Assessment of the Patient with Vaginal Bleeding

1
Assessment of the Patient with Vaginal Bleeding
2
Clinical Background
Vaginal bleeding is considered abnormal if it
occurs

• - In childhood
• At menses longer duration
• At menses increased flow
• Between menstrual periods
• After menopause

3
Terminology
Abnormal menstrual patterns are characterized by
flow or volume abnormalities

• Hypermenorrhea
• Hypomenorrhea
• Polymenorrhea
• Oligomenorrhea
• Menometrorrhagia

4
Frequent causes pediatric patients

• Genital lesions
• Vaginitis
• Foreign body
• Trauma
• Tumors
• Endocrine changes

5
Frequent causes Adult patients

• DUB
• Estrogen breakthrough
• Estrogen withdrawal
• Diseases of genital tract
• Uterine
• Cervical
• Vaginal

6
Frequent causes Adult patients

• Pregnancy
• Implantation bleeding
• Threatened abortion
• Embryonic demise
• Ectopic pregnancy

7
Clinical Significance

• Seek medical attention!
• Most common indication for hysterectomy
• Necessitates change in lifestyle
• Complete workup HP pelvic exam
• Pregnancy test in initial evaluation!!!

8
Clinical Evaluation
Pregnancy Test

-
Obstetrics
Gynecology
Implantation Failed pregnancy Ectopic pregnancy
Pediatric Pre-menopausal Post-menopasual
9
Negative Pregnancy Test

• Pre-menopausal
• Fibroids, especially submucosal
• Endometrial hyperplasia
• Uterine polyps

10
Negative Pregnancy Test

• Post-menopausal
• Exogenous hormone therapy
• Endometrial atrophy
• Endometrial carcinoma
• Cervical carcinoma
• Estrogen producing tumor of ovary

11
Exogenous Hormone Administration
Most Common Cause

• Uterine and cervical contours maintained
• Normal endometrium appears as stripe
• Measurements vary with hormone status

12
Exogenous Hormone Administration
Normal Appearance- No HRT
13
Exogenous Hormone Administration
Measurements (AP)

• As a rule ? estrogen thinner stripe
• No HRT 5mm upper limit of normal
• Estrogen only 8mm

14
Unopposed estrogen
15
Unopposed estrogen
16
Unopposed estrogen
17
Cyclical hormones
18
Cyclical hormones
19
Endometrial carcinoma

• EV sonography biopsy in sensitivity when EC
  gt5mm
• Strict technical requirements to obtain this
  sensitivity

20
Endometrial carcinoma
Measurement Technique

• EV in sagittal plane
• Thickest portion measured
• Double thickness
• Entire endometrium must be visualized

21
Endometrial carcinoma
Measurement Technique
22
Endometrial carcinoma
Abnormal US Findings

• double-thickness gt5mm
• Any focal endometrial abnormality
• Indistinct endometrial margins

23
Endometrial carcinoma
Abnormal US Findings
24
Endometrial carcinoma
Abnormal US Findings
25
Endometrial carcinoma
Abnormal US Findings
26
Endometrial carcinoma
Pathology

• Most common type of Gynecologic cancer
• 75-79 occur in PM patients
• Histology includes
• Adenocarcinoma
• Adenocanthoma
• Adenosquamous carcinoma

27
Endometrial carcinoma
Risk factors

• Obesity
• Hypertension
• Diabetes mellits
• Strong family history

28
Endometrial carcinoma
Clinical signs

• Vaginal bleeding postmenopausal
• Hypermenorrhea, inter-menstrual flow
• Pain - Late stage

29
Endometrial carcinoma
Sonographic findings

• Thickening, inhomogeneity of endometrium
• Alteration in normal uterine appearance
• Increased uterine size
• Fluid in endometrial cavity

30
Endometrial carcinoma
Sonographic findings
31
Endometrial carcinoma
Sonographic findings
32
Endometrial carcinoma
Sonographic findings
33
Endometrial carcinoma
Sonographic findings
34
Clinical Evaluation
Pregnancy Test

-
Obstetrics
Gynecology
Implantation Failed pregnancy Ectopic pregnancy
Pediatric Pre-menopausal Post-menopasual
35
Positive Pregnancy Test

• Implantation bleeding
• Failed pregnancy
• Ectopic pregnancy
• Gestational trophoblastic disease

36
Implantation bleeding

• Passage of blood per vaginum following
  implantation
• Occurs at about time of expected menstrual period
• Typically ? flow volume

37
Failed pregnancy

• Complete abortion
• Incomplete abortion
• Missed abortion
• Threatened abortion
• Anembryonic pregnancy
• Ectopic pregnancy
• Gestational trophoblastic disease

38
Failed pregnancy