring.

An endometrial

biopsy should always be

Case 3 The patient was a 57-year-old GOP0 woman who presented with one episode of painless vaginal

spotting. Her last normal period was at age 48.

She never took estrogen replacement

denied weight

toms. She was obese with diet-controlled diabetes,

She was taking

a beta-blocker, a diuretic, and thyroid replacement.

therapy.

She

loss, and bowel

or bladder

symp-

hypertension,

and hypothyroidism.

Workup: Her general examination was nonfocal. On pelvic examination, there were no vulvar, vagi- nal, or cervical lesions. There was some old blood

performed.

REFERENCES

1. Haynes FJ, Hodgson H, Anderson ABM.

Measure-

ment of menstrual blood loss in patients complain- ing of menorrhagia Br J ObstetGynaecol. 1977;84:

763-768.

2. Fraser IS, Michie EA, Wide L, et al. Pituitary gonadotropins and ovarian function in adolescent dysfunctional uterine bleeding. J Clin Endocrinol Metab. 1973;37:407-414.

3. Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-

32

herb interactions. Arch Intern Med.

2200-2211.

1998;158:

4. Fishman A, Paldi E. Vaginal bleeding in premenar-

chal girls: areview.

457-460.

Obstet Gynecol Surv. 1991;46:

5. Long CA.

Evaluation of patients with abnormal

uterine bleeding. Am J Obstet Gynecol.

784-786.

1996;175:

6. Sherman BM, West JH, Korenman SG. The meno- pausal transition: analysis of LH, FSH, estradiol, and progesterone concentrations during menstrual cycles of older women. J Clin Endocrinol Metab.

1976;42:629-636.

7. Karlsson B, Granberg S, Wikland M, et al. Trans- vaginal ultrasonography of the endometrium in women with postmenopausal bleeding: a Nordic multicenter study. Obstet Gynecol. 1995;172:

1488-1494.

8. Indman PD. Abnormal uterine bleeding: accuracy of vaginal probe ultrasound in predicting abnormal hysteroscopic findings. J Reprod Med. 1995;40:

545-548.

9. Iatrakis G, Diakakis I, Kourounis G, et al. Post-

menopausal uterine bleeding.

Gynecol.

1997;24:157-165.

Clin Exp Obstet

10. Lee KR, Ashfaq R, Birdsong GG, et al. Comparison of conventional Papanicolaou smearsand a fluid based, thin-layer system for cervical cancer screen-

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ing. Obstet Gynecol. 1997;90:278-284.

11. Grimes DA.

Diagnostic dilation and curettage: a

1982;142:1-6.

reappraisal. Am J Obstet Gynecol.

12. Gimpelson RJ, Rappold HO. A comparison study between panoramic hysteroscopy with a directed biopsy and dilation and curettage: a review of 276 cases. Am J Obstet Gynecol. 1988;158:489-492.

13. Naether OGJ, Fischer R, Weise HC, et al. Laparo- scopic electrocoagulation of the ovarian surface in infertile patients with polycystic ovarian disease.

Fertil Steril.

1993;60:88-94.

14. Shah PN, Kell PD, Barton SE. Gynaecological dis-

orders and human immunodeficiency virus infection.

Znt JSTDAZDS.

1994;5:383-386.

15. Widrich T, Bradley LD, Mitchinson A, et al. Com- parison of saline infusion sonography with office hys- teroscopy for the evaluation of the endometrium. Am

JObstet Gynecol. 1996;174:1327-1334.

16. Weinreb JC, Barkoff ND, Megibow A, et al. The value of MR imaging in distinguishing leiomyomas from other solid pelvic masseswhen sonography is indeterminate. Am J Roentgenol. 1990;154: 295-299.

17. Walker W, Green A, Sutton C. Bilateral uterine artery embolization for myomata: results, complica- tions and failures. Minimally Invasive Ther Allied Technol. 1999;8:449%454.

Minimally Invasive Ther Allied Technol. 1999;8:449%454. ADVISORY BOARD In managing bleeding in the female patient
Minimally Invasive Ther Allied Technol. 1999;8:449%454. ADVISORY BOARD In managing bleeding in the female patient
Minimally Invasive Ther Allied Technol. 1999;8:449%454. ADVISORY BOARD In managing bleeding in the female patient

ADVISORY

BOARD

In managing bleeding in the female patient with DUB, what determines whether you prescribe a progestin agent alone versus an estrogen/pro- gestin regimen as you did in your case study?

GOODMAN

Generally, there are 2 scenarios that occur in DUB.

There is the patient month or so before

patient doesn’t have much endometrial lining

remaining and is likely to require some estrogen to

help slow the hemorrhaging

endometrial

patient who has been anovulatory and hasn’t had a period and then suddenly begins to bleed. If this patient presents within a week or so of the onset of bleeding and before she’s had time to drop her

who has been bleeding for a

she comes in to seeyou.

This

occurring on the “raw”

surface. On the other hand, there is the

hematocrit or has exhausted the endometrial lining, you usually can adequately treat her with a pro- gestin agent alone.

ADVISORY

BOARD

In the former situation, where you would favor

using the birth

a pill formulation that you prefer?

control

pill to treat DUB,

is there

GOODMAN The formulation doesn’t matter. Simply titrate up the number of pills as required to stop the bleeding. As far as i’m concerned, you’re likely to get the same desired effect prescribing a pill containing 30 to 35 ng of estrogen 4 times a day as you would prescribing a 50-pg formulation twice a day. Once control is achieved, taper the dose down and cycle her on the pill you prescribed. Although some

twice a day. Once control is achieved, taper the dose down and cycle her on the

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clinical CORNERSTONE n OFFICE GYNECOLOGY 1 Vol. 3 No. I experts may have a favorite pill
clinical CORNERSTONE n OFFICE GYNECOLOGY 1 Vol. 3 No. I experts may have a favorite pill

experts may have a favorite pill for doing this and advocate a specific regimen, I don’t think it really matters. Just make sure the patient doesn’t inadvertently take the inert pills present in a 2%day pack.

ADVISORY BOARD With regard to the role of the endometrial

sy in the workup of abnormal uterine bleeding, many textbooks recommend that a biopsy be routinely performed in all patients >40 years of age. Do you agree with this cutoff?

hiop-

GOODMAN

Generally speaking, yes. I would agree that bleed- ing in patients <40 years of age is not likely to be

Having said

that, there are certain subsets of women ~40 years

of age who are considered to be at increased risk for endometrial cancer and should undergo an

endometrial biopsy.

who are anovulatoty and are chronically exposed to unopposed estrogen. Women with PCOS also fall into this category of patients at risk for preinvasive and invasive endometrial lesions. Another subset are women with a strong family history of endome- trial cancer. The classic case is a woman with hereditary nonpolyposis colon cancer (HNPCC) syndrome, in which an autosomal dominant gene is responsible for a >.50% risk of endometrial cancer plus colon and breast cancer. These are the types of women for whom you should immediately jump to thinking about doing an endometrial biopsy in your evaluation of abnormal bleeding. For every- one else in their 3Os, my first thought would be that I’m likely dealing with DUB or possibly fibroids. Conversely, I would seriously consider adding an endometrial biopsy to my evaluation of abnormal bleeding in all women who are in their 40s.

caused by an endometrial malignancy.

One subset includes women

ADVISORY BOARD Would you perform

year-old woman with 5 children if there was noth- ing suspicious in her medical or family history?

an endometrial

biopsy in a 42

GOODMAN

I probably wouldn’t

she didn’t respond as expected to my interventions

or if she had atypical bleeding. Regardless,

a patient, it is important

over time and make sure the bleeding resolves to

your satisfaction.

initially

do it, but I would

if

in such

that you follow her course

ADVISORY BOARD In a postmenopausal woman who develops abnormal bleeding, does a normal endometrial stripe on the TVUS preclude the need for an endometrial biopsy?

GOODMAN

No, I view the TVUS as playing primarily an

adjunctive role in such a patient. Thus, I would per- form an endometrial biopsy even if the TVUS was normal. However, comparing the results of both studies can be diagnostically helpful; for example, if you had an ultrasound that showed a thick stripe with some cystic spaces within it and yet the biop-

sy only showed atrophic endometrium,

have to wonder about the discrepancy between

those 2. In such a patient, further evaluation of the

endometrium

what some regard as the reigning “gold stan-

dard”-hysteroscopy-should be performed.

you would

with either a repeat biopsy or with

ADVISORY BOARD How about in a postmenopausal woman on hor- mone replacement therapy (HRT) who had been

doing fine but then developed a little spotting?

Does a normal

the need for an endometrial biopsy?

TVUS in this patient

preclude

but then developed a little spotting? Does a normal the need for an endometrial biopsy? TVUS

34

but then developed a little spotting? Does a normal the need for an endometrial biopsy? TVUS

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clinical CORNERSTONE n OFFICE GYNECOLOGY 1 Vol.3 No. I GOODMAN more for fibroids, ovarian masses, and
clinical CORNERSTONE n OFFICE GYNECOLOGY 1 Vol.3 No. I GOODMAN more for fibroids, ovarian masses, and

GOODMAN

more for

fibroids, ovarian

masses, and other forms

No. Taking HRT does not place her in a different

of pelvic pathology that might be responsible for

category from anybody else. It is important to not forget that HRT does carry a risk of endometrial

her bleeding.

cancer, particularly in light of the current trend of

ADVISORY

BOARD

using lower and lower doses of the progestin agent in HRT regimens.

What is the current thinking regarding the use of TVUS for monitoring women taking tamox- ifen for endometrial neoplasia?

ADVISORY

BOARD

Is the criterion of a “normal” endometrial stripe being 54 mm in a postmenopausal woman applicable to women taking HRT?

GOODMAN

First of all, it is important to be aware that different

institutions may have different

since there is some variability as to what is actually

measured when determining the thickness of the stripe. Thus, it is important for clinicians to check with the ultrasonographer at the laboratory to which they refer their patients and find out what exactly has been established as “normal.” Second, although some investigators have published data suggesting that the endometial stripe can be thick- er in women receiving HRT, I’m a bit more conser- vative and apply the 4-mm criterion regardless of, whether a patient is taking hormones.

cutoffs for “normal”

GOODMAN

There have been a lot of changes in the thinking

about tamoxifen.

all patients with TVUS. The only problem was that we began to seea lot of abnormally thickened

endometrial stripes and consequently performed a lot of biopsies that proved to be negative. It turned out that there was a high percentage of false-posi-

tive thickened endometrial

as a result

edema. A saline infusion sonography or sonohys- terography can distinguish between an endometrial lesion and submucosal edema. The saline in the cavity provides you with sufficient contrast to determine that the “true” endometrial stripes in such patients are fine.

stripes in these patients

At one time we were screening

of tamoxifen causing subendometrial

ADVISORY

BOARD

ADVISORY

BOARD

What then are the guidelines for screening in a patient receiving tamoxifen?

What is the role of TVUS in the premenopausal patient?

GOODMAN Since the thickness of the endometrial

premenopausal patient varies with the phase of the patient’s menstrual cycle, its determination does not have the same diagnostic value as it does in the postmenopausal patient. When I think of using ultrasound in a premenopausal woman, I’m looking

stripe in the

GOODMAN Screening is not generally indicated and an

endometrial biopsy should be performed at the first

sign of bleeding.

HNPCC or has risk factors for endometrial cancer in her medical or family history, I would favor get- ting annual endometrial biopsies? sonohystero- grams, or both.

However, if the patient has

history, I would favor get- ting annual endometrial biopsies? sonohystero- grams, or both. However, if the
history, I would favor get- ting annual endometrial biopsies? sonohystero- grams, or both. However, if the
history, I would favor get- ting annual endometrial biopsies? sonohystero- grams, or both. However, if the

35

history, I would favor get- ting annual endometrial biopsies? sonohystero- grams, or both. However, if the