Monday, August 8 th, 2011

 Normal cycle lasts: 26 to 30 days, but may vary from 21 to 35 days  Normal menstrual flow lasts: 3 to 7 days A period lasting longer than 10 days is considered pathologic  Average amount of blood loss per cycle: 30 to 40ml More than 80ml is considered pathologic

 Terms: Menorrhagia  Heavy (>80ml) or prolonged bleeding (>7 days) that occurs at regular cyclic intervals Metorrhagia  Irregular vaginal bleeding (acyclic) Menometorrhagia  Heavy vaginal bleeding occurring at irregular intervals Polymenorrhea  Frequent vaginal bleeding at intervals more often than every 21 days

 “Abnormal vaginal bleeding”= all cases of irregular, heavy, or frequent bleeding  “Dysfunctional uterine bleeding” = bleeding that is not due to underlying anatomic abnormalities or systemic conditions *Most frequently caused by chronic anovulation and immaturity of the hypothal-pit-ovarian axis Diagnosis of exclusion

 Most common is anovulatory bleeding due to immature hypothal-pituitary-ovarian axis (DUB)  Anovulatory bleeding is the most common cause of acyclic bleeding and may be associated with: Sports Stress Disordered eating Endocrinopahties (thyroid problems, DM, Cushings)

 May suggest bleeding disorders or uterine pathology  The most common bleeding disorders are: Thrombocytopenia (usually ITP) von Willebrand disease (occurs in 95% of women)  Usually a history of heavy bleeding from first menstrual period

 vWf – role in hemostasis by binding to platelets and endothelial components; carrier protein for Factor 8  Presents with easy bruising, skin bleeding, prolonged bleeding from mucosal surfaces (ex: OP, GI, uterine) Nose bleeds >10 minutes Bleeds after tooth extraction

 Varies from subtle onset of fatigue due to iron deficiency anemia to acute mental status changes or syncope caused by severe blood loss (like our patient!)

 Menarche  Usual pattern of bleeding Frequency and duration of menses  Presence of menstrual cramping  LMP  Sexual history Any STDs  ROS Symptoms of PCOS, thyroid disease, bleeding disorders, hypothalamic amenorrhea

 Depo  OCPs  IUDs  Psychotropic medications Risperidone  Illicit drugs  Herbs  Dietary supplements

 Vital signs Include orthostatic measurements  Look for signs of conditions in your DDx: PCOS Thyroid Bruising or petechiae  Consider bimanual and pelvic exam Pelvic U/S in those who can’t tolerate and exam

 CBC  UPT (exclude pregnancy in everyone!!)  PT  PTT  von Willebrand panel Should be drawn before hormonal therapies start because estrogen increases concentration  Platelet function assay  GC/Chlamydia (in sexually active)  TSH  Testosterone, DHEAS (if suspect PCOS)

 Perimenarchal DUB requires only reassurance and iron therapy  NSAIDS can help reduce blood loss  Combination oral contraceptives Bleeding usually decreases significantly with 24 to 36 hours of hormonal therapy Estrogen = promotes clotting and causes endometrial proliferation Progestin = stabilized the endometrial lining  *Surgery is rarely necessary (endometrial ablation, hysterectomy)

 Kids: 3-6 mg elemental Fe/kg/day  Adults: mg elemental Fe BID  Less GI irritation when given with or after meals  Vitamin C may enhance absorption  Antacids may decrease absorption  Hgb should rise after 1-2 weeks of treatment  Hgb should return to normal at 6-8 weeks  Tx for 6 months

Immunizations, Dr. Begue