72 Questions
What is a potential indication of cervicitis, ectropion, or cervical cancer?
Postcoital bleeding
What is a consideration for clinicians when evaluating women with abnormal uterine bleeding?
Underestimating the prevalence of coagulopathies
What is a characteristic of hemodynamic stability?
Changing pads/tampons at least hourly
What is a potential underlying cause of abdominopelvic pain in women with abnormal uterine bleeding?
Endometriosis
What is a consideration for women with a family history of abnormal bleeding or a personal history of bleeding disorders?
The possibility of coagulopathy
What is the primary goal of standard resuscitative measures in women with abnormal uterine bleeding?
To stabilize the patient's hemodynamics
What is the primary risk factor for endometrial cancer?
Long-term unopposed estrogen exposure
What is the most common symptom of endometrial cancer?
Abnormal uterine bleeding
What percentage of new diagnoses of endometrial cancer occur in patients younger than 55 years?
Close to one-fourth
What is the most common cause of iatrogenic uterine bleeding?
Hormonal contraception
What is the primary cause of primary disorders of endometrial hemostasis?
Inflammation or infection
What is the diagnosis of endometrial cancer typically considered?
After other causes are excluded
What percentage of reduction in bleeding can be achieved by using oral tranexamic acid?
26% to 54%
What is the typical pattern of bleeding in patients with uterine malignancy?
Variable and unpredictable
What is the recommended approach for diagnosing endometrial cancer?
Laboratory tests and imaging studies
What is the benefit of using tranexamic acid while attempting to conceive?
It is safe to use
What is the primary goal of using oral progestins in patients with ovulatory dysfunction?
To reduce bleeding
What is the limitation of using oral progestins in patients with ovulatory dysfunction?
Long-term patient satisfaction is low
What is the difference between oral tranexamic acid and nonsteroidal anti-inflammatory drugs?
Oral tranexamic acid reduces bleeding by 26% to 54%, while nonsteroidal anti-inflammatory drugs reduce bleeding by 10% to 52%
What is the search criteria used to evaluate the literature on abnormal uterine bleeding?
Meta-analyses, randomized controlled trials, clinical trials, and reviews
What is the purpose of searching the Agency for Healthcare Research and Quality evidence reports?
To find evidence-based information on abnormal uterine bleeding
What is the benefit of using multiple sources to evaluate the literature on abnormal uterine bleeding?
It provides a comprehensive overview of the topic
What is the primary indication for pelvic imaging in patients with abnormal uterine bleeding?
Abnormalities palpated on bimanual examination or persistent symptoms despite initial treatment
What is the first-line approach for most patients with abnormal uterine bleeding?
Transvaginal ultrasonography
When should hysteroscopic dilation and curettage be performed in patients with abnormal uterine bleeding?
When symptoms persist despite normal biopsy results
What is a major limitation of blind sampling in patients with abnormal uterine bleeding?
It may miss focal lesions
What is a key factor to consider when choosing among treatment options for abnormal uterine bleeding?
Cause and acuity of the bleeding
What is a potential benefit of identifying and treating the underlying cause of abnormal uterine bleeding?
It may resolve symptoms without the need for additional intervention
What is the purpose of saline infusion sonohysterography in patients with abnormal uterine bleeding?
To evaluate the endometrial cavity and identify lesions
Why is routine use of magnetic resonance imaging discouraged in patients with abnormal uterine bleeding?
It may not provide additional information beyond what is available with transvaginal ultrasonography
What is the primary reason for inducing ovulatory cycles or administering supplemental progesterone in treating anovulatory abnormal uterine bleeding?
To antagonize estrogen's proliferative effect on the endometrium
According to the International Federation of Gynecology and Obstetrics classification system, what should be used to characterize abnormal uterine bleeding?
A standardized system
What is the primary indication for performing an endometrial biopsy in patients with abnormal uterine bleeding?
All of the above
What is the primary reason for testing all patients with abnormal uterine bleeding for anemia?
Because anemia is an indication for treatment
What is the primary purpose of inducing ovulatory cycles in patients with anovulatory abnormal uterine bleeding?
To regulate estrogen's effect on the endometrium
What is the primary consideration for clinicians when evaluating patients with abnormal uterine bleeding?
Unopposed estrogen exposure
What is the primary reason for performing an emergent endometrial biopsy in patients with abnormal uterine bleeding?
To rule out endometrial cancer
What is the primary purpose of testing all patients with abnormal uterine bleeding for pregnancy?
To rule out pregnancy-related bleeding
What is a possible indication of hemodynamic instability in a patient with abnormal uterine bleeding?
Passing blood clots
Which of the following may suggest an underlying infection in a patient with abnormal uterine bleeding?
Abdominopelvic pain
What is a potential underlying cause of abnormal uterine bleeding that clinicians may underestimate?
Coagulopathies
Which of the following is a crucial consideration in the evaluation of women with abnormal uterine bleeding?
Family history of abnormal bleeding
What is the primary goal of standard resuscitative measures in women with abnormal uterine bleeding?
To stabilize hemodynamics
What is the likely underlying mechanism of primary disorders of endometrial hemostasis?
Vasoconstriction disorders, inflammation, or infection
What is the recommended approach for patients with uterine malignancy?
Further evaluation and management as outlined in a previous American Family Physician article
Which of the following is a potential underlying cause of abdominopelvic pain in women with abnormal uterine bleeding?
All of the above
What percentage of new diagnoses of endometrial cancer occur in patients younger than what age?
55 years
What is the primary risk factor for endometrial cancer?
Long-term unopposed estrogen exposure
What is the most common cause of abnormal uterine bleeding in patients with iatrogenic uterine bleeding?
Hormonal contraception
What is a characteristic of bleeding patterns in patients with uterine malignancy?
Variable bleeding patterns
What is the primary presentation of endometrial cancer?
Abnormal uterine bleeding
What is a common factor in primary disorders of endometrial hemostasis?
Predictable ovulatory cycles
In hemodynamically unstable patients, what is the primary goal of uterine tamponade using a Foley catheter or gauze packing?
To achieve rapid but temporary control of blood loss
What is the most effective treatment for reducing heavy menstrual bleeding?
Hysterectomy
Which of the following is the first-line imaging choice for evaluating abnormal uterine bleeding in most patients?
Transvaginal ultrasonography
What is the primary benefit of using the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena)?
Reducing heavy menstrual bleeding
What is the primary indication for emergency interventions in hemodynamically unstable patients with abnormal uterine bleeding?
Achieving rapid control of bleeding
What is the primary role of medical therapy in treating hemodynamically stable patients with severe bleeding?
To provide adequate treatment
What is the primary indication for performing a transvaginal ultrasonography in patients with abnormal uterine bleeding?
To rule out endometrial cancer
Which of the following medications is NOT a long-term medical therapy option for abnormal uterine bleeding?
Aspirin
What is the primary goal of endometrial ablation in patients with abnormal uterine bleeding?
To reduce menstrual bleeding
Which of the following conditions is NOT a potential underlying cause of abnormal uterine bleeding?
Hypertension
What is the primary indication for performing a hysterectomy in patients with abnormal uterine bleeding?
When other treatments have failed
Which of the following medications is used to treat coagulopathy in patients with abnormal uterine bleeding?
Intravenous tranexamic acid
What is the primary goal of using high-dose oral progestins in patients with abnormal uterine bleeding?
To reduce menstrual bleeding
Which of the following is a long-term surgical option for abnormal uterine bleeding?
Uterine artery embolization
What is the primary goal of medical management in patients with abnormal uterine bleeding?
To preserve fertility and avoid surgical risks
What is the effectiveness of the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) in decreasing heavy menstrual bleeding?
71% to 95% reduction in blood loss
What is the equivalent treatment option to the levonorgestrel-releasing intrauterine system in terms of bleeding outcomes and patient satisfaction?
Endometrial ablation
What is the indication for estrogen-progestin oral contraceptives in patients with abnormal uterine bleeding?
To regulate bleeding and reduce blood loss
What is the contraindication for surgical interventions in patients with abnormal uterine bleeding?
Patients who wish to preserve fertility
What is the treatment option for leiomyomas and endometrial polyps in patients with abnormal uterine bleeding?
Myomectomy and uterine artery embolization
Study Notes
Abnormal Uterine Bleeding
- Abnormal uterine bleeding is the most common symptom of endometrial cancer, with around 25% of new diagnoses occurring in patients under 55 years old.
- Long-term unopposed estrogen exposure is the primary risk factor for endometrial cancer.
Primary Disorders of Endometrial Hemostasis
- Typically occur in the setting of predictable ovulatory cycles
- Likely due to vasoconstriction disorders, inflammation, or infection
- Endometrial dysfunction is poorly understood, with no reliable diagnostic methods, and should be considered only after other causes are excluded.
Iatrogenic Causes
- Medical treatments can provoke abnormal uterine bleeding
- Hormonal contraception is the most common cause of iatrogenic uterine bleeding (breakthrough bleeding)
Diagnosis
- Historical clues such as passing blood clots or changing pads/tampons at least hourly suggest heavy menstrual bleeding
- A history of postcoital bleeding may indicate cervicitis, ectropion, or cervical cancer
- Abdominopelvic pain may suggest infection, structural lesions, or endometriosis
- Coagulopathies should be considered in women with a family history of abnormal bleeding or a personal history of abnormal bleeding
Imaging
- Indications for pelvic imaging include abnormalities palpated on bimanual examination or symptoms that persist despite initial treatment
- Transvaginal ultrasonography is the first-line approach for most patients
- Saline infusion sonohysterography is better at detecting intracavitary lesions
Management
- Multiple factors should be considered when choosing among treatment options, including the cause and acuity of the bleeding, fertility and contraceptive preferences, medical comorbidities, adverse effects, cost, and relative effectiveness
- If the underlying cause of bleeding can be identified and treated, symptoms may resolve without the need for additional intervention
- Anemia is an indication for treatment, as is bleeding that negatively affects the patient's quality of life
Treatment Options
- Inducing ovulatory cycles or administering supplemental progesterone to antagonize estrogen's proliferative effect on the endometrium
- Oral tranexamic acid (Lysteda) and nonsteroidal anti-inflammatory drugs are effective, well-tolerated, nonhormonal treatment options
- Continuous dosing of oral progestins is another effective hormonal treatment option (87% reduction), but long-term patient satisfaction is low
Abnormal Uterine Bleeding
- Abnormal uterine bleeding is the most common symptom of endometrial cancer
- The prevalence of endometrial cancer increases with age, but 1/4 of new diagnoses occur in patients younger than 55 years
- Long-term unopposed estrogen exposure is the primary risk factor for endometrial cancer
Primary Disorders of Endometrial Hemostasis
- Typically occur in the setting of predictable ovulatory cycles
- Likely due to vasoconstriction disorders, inflammation, or infection
- Endometrial dysfunction is poorly understood, with no reliable diagnostic methods
Iatrogenic Causes
- Hormonal contraception is the most common cause of iatrogenic uterine bleeding (i.e., breakthrough bleeding)
- Other medical treatments can also provoke abnormal uterine bleeding
Evaluation and Management
- Initial history or physical examination suggests acute or severe blood loss
- Transvaginal ultrasonography is the first-line imaging choice for evaluating abnormal uterine bleeding
- Levonorgestrel-releasing intrauterine system (Mirena) is more effective than other medical therapies for reducing heavy menstrual bleeding
- Hysterectomy is the most effective treatment for reducing heavy menstrual bleeding and yields a high level of patient satisfaction
Nonemergent Treatment
- Medical therapy is usually adequate for treating hemodynamically stable patients with severe bleeding
- Hysterectomy is the definitive and most effective treatment for abnormal uterine bleeding
- Endometrial ablation is a less invasive, lower-risk surgical option that is as effective as the levonorgestrel-releasing intrauterine system
- A variety of ablative techniques are available, and all are equivalent in terms of bleeding outcomes and patient satisfaction
This quiz covers the symptoms and risk factors of endometrial cancer, including abnormal uterine bleeding. It also explores primary disorders of endometrial hemostasis, including their causes and effects.
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