Podcast
Questions and Answers
What is the recommended action when endometrial thickness is greater than 12 mm in a reproductive age female with normal ultrasound and persistent bleeding?
What is the recommended action when endometrial thickness is greater than 12 mm in a reproductive age female with normal ultrasound and persistent bleeding?
- Start hormone therapy
- Administer tranexamic acid
- Schedule a follow-up ultrasound
- Perform an endometrial biopsy (correct)
The average age of menopause is the same in India and worldwide.
The average age of menopause is the same in India and worldwide.
False (B)
What is the gold standard for diagnosing endometrial pathology in postmenopausal females?
What is the gold standard for diagnosing endometrial pathology in postmenopausal females?
Fractional curettage and hysteroscopy
In perimenopausal women, the age considered for menopause is typically over ______ years.
In perimenopausal women, the age considered for menopause is typically over ______ years.
Match the following drugs to their general use for the management of AUB:
Match the following drugs to their general use for the management of AUB:
Which of the following is NOT a cause of abnormal uterine bleeding in a pubertal female?
Which of the following is NOT a cause of abnormal uterine bleeding in a pubertal female?
Urgent ultrasound (USG) is mandatory for investigating abnormal uterine bleeding in pubertal females.
Urgent ultrasound (USG) is mandatory for investigating abnormal uterine bleeding in pubertal females.
What initial treatment is recommended for severe bleeding with hemoglobin less than 8 g/dL?
What initial treatment is recommended for severe bleeding with hemoglobin less than 8 g/dL?
For mild bleeding with hemoglobin levels between 10-12 g/dL, patients should maintain a __________.
For mild bleeding with hemoglobin levels between 10-12 g/dL, patients should maintain a __________.
Match the treatment regimen with its severity:
Match the treatment regimen with its severity:
What is the primary mechanism of action of Ormeloxifene?
What is the primary mechanism of action of Ormeloxifene?
Hysterectomy is indicated for all females with Atypical Uterine Bleeding.
Hysterectomy is indicated for all females with Atypical Uterine Bleeding.
What is the dosage of IV Estrogen/Ethinyl estradiol for managing severe bleeding?
What is the dosage of IV Estrogen/Ethinyl estradiol for managing severe bleeding?
Endometrial ablation can destroy the endometrial lining up to ____ mm deep.
Endometrial ablation can destroy the endometrial lining up to ____ mm deep.
Match the following surgical management techniques with their indications:
Match the following surgical management techniques with their indications:
What is the most common cause of precocious puberty?
What is the most common cause of precocious puberty?
Peripheral precocious puberty is characterized by premature activation of the HPO axis.
Peripheral precocious puberty is characterized by premature activation of the HPO axis.
Name one psychological consequence of precocious puberty.
Name one psychological consequence of precocious puberty.
In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.
In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.
Match the following types of precocious puberty with their characteristics:
Match the following types of precocious puberty with their characteristics:
Which of the following statements about estrogen in precocious puberty is correct?
Which of the following statements about estrogen in precocious puberty is correct?
In peripheral precocious puberty, FSH and LH levels are significantly increased.
In peripheral precocious puberty, FSH and LH levels are significantly increased.
What is a common risk associated with the underlying causes of precocious puberty?
What is a common risk associated with the underlying causes of precocious puberty?
Which of the following describes the mechanism of action of progesterone?
Which of the following describes the mechanism of action of progesterone?
Oral progesterone should be administered for 1 week without interruption for effective treatment of AUB.
Oral progesterone should be administered for 1 week without interruption for effective treatment of AUB.
What is the preferred treatment for thick endometrium with estrogen upregulation?
What is the preferred treatment for thick endometrium with estrogen upregulation?
The Mirena is a progesterone-releasing ______ that causes endometrial atrophy.
The Mirena is a progesterone-releasing ______ that causes endometrial atrophy.
Match the treatment with its indication for AUB:
Match the treatment with its indication for AUB:
What is the primary function of tranexamic acid in the management of abnormal uterine bleeding (AUB)?
What is the primary function of tranexamic acid in the management of abnormal uterine bleeding (AUB)?
Mefenamic acid is typically the first-line treatment for AUB.
Mefenamic acid is typically the first-line treatment for AUB.
At what average age do females typically experience the onset of puberty?
At what average age do females typically experience the onset of puberty?
What is the dose of tranexamic acid prescribed for treating AUB?
What is the dose of tranexamic acid prescribed for treating AUB?
Males typically experience their growth spurt earlier and for a shorter duration than females.
Males typically experience their growth spurt earlier and for a shorter duration than females.
OCPS provide contraceptive benefits when started between days __ to __ of the menstrual cycle.
OCPS provide contraceptive benefits when started between days __ to __ of the menstrual cycle.
Match the following drugs to their mechanisms of action:
Match the following drugs to their mechanisms of action:
What is the first visible sign of puberty in females?
What is the first visible sign of puberty in females?
The average age for menarche in females is ______ years.
The average age for menarche in females is ______ years.
Match the following features with the correct gender:
Match the following features with the correct gender:
What characterizes the initial phase of the menstrual cycle?
What characterizes the initial phase of the menstrual cycle?
Irregular menstrual cycles are typically painless.
Irregular menstrual cycles are typically painless.
What is the term used for menstruation that occurs earlier than expected?
What is the term used for menstruation that occurs earlier than expected?
Heavy bleeding during the menstrual cycle is often described as ______.
Heavy bleeding during the menstrual cycle is often described as ______.
Match the following terms related to the menstrual cycle with their definitions:
Match the following terms related to the menstrual cycle with their definitions:
What is the primary advantage of using continuous progesterone in the treatment of AUB?
What is the primary advantage of using continuous progesterone in the treatment of AUB?
Blood transfusions are only indicated for patients with hemoglobin levels below 7 g/dL.
Blood transfusions are only indicated for patients with hemoglobin levels below 7 g/dL.
What is the maximum duration for the use of GnRH analogues in managing AUB?
What is the maximum duration for the use of GnRH analogues in managing AUB?
In cases of AUB with persistent bleeding, blood transfusion may be necessary if hemoglobin levels drop below _______ g/dL.
In cases of AUB with persistent bleeding, blood transfusion may be necessary if hemoglobin levels drop below _______ g/dL.
Match the following conditions with their corresponding hemoglobin thresholds for transfusion:
Match the following conditions with their corresponding hemoglobin thresholds for transfusion:
What is the primary change that occurs in the body during puberty?
What is the primary change that occurs in the body during puberty?
The HPO axis remains inactive throughout childhood until puberty.
The HPO axis remains inactive throughout childhood until puberty.
What role does adipose tissue play in puberty?
What role does adipose tissue play in puberty?
In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.
In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.
Match the following components of puberty with their descriptions:
Match the following components of puberty with their descriptions:
Study Notes
Precocious Puberty
- Two Types: Central/True (80%) and Peripheral (20%)
- Central/True: Premature activation of hypothalamic-pituitary-ovarian (HPO) axis
- Peripheral: Not related to HPO axis; ovary/adrenal gland
- Central/True: ↑ GnRH → ↑ FSH, ↑ LH → ↑ Estrogen
- Peripheral : ↑ Estrogen/↑ Androgen → Negative feedback → ↓ FSH, ↓ LH
- Central/True: Depends on Gonadotropin, FSH, LH, and Estrogen levels
- Peripheral: Does not depend on Gonadotropin, FSH, or LH levels; Estrogen or Androgen levels are elevated
- Central/True: Premature Ovulation
- Peripheral: No premature Ovulation
- Central/True: May have psychological and emotional stress, Estrogen exposure at a young age, and risk related to the underlying cause
Atypical Uterine Bleeding (AUB)
- Investigatory Algorithm for Atypical Uterine Bleeding (AUB) depends on age
- Reproductive Age: Endometrial thickness > 12mm
- High Risk Factors for AUB: PCOS, granulosa cell tumor, obesity
- Perimenopausal:
- Menopause: India (47 years) | Worldwide (51 years)
- Perimenopause: Over 40 years (FOGSI) | Over 45 years (ACOG)
- UPT (regardless of ultrasound) → TVS + Endometrial Biopsy
- Postmenopausal:
- Endometrial thickness < 4mm: Tranexamic acid + Bleeding
- Endometrial thickness ≥ 24mm: Endometrial biopsy
- Fractional Curettage + Hysteroscopy: Gold standard for endometrial pathology
- Fractional Curettage + Hysteroscopy done under general anesthesia (GA) in the operating theater (OT)
Management of AUB
- Drugs:
- Tranexamic acid
- OCP (oral contraceptive pills)
- Progesterone
Pubertal Menorrhagia
- Abnormal uterine bleeding (AUB) in a pubertal female
- Causes: Amenorrhea, coagulation defect, thyroid dysfunction
Management of Pubertal Menorrhagia
- History
- Physical examination
- Per vaginal examination (contraindicated in virgins)
Investigations
- Ultrasound (USG): Not mandatory
- Routine investigations
- Urine pregnancy test (UPT): If sexually active
Treatment
- Three drugs for any AUB:
- Tranexamic acid
- Combined Oral Contraceptives (OCP) (estrogen + progesterone)
- Progesterone only
Mild Bleeding (Hb: 10-12 g/dL)
- Oral iron tablets
- Reassurance
- Maintain menstrual diary/calendar
Moderate Bleeding (Hb: 8-10 g/dL)
- Combined Oral Contraceptives (OCP)
- Maintain regular menstrual cycle
Severe Bleeding (Hb < 8 g/dL)
- Initial treatment: IV estrogen (high dose) - unavailable in India
- Alternative: Ethinylestradiol (50mg x 5 days)
- Or combined oral contraceptives (OCP) (20-30mg estrogen), 2 days every 8 hours, for 5 days every 12 hours, for 2 weeks, followed by maintenance dose
- Maintenance:
- Progesterone pills (OD: daily during menstruation cycle) D5 (5th day of period) x 6 cycles
- OCP (OD): D25 x 6 cycles
- Progesterone - 1 day every 24 hours of the cycle x 6 cycles
Ormeloxifene
- Obsolete
- Selective estrogen receptor modulator (SERM)
- MOA: Antagonizes the effect of estrogen on endometrium → Atrophy
- Dose: 60mg twice daily x 12 weeks
Surgical Management
- Endometrial ablation:
- Uterine arterial embolization:
- Indication: Fibroid
- Uterine arterial embolization:
- Hysterectomy: In perimenopausal female with concomitant uterine pathology
Scenario
- Indications: Both conditions to be fulfilled:
- a. Failure of medical mx
- b. Complete family
- Severe bleeding x 15 days
- USG: N
- UPT: -ve
- Endometrial biopsy: N
Medical Management
- IV Estrogen/Ethinyl estradiol: 50mg x 5 days (If/b)
- Progesterone
- OCPS:
- First 2 days: 4 - 8th hourly
- Next 5 days: 12th hourly
- Next 14 days: Once daily
Endometrial Ablation
- Endometrial lining destroyed upto 4-6mm deep
- 1st Generation:
- Rollerball, laser, TCRE
- Done under hysteroscopic guidance → Increased risk of fluid
- 2nd Generation:
- Cryosurgery, hydrothermal ablation
- Not done under hysteroscope → No risk of fluid overload
- 1st Generation:
Contraindications (C/I)
- Pregnancy
- Incomplete family/Desires pregnancy
- Endometrial hyperplasia/Cancer
- Active pelvic infection
- UCCD
Tranexamic Acid
- Antifibrinolytic
- Reduces AUB by 50%
- Dose: 1 gm thrice daily x 3-4 days
- Well tolerated in cyclical bleeding with normal size uterus
Mefenamic Acid
- Prostaglandin synthetase inhibitor
- MOA: Blocks prostaglandin receptor
- AUB/Dysmenorrhoea: Mediated by prostaglandin
- Indication: C/O AUB + Dysmenorrhoea
- Usage:
- Not used as 1st line drug
- Used with tranexamic acid
- Dose: 500mg thrice daily
Ethamsylate
- ↓ Capillary fragility
- Not effective in mixed AUB
OCPS
-
Estrogen (E) + Progesterone (P)
-
Stabilize endometrium - ↓ Bleeding
-
-ve feedback on LH, FSH → Anovulation
- → contraception
- → suppression of ovaries
-
Pack of 21 tablets
-
For contraceptive benefit:
- Started between D1 to D5 of cycle → 21 days → Progesterone withdrawal → Bleeding → Repeat cycle
-
In AUB:
- Hb < 10 g/dL ↓ (causes anemia)
- Hb ≥ 10 g/dL (normal level)
-
Continuously for 3 months:
- Advantage:
- Control blood loss
- Regularise cycles (DOC by regularising cycles: OCP)
- Contraceptive benefit
- 3 weeks of ocp f/b 1 week off x 3 cycles
- Advantage:
MOA (OCPS)
- Estrogen (e): Upregulates progesterone receptors on the endometrium
- Progesterone (P): Acts only on primed endometrium; downregulates estrogen receptors on endometrium
Indications of Drugs for AUB
| Condition | Treatment |
|---|---|
| Thick endometrium, estrogen upregulation of progesterone(+) | Combined Oral Contraceptives (OCP) |
| Thin endometrium or prolonged/severe bleeding | Progesterone only |
Progesterone
- MOA:
- Supports the endometrium, decreasing shedding
- Downregulates estrogen receptors, leading to less blood loss
- (If given continuously) Results in endometrial atrophy
- Protects the endometrium from the proliferative effects of estrogen
Supplementation
- Oral Progesterone/Cyclic Progesterone: Effective in treating AUB
- Continuously for 3-6 months (without interruption): This method results in endometrial atrophy. Preferred mode of therapy for AUB.
- IUCD: Mirena:
- Progesterone-releasing intrauterine device
- Causes endometrial atrophy
- Relief from AUB occurs in 30-40% of cases
Puberty and Precocious Puberty
- Growth Spurt:
- Females: Earlier and shorter
- Males: Later and longer
- Same until 10.5 years
Puberty in Females vs Males
| Feature | Females | Males |
|---|---|---|
| Age | 10.5 years | 11.5 years |
| Sequence | 1st sign: Growth spurt (Skeletal growth) * 1st visible sign: Breast budding (Thelarche: most specific) * Appearance of pubic & Axillary hair (pubarche) * Peak height velocity (6 months) * Menarche (12.5 years) * 2° sexual characters appear | Growth spurt (Skeletal growth) * Appearance of pubic & Axillary hair (pubarche) * Increase in testicular size (most specific sign) * Penis growth * Peak height velocity (14 years) * Change in voice * Facial hair * 2° sexual characters appear |
Menstrual Cycle
- Initially: Anovulatory
- Irregular
- Heavy Bleeding
- Painless
- Precocious Menstruation: Menstruation before 10 years of age
Preferred Treatments for AUB
- For:
- Reproductive age females
- Perimenopausal females
- To prevent endometrial proliferation
- Advantages:
- Good compliance
- Reduces the need for hysterectomy
- If patient refuses continuous progesterone: Minimum 12 days/month of protective effect is required
SPECIFIC MANAGEMENT of AUB
-
Structural Lesion:
- Mx of Cause: Bleeding controlled
- Oral iron + Maintenance drugs
-
Non-structural Lesion:
- Bleeding persists:
- Blood transfusion (if needed)
- Second-line medical mx (or) Sx
- Bleeding persists:
Indications for Blood Transfusion
- Puberty menorrhagia: Hb < 7 g/dL
- Hb < 5 g/dL or unstable vitals
- Before planned surgery (Sx): Hb < 10 g/dL
Second-line Drugs for Medical Management
- GnRH analogues:
- ↓ LH, FSH, ↓ E on continuous administration:
- ↓ Endometrial proliferation
- ↓ blood loss
- ↓ LH, FSH, ↓ E on continuous administration:
- Disadvantages:
- Expensive
- Menopause-like symptoms due to ↓ e
- Use:
- Maximum duration of use: 6 months
- Before surgery (Sx) or endometrial ablation
Definition of Puberty
- Period which involves childhood to adulthood
- Onset of development of secondary sexual characters
- Attainment of reproductive capacity
Physiology of Puberty
- Occurs due to activation in the HPO axis
HPO Axis
-
Dormant: After birth (Intra-uterine life)
-
Activated: At puberty
-
Central Inhibition (Dormant):
- Neurotransmitters: GABA, Neuropeptide Y (Inhibitory)
-
Hormonal Processes (Activated):
- Adrenal gland: Produces androgens
- Adipose tissue: Converts androgens to estrogen via aromatase.
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Description
Test your knowledge on the management and diagnosis of abnormal uterine bleeding (AUB) in different age groups and situations. This quiz covers essential practices including ultrasound use, treatment options, and understanding of endometrial pathology. Evaluate your comprehension of AUB guidelines and recommendations for reproductive-age females and postmenopausal women.
