Premenopausal Bleeding Disorders in non-pregnant women- Menstrual history :The characteristics of normal menstrual bleeding are
- Frequency every 21 to 35 days
- Occurs at fairly regular intervals
- Volume of blood ≤80 mL
- Duration is 5 days
- Dysmenorrhea, or painful menstruation
- Prostaglandins released from endometrial sloughing at the beginning of menses play a major role in inducing contractions
- Treatment
- ibuprofen 400 to 600 mg every four to six hours or 800 mg every eight hours to a maximum dose of 2400 mg per day, starting with the onset of symptoms or menses, and continue this dose for two or three days based on the patient's usual symptom pattern
- Note: fenamates (mefenamic acid, tolfenamic acid, flufenamic acid, meclofenamate, bromfenac) may have slightly better efficacy than the phenylproprionic acid derivatives (ibuprofen, naproxen)
- Estrogen-progestin methods — Estrogen-progestin contraceptives contain potent synthetic progestins, which suppress ovulation and cause the endometrium to become thin over time. The thin endometrium contains relatively small amounts of arachidonic acid, the substrate for most prostaglandin synthesis. As a result of these changes in the endometrium, estrogen-progestin contraceptives reduce both menstrual flow and uterine contractions at menses, thereby decreasing dysmenorrhea.
- Progestin-only methods — Since the progestin component of estrogen-progestin contraceptives induces the endometrial atrophy that leads to relief of dysmenorrhea, progestin-only contraceptives may be an effective treatment, but have not been studied as extensively as estrogen-progestin contraceptives
- Reference: Up-to-date (see uptodate for details)
- AUB in nongravid reproductive-age women
- New international consensus is to use this term to avoid the use of poorly defined or confusing terms used previously (eg, menorrhagia, menometrorrhagia, oligomenorrhea).
- Approach: Questions to ask
- Is the uterus the source of the bleeding?
- Bleeding from the vulva, vagina, or cervix
- Or is it Urinary or gastrointestinal tract bleeding
- Other Questions to ask are
- What is the bleeding pattern?
- Should endometrial sampling be performed?
- Should a coagulation evaluation be performed?
- Is bleeding related to a contraceptive method?
- Is the patient premenarchal or postmenopausal?
- Is the patient pregnant?
- Identify the bleeding pattern by asking the patient the following questions:
- What was the first day of the last menstrual period and several previous menstrual periods?
- For how many days does bleeding continue? How many days of full bleeding and how many days of light bleeding or brown staining does this include?
- Does bleeding occur between menstrual periods?
- How heavy is the bleeding? The definition of normal menses is <80 mL of blood. Population-based studies that employed precise assessment of menstrual blood loss found that women with a loss per cycle of >80 mL were more likely to become anemic. However, volume of blood is difficult to measure. In clinical practice, heavy menses are generally defined as soaking a pad or tampon more than every two hours or as a volume of bleeding that interferes with daily activities (eg, wakes patient from sleep, stains clothing or sheets). Questions that help to characterize the volume of uterine bleeding are shown in the table
- If bleeding is irregular, how many bleeding episodes have there been in the past 6 to 12 months? What is the average time from the first day of one bleeding episode to the next?
- Indications for treatment — Types of chronic AUB include:
- Heavy menstrual bleeding (HMB) – HMB is ovulatory (cyclic), heavy bleeding. The impact on quality of life in women with HMB includes the need to change pads or tampons frequently, heavy bleeding that stains clothing or bedding, and avoidance of activities due to bleeding
- estrogen-progestin contraceptives or the LNg20 (Levonorgestrel intrauterine device) as first-line therapy rather than other medications
- Both provide effective contraception
- Both are well tolerated and have a low risk of adverse effects
- Intermenstrual bleeding – Intermenstrual bleeding occurs in between otherwise regular menses. The primary etiology can often be identified and treated (eg, endometrial polyp, chronic endometritis). An evaluation should be performed to identify the etiology and exclude malignancy. If no etiology is found, the goal of treatment is to resolve this bothersome symptom. The volume of blood loss is typically small, and anemia is not generally a concern.
- Ovulatory dysfunction (AUB-O) – AUB-O is irregular, nonovulatory (noncyclic) bleeding. Prolonged or heavy bleeding, even hemorrhage, may occur. The etiology of AUB-O should be identified, since treatment of some etiologies (eg, thyroid disease, hyperprolactinemia) may restore cyclic menses. In many cases, polycystic ovarian syndrome is the etiology, and this cannot readily be corrected. The goals of treatment of AUB-O are to establish a regular bleeding pattern (or amenorrhea), prevent heavy bleeding, and prevent development of endometrial hyperplasia/cancer. In addition, women with ovulatory dysfunction often require fertility treatment if they wish to conceive.
- estrogen-progestin contraceptives, oral progestin therapy, or the LNg20 are first-line treatment options, as these approaches reduce bleeding and decrease the risk of endometrial hyperplasia or cancer.
- Other bleeding patterns – oligomenorrhea or amenorrhea
- Reference: Up-to-date (see uptodate for details)
Cervical Cancer Sreeening
 
- Misc
- PID: Please see Infectious Syndrome (Under Infectious Disease)
- Vaginal Discharge
- Diagnostic Studies (Ref: Up-to-Date)
- pH: Single most important finding. Should always be determined.
- pH > 4.5 (BV)
- pH 5 - 6 (Trichomoniasis)
- pH 4 - 4.5 (Candida vulvovagnititis)
- Why is normal Vaginal pH around 4.5?
- The pH of the normal vaginal secretions in premenopausal women is 4.0 to 4.5 because these women have relatively high estrogen levels. Under the influence of estrogen, the normal vaginal epithelium cornifies and produces glycogen, which is the substrate for lactic acid production by lactobacilli. In premenarchal and postmenopausal women in whom estrogen levels are low, the pH of the normal vaginal secretions is ≥4.7. The higher pH is due to less glycogen in epithelial cells, reduced colonization of lactobacilli, and reduced lactic acid production. Thus measurement of pH for diagnosis of bacterial vaginosis, trichomoniasis, or candidiasis is less useful at the extremes of age.
- Microscopy:
- Saline wet mount
- Potassium Hydroxide wet mount
- Vaginal Culture
- Cervical Culture
Persistent Genital Malodor - References:
- DDx:
- Neglected foreign body (including retained tampon)
- Bacterial vaginosis
- Trichomoniasis
- Infectious ulcer/pelvic inflammatory disease (PID)
- Pelvic fistula (rectovaginal, vesicovaginal, ureterovaginal)
- Hidradenitis suppurativa
- Chronic constipation
- Urinary incontinence
- Fecal incontinence
- Poor hygiene
- Malignant ulcer
- Excessive genital perspiration and local bacterial colonization related to obesity
Causes of Post-Coital Bleeding
|
