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• Metrorrhagia– bleeding which occurs at any time during the menstrual cycle
• Menometrorrhagia – heavy bleeding which occurs at any time during the menstrual cycle
• Dysmenorrhea – menstrual pain which interferes with activities of daily living (ADLs)
• Hypomenorrhea – extremely light menstrual flow
• Oligomenorrhea – menstrual periods which occur at intervals greater than 35 days

Dysfunctional Uterine Bleeding (DUB)

• Abnormal bleeding from the uterus without any problems found in the uterus.

Clinical Presentation

• Woman of any age
• Bleeding from the uterus that is not consistent with normal menstruation

Labs and Studies

• Blood work
  • CBC
  • Iron Studies
  • PT/PTT
  • beta hCG
  • FSH
  • Thyroid panel
• Pap smear
• Endometrial biopsy
• Pelvic U/S
• Hysteroscopy
• D&C

Treatment

• Blood loss
  • Watchful waiting
  • Iron replacement
  • IV fluids
  • Blood products
• Hormone therapy
  • Oral contraception
• D&C
• Endometrial ablation
• Hysterectomy

Fibroids

• Benign tumor of the uterus
• Most have no symptoms
• Clear genetic component

Risk factors

• African American
• Obesity
• Diabetes
• Hypertension
• Nulliparity
• Polycystic ovarian syndrome

Clinical Presentation

• Large mass in the lower abdomen which may be firm and irregular
• Menorrhagia
• Menorrhagia
• Menometrorrhagia
• Dysmenorrhea
• Dyspareunia
• Infertility or multiple spontaneous abortions
• Urinary frequency

Labs And Studies

• Pelvic U/S
• Pelvic MRI
• D&C
• Hysteroscopy
• Laparoscopy

Treatment

• Watchful waiting
• Medical
  • Gonadotropin releasing agonist ()GnRH agonist)
    • Leuprorelin (Lupron)
    • Causes an decrease in LH and FSH and thereby a decrease in estrogen
• Surgical
  • Myomectomy
  • Hysterectomy

Endometriosis

• Growth of endometrial tissue outside of the uterus
• Most commonly found on the ovaries

Clinical presentation

• Dysmenorrhea
• Dyspareunia
• Cyclic pelvic pain

Physical exam findings

• Pelvic tenderness
• Nodules in the pelvis
• Fixed uterus

Labs and Studies

• Pelvic U/S
• Exploratory laparoscopy
• Endometrial Biopsy
• Hysteroscopy

Treatment

• Medical
  • NSAIDS
  • Oral contraception
  • GnRh agonist
  • Danazol which has largely been replaced by GnRH agonists
• Surgical
  • Laparoscopic fulguration – destruction of tissue using high voltage electricity
  • Hysterectomy with bilateral salpingo oophorectomy

Endometrial Cancer

• The most common gyn malignancy in the United States

Clinical Presentation

• Abnormal uterine bleeding in 80-90% of cases
• Pelvic pain

Risk Factors

• Family history of colon cancer
• Advancing age
  • Postmenopausal women make up 75% of cases.
• Obesity
• Diabetes
• Polycystic ovarian syndrome
• Hypertension
• Unopposed estrogen stimulation
  • Nulliparity

Labs and Studies

• Beta hCG
• PAP smear is usually negative
• Vaginal and/or pelvic U/S
• Biopsy
  • Endocervical
  • Endometrial

Treatment

• Medical
  • For metastatic disease and recurrent disease high dose progestins may be helpful.
  • Radiation
  • Chemotherapy
• Surgery
  • Total hysterectomy and BSO with peritoneal lymph node and tissue sampling

Pelvic Organ Prolapse

• Uterine Prolapse
  • Ligaments and/or pelvic muscles which suspend the uterus are damaged or stretched often secondary to vaginal delivery though it may occur even to women without children
• Cystocele – bladder herniating into vagina
• Rectocele – rectum herniating into the vagina
• Enterocele – small intestine herniating into the vagina

Clinical Presentation

• Feeling of pelvic pressure
• Protrusion or bulge in or from the vagina
• Dyspareunia
• Difficulty emptying the bladder
• Incontinence

Treatment

• Non Surgical
  • Vaginal Pessary
  • Kegal’s
• Surgical
  • Vaginal surgery either with or without the use of mesh depending on the extent of the prolapse.
  • More extensive surgery including hysterectomy, sacrocolpopexy or uterosacral ligament suspension may also be necessary.