Year 3, 2nd Semester AY 2017-2018 // March 6, 2018

GYNECOLOGY
2.06 – Abnormal Uterine Bleeding
Dr. Raul M. Quillamor, FPOGS, FPSMFM, FPSUOG

OUTLINE  Relationship of Progesterone and Estrogen

o The first half of the menstrual cycle would be
I. Hormone Regulation of Menstrual Cycle predominantly influenced by estrogen, which stimulates
II. Cyclin Progestin for Anovulatory Bleeding the growth, proliferation and thickening of the functional
III. Characteristics of Menstruation layer of the endometrium.
IV. Abnormal Uterine Bleeding ▪ The endometrium with regards to the menstruation
V. Acute vs. Chronic AUB should only be focused on the functional layer -- the
VI. Etiologies of AUB zona functionalis which is further made up of two
A. Leiomyoma sublayers the zona spongiosa and zona compacta
B. Malignancy and Hyperplasia which are sloughed off during each menstrual cycle.
C. Coagulopathy ▪ After each menstrual cycle, the basal layer is left
D. Ovulatory Dysfunction behind, because it is where the new cells of the zona
E. Endometrial functionalis will come from.
F. Iatrogenic  During the first half of the cycle estrogen increases and at
G. Not Yet Classified around the 11th or 12th day of the cycle, estrogen levels go
VII. Cases down in concurrence with the increase in level of
progesterone.
OBJECTIVES  Progesterone stops the proliferation of the endometrium
during the first half of the cycle and makes it mature.
No objectives were given during the lecture.  Proliferation of the endometrium cells – Estrogenic
 Maturation of the Endometrium – Progestogenic
 From book (Lentz Compre Gyne) o If there is decreased progesterone in women, there will be
 From old trans (Dr. Nagtalon) no menstruation. The endometrium keeps on proliferating
 Highlighted by lecturer and continuously thickens at such time that it over grows
its blood supply – It is when women bleed.
I. HORMONE REGULATION OF MENSTRUAL CYCLE o With good progesterone level, during the 2nd half of the
cycle, progesterone continuously increases and at the
end of the cycle if there is no pregnancy, progesterone
levels go down and that is the time women menstruate.

II. CYCLIN PROGESTIN FOR ANOVULATORY BLEEDING

Figure 2: Biomolecular processes that occur with the withdrawal of

progesterone.

 Progesterone withdrawal will always lead to

menstruation. In a woman without progesterone withdrawal
there will be no menstruation.

In Progesterone Withdrawal:

Figure 1: Follicular Phase. Hormonal regulation of the menstrual • There will be an increase in IL8 and MCP
cycle. o Interleukin 8 - inflammatory substances

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 GYNE 2.06 : AUB (Dr. Quillamor)

o Monocyte Chemoattractant Protein (MCP) – protein III. CHARACTERISTICS OF MENSTRUATION

that dictates the migration of the monocytes and push
them to where they are needed. Table 1: POGS clinical practice guidelines on abnormal uterine
▪ Ex. If there is an inflammation in one particular part of bleeding 2013.
the body MCPs will dictate where monocytes should
take effect on. Clinical
• There will also be an Increase in Cox2 – Cyclooxygenase Dimensions of Normal limits
Descriptive
which will convert cholesterol to arachidonic acid and menstruation (5th to 95th
terms
subsequently to prostaglandin. and menstrual percentile)
o Results to increase in the different prostaglandins: cycle
▪ PGE2 – Prostaglandin Frequent <24 days
▪ TxA2 – Thromboxane Frequency of
Normal 24-38
▪ PgI2 – Prostacyclin menses (day)
• Increased leukocytic infiltration within the particular area of
Infrequent >38
the endometrium.
• Increase in Cox-2 and PGF2a will cause vasoconstriction Absent --
Regularity of
ending up with hypoxia. Regular Variation ± 2-20
menses, cycle-to-
• Hypoxia will stimulate the increase in the release of Vascular cycle variation
days
Endothelial Growth Factor (VEGF) and Kinase Insert over 12 months Irregular Variation > 20
Domain Receptor (KDR) which is an encoder of the VEGF.
This will result in the eventual increase of Matrix day
Metalloproteinases (MMPs) Prolonged >8.0
o MMPs destroys the extracellular matrix of any connective Duration of flow
(days)
Normal 4.5-8.0
tissue.
Shortened <4.5
 The withdrawal of progesterone triggers vasoconstriction
leading to hypoxia of the functional layer of endometrium. This Volume of >80
Heavy
will lead to necrosis and shedding of the layer during the monthly blood
Normal 5-80
menstrual period. loss (mL)
Light <5
 The blood vessels that supply the functional layer is called the
spiral arterioles and branch of the uterine artery supplying the
basal endometrium is called the straight arteriole.  Four main clinical dimensions of menstruation:
 The egg is released from the follicle at Day 14 in a 28-day o Frequency
cycle. The follicle from which the egg ruptured will then o Regularity
become a corpus luteum which secretes progesterone. The o Duration
corpus luteum will continue to secrete the hormone if o Volume
pregnancy takes place. However, if there is no pregnancy,
progesterone level goes down at Day 16 up to the end of the
IV. ABNORMAL UTERINE BLEEDING
cycle.
 End effect will be an hypoxic event which will lead to necrosis
• Occurs if without the growth limiting & organizing effects of
of the particular area of the endometrium including the blood
progesterone and lack of stromal support
vessels. The spiral arterioles will be cut off revealing open
• Focal areas breakdown heal other areas breakdown
ends, bleeding will come from these open ends.
and bleed
 Why is it in some women bleeding only occurs for 3 to 4 days
while is some women It occurs for up to 2 weeks? Because • In a woman who does not ovulate, meaning there is no proper
with each menstrual cycle in a normal woman three events balance of estrogen and progesterone.
take place, in a woman abnormally bleeding, these events do • With a rising estrogen level the follicle stimulating hormone will
not happen. not be able to stimulate the production of luteinizing hormone.
1. Vasoconstriction - diameter of blood vessels become There will be no ovulation in that particular cycle. Whether
smaller allowing adherence of platelets together causing there is no ovulation, you expect estrogen to be dominant
clot formation. because there is no progesterone.
2. Clot Formation o Because there is lack in LH which is responsible for the
3. Stabilization of Clot at the open end of the spiral arteriole production of progesterone.
 These events are very important to stop the bleeding in a  If there is no or very little progesterone present, you only have
normal individual, however, in a woman who has an AUB, one an estrogenic effect leading to a thickened endometrium, and
or two of these events do not happen. as earlier mentioned with continuous thickening the blood
supply cannot supply the blood demanded by the
endometrium. The demand is more than the supply leading to
HYPOXIA, and then NECROSIS and SLOUGHING OFF.
• In abnormal bleeding, the sloughing off and regeneration does
not occur at the same time as opposed with a normally

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menstruating individual where sloughing off occurs at the
same time with regeneration happening with a uniform rate.
o There is an unpredictable pattern resulting to prolonged
duration of bleeding.
V. ACUTE VS. CHRONIC AUB
• Acute AUB - sufficient quantity of bleeding; requires
immediate intervention to prevent further blood loss
o Patient is not hemodynamically stable, there is profuse
bleeding.
o Clinically this presents with tachycardia, decreased blood
pressure, cold clammy and pale patients.
o May need transfusion
 In women who are bleeding very heavily and are
hemodynamically unstable, the quickest way to stop acute
bleeding is with a curettage. This should also be the preferred
approach for older women and those with medical risk factors
for whom high-dose hormonal therapy might pose a great risk.
• Chronic AUB – abnormal in duration, volume, regularity
and/or frequency and has been present for the majority of the
last 6 months or more.
o With compensation
o Prolonged bleeding but with normal heart rate, normal
blood pressure, patient appears pale but everything
seems normal.
o Needs Iron preparation only
VI. ETIOLOGIES OF AUB
Structural Non- Structural
P olyp C oagulopathy
A denomyosis O vulatory dysfunction
L eiomyoma E ndometrial
alignancy and hyperplasia atrogenic
M I
N ot yet classified
• In general, the components of the PALM group are discrete
(structural) entities, with organic causes that can be measured
visually with imaging techniques and/or histopathology,
whereas the COEIN group is related to entities that are not
defined by imaging or histopathology (non-structural or non-
organic)
• PALM: Rarely seen during teenage years. Common during
reproductive, perimenopausal and post- menopausal period.
(Structural factors)
• COIEN: Can occur in any age. Example: If a 12-year old girl
comes to you with heavy vaginal bleeding, you would ask for
“COEIN” (Non-structural factors)
 REVIEW: Adenomyosis vs. Endometriosis
• Endometriosis is proliferation of endometrial tissue with gland
in any part of the body outside the uterus while Adenomyosis
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GYNE 2.06 : AUB (Dr. Quillamor)
is the presence of endometrial tissue and glands within the
myometrium.
A. Polyp
 Often asymptomatic
 These epithelial proliferations comprise a variable vascular,
glandular, fibromuscular, and connective tissue component
 The lesions are usually benign but a small minority may have
atypical or malignant features
 Polyps are categorized as being either present or absent, as
defined by 1 or a combination of ultrasound and hysteroscopic
imaging with or without histopathology.
 Why is there excessive bleeding? Because there is excess
tissue to be sloughed off.
B. Adenomyosis
 Seen in women in the reproductive or pre-menopausal stages
in women
 Defined as presence of endometrial glands in the myometrium
 Adenomyosis is derived from aberrant glands of the basalis
layer of the endometrium
 Anatomic uterine abnormalities such as submucous myomas,
endometrial polyps, and adenomyosis frequently produce
symptoms of prolonged and excessive regular uterine
bleeding. This is probably secondary to abnormal vasculature
and blood flow, as well as increased inflammatory changes
 The disease is associated with increased parity, particularly
uterine surgeries and traumas. The pathogenesis of
adenomyosis is unknown but is theorized to be associated with
disruption of the barrier between the endometrium and
myometrium as an initiating step.
C. Leiomyoma
• Increased surface area of the endometrium will cause heavy
bleeding
 Leiomyomas, also called myomas, are benign tumors of
muscle cell origin. These tumors are often referred to by their
popular names, fibroids or fibromyomas, but such terms are
semantic misnomers if one is referring to the cell of origin.
 Most leiomyomas contain varying amounts of fibrous tissue,
which is believed to be secondary to degeneration of some of
the smooth muscle cells.
 Risk factors associated with the development of myomata
include increasing age, early menarche, low parity, tamoxifen
use, obesity, and in some studies a high-fat diet.
 Although leiomyomas arise throughout the body in any
structure containing smooth muscle, in the pelvis the majority
are found in the corpus of the uterus.
 Initially most myomas develop from the myometrium,
beginning as intramural myomas. As they grow, they remain
attached to the myometrium with a pedicle of varying width and
thickness. Small myomas are round, firm, solid tumors.
 Continued growth in one direction determines which myomas
will be located just below the endometrium (submucosal) and
which will be found just beneath the serosa (subserosal).
 GYNE 2.06 : AUB (Dr. Quillamor)

 Anovulatory bleeding occurs most commonly during the

Figure 3: Leiomyoma sub classification system.
Table 2: Leiomyoma sub classification system
extremes of reproductive life 
o Adolescent – immaturity of the hypothalamic-pituitary-
ovarian (HPO) axis and failure of positive feedback of
estradiol 
o Perimenopausal woman – lack of synchronization
between the components of HPO axis 
 Pattern of anovulatory bleeding is probably related to
variations in the integrity of the endometrium and its support
structure. 
 20% of women with normal menses may also be anovulatory 

Causes:

• Obesity
• Low body weight: determine BMI
• Sudden weight change: hormonal imbalance between
estrogen (more dominant) and progesterone  AUB
• Psychological stress
• Elite athletes
• Endocrinopathy
• Idiopathic
• Hypothyroidism
D. Malignancy and Hyperplasia • PCOS/hyperandrogenic disorder: most common now
because of obesity or overweight
• Hyperplasia: forerunner of malignancy • Luteal out of phase cycles
o Endometrial hyperplasia with atypia: continue to
become a malignancy (result in destruction of G. Endometrial Disturbances
myometrium and adjacent myometrial surface) 
more bleeding and foul-smelling discharge from  Caused by disturbance in endometrial function- deficiencies or
endometrial cavity other entities that have an adverse impact on hemostasis
o W/o atypia • Usually inflammatory process e.g. endometritis
• Endometrial hyperplasia is believed to result from an excess • History of instrumentation e.g. abortion  infection of
of estrogen or an excess of estrogen relative to progestin, such endometrium
as occurs with anovulation  Prolonged or heavy bleeding can occur with abnormalities of
the platelet plug or inadequate uterine levels of PGF2a or
E. Coagulopathy excessive production of PGE 
 Endothelins and vascular endothelial growth factor (VEGF)
may be abnormal in some women with heavy menstrual
• Higher incidence of Von Willebrand disease and thalassemia
bleeding. Subclinical infection with Chlamydia trachomatis has
because of inter-racial marriages of Filipino with other races also been associated with AUB 
(e.g. European or Mid-Eastern) 
• 13% of women with HMB have a disorder of hemostasis that H. Iatrogenic
may be overlooked during the differential diagnosis.
 Present in approximately 25% of those whose Hg levels fall • Medications cause iatrogenic UB
below 10 g/100 mL
• Aspirin for RHD, anti-coagulants, see diagram
 Disorders of platelet are most often quantitative
 Rare inherited coagulopathies of the clotting factors (V, VII, X,
XI, XIII) include menorrhagia as potential symptom. Systemic
 Chronic anticoagulation as a result of heparin, low-molecular- Pharmacotherapy
weight heparin, direct thrombin inhibitors, and direct factor Xa
inhibitors are necessary for prevention of thrombosis in women
Gonadal Others
with inherited thrombophilias Steroids

F. Ovulatory Dysfunction
Testosterone Tricyclic Anti-
Depressants
• Most common: nutritional and hormonal
 Predominant cause in post-menarchal and premenopausal Estrogens
women is secondary to alterations in neuroendocrine function.  Phenothiazines
 Continuous estradiol production leads to a continuously
proliferating endometrium, which may outgrow its blood supply
Progestins
or lose nutrients with varying degrees of necrosis. 

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 GYNE 2.06 : AUB (Dr. Quillamor)

I. Not Yet Classified o Small uterus

o Thin endometrium
 Ask questions to rule in or out the conditions in the o Normal ovaries
PALM and COEIN to diagnose the etiologic factor of AUB o Remember: You cannot do transvaginal ultrasound
• Diagnose by tests such as AVM using Doppler Colorflow without consent on a minor/child. Instead, you can do
Mapping transabdominal ultrasound with full bladder or transrectal
• AVM scan.
• Myometrial Hypertrophy
• Associations with some other diseases
• Other
 Abnormal bleeding resulting from medications.
 The most common of these are hormonal preparations
including SERM and GnRH Agonists and Antagonists.
 All hormonal long-acting reversible contraceptives result in
some degree of anovulation and irregular or intermenstrual
bleeding.
 Hyperprolactinemia can result from CNS Dopamine
antagonism of certain antipsychotic drugs.
 It is well-known that commonly combined and POPs may result
in breakthrough bleeding (BTB)

VII. CASES

A. G.M. 17 y/o

• CC: profuse menstrual bleeding of 10 days, soaking 4-5
pads/day (before 2 pads/day)
• Menstrual Hx: Menarche – 11 y
1. What additional pertinent data in the clinical history and
physical examination should be elicited?
HISTORY AND PHYSICAL EXAMINATION
• BMI – determine BMI
• Heavy menstrual bleeding since menarche
 History of easy bruising, gum bleeding, epistaxis (Important
since one of the most common etiology of AUB in teenagers is
COAGULOPATHY)
• History of systemic diseases
• Family history of hematologic disorders
• Intake of medications
• Sexual history
• Evaluate for presence of bruises, sites of bleeding in the body
Figure 6: Ultrasonogram of the patient’s uterus (transabdominal
scan).
3. What is your diagnosis?
Abnormal Uterine Bleeding probably secondary to ovulatory
dysfunction (anovulatory menses) (AUB-O1)
Remember COIEN:
Coagulopathy – coagulation parameters are normal. Rule Out.
Endometrium – ultrasound showed thin endometrium and patient
is not sexually active. Rule Out.
Iatrogenic – No medications taken. Rule Out.
Not yet classified – Not associated with other diseases. Rule Out.
4. Is this pattern of bleeding expected in the patient? Why?
Yes because there is immaturity of the HPO axis – Irregular
menses are common in the first few years following menarche

2. What laboratory examinations should be requested? Why? 5. What are the differential diagnoses:
LABORATORY TESTS (All values given is for Case A) • Coagulation disorders
 CBC with BLOOD TYPING & RH TYPING • Platelet disorders
o Hgb 102g/dL • Platelet dysfunction secondary to drugs
o Hct 0.30 • Dengue hemorrhagic fever
o Platelet 250 • Congenital anomalies/malfunction of reproductive organs/tract
• Pregnancy test / Serum HCG • Stress
o Negative
 Any woman with vaginal bleeding in the reproductive age 6. What are the objectives in the management of this patient?
should be suspected as pregnant until proven otherwise • Short-term
o Serum HCG if entertaining molar pregnancy • Long-term
• Coagulation Profile “We have to differentiate acute and chronic because we also have
o PT: 13.5 (Ref: 14) a short term and long term plan. For acute management (short-
o % activity: >1 term), our objective is to control the bleeding. We want to control
o INR: 0.96 the bleeding because we wanted to prevent anemia.”
o aPTT: 21.1 (ref: 30.6)
• Transabdominal Ultrasound

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 GYNE 2.06 : AUB (Dr. Quillamor)

“We may have stopped the bleeding now but it may recur the next
month or the next year. We want to prevent the recurrence of the
problem which would be the long-term goal.”

7. What is the appropriate management for the patient?

• Assurance
o “You want to assure not only the patient but also the
parents.”
o “You want to assure them that it is a normal physiologic
process that your daughter has to undergo to prevent
recurrence of this problem.”
• Proper nutrition
o “If patient is obese, advise the parents to modify the diet
of the patient”
• Adequate fluid intake
• Regular exercise
• Adequate rest
Figure 8: Algorithm for diagnosing abnormal uterine bleeding
• Proper hygiene based on the age of the patient. If there is abnormal uterine
• Positive body image bleeding during puberty, then blood dyscrasias and coagulopathy
• Positive outlook in life should be ruled out. For reproductive age and some
 Counselling session may last an hour, it may be more perimenopausal women, don’t forget to use pregnancy test to rule
important than what you give her medication-wise out pregnancy. In postmenopausal women who came in with
• Vitamin/mineral supplementation profuse bleeding, the problem could be secondary to malignancy
 Tranexamic acid 1g, 4x a day, using 3-5 days for profuse either in the cervix or the endometrial cavity. You should know
bleeding when to refer to a gynecologist and not manage it on your own.
o Antifibrinolytic agent
o Warn the patient to take it on a full stomach because it is If heavy menstrual bleeding is encountered:
a gastric irritant In idiopathic AUB, the first line treatment is medical, with efficacy
o “We used to give pure estrogen preparation that would ranked as follows:
stop the bleeding. But the drug was discontinued and has  Levonorgestrel IUD (Grade A) – most effective
off the market for several years because it can stimulate • Tranexamic acid (Grade A)
endometrial and breast cancer.” • Oral contraceptives, estrogens and/or progestins (Grade B)
 Management Algorithm • NSAIDS (Grade B)
o NSAID is a drug that inhibits cyclooxygenase (COX)
Diagnosis Pregnancy Test o COX convert arachidonic acid to prostaglandins
o Vasoconstriction requires thromboxane which in contrast
No structural Polycystic ovary with prostacyclin which is a vasodilator
cause syndrome  But why do we have to give NSAID if we need
Pelvic thromboxane? If we give NSAID, theoretically it will
Ultrasound Cervical decrease both thromboxane and prostacyclin. But if we
Pelvic masses take a look in the ratio between thromboxane and
Endocrine
conditions prostacyclin, both of these would go down but the effect
Uterine
will be more on prostacyclins, in which thromboxane will
Figure 7: Management Algorithm. When we diagnose AUB we do be relatively higher than prostacyclin with the net effect
pregnancy test, pelvic ultrasound and test for some endocrine of vasoconstriction
conditions and other possible diseases. If there is no structural • Synthetic progestins (Grade B)
cause, it could be polycystic ovary syndrome especially if you are o We can give this from day 1 to 21
dealing with reproductive age women. With pelvic masses, you o Or we can give it from the first to the tenth day of each
must rule out if there is a cervical or uterine origin month
o Or from day 16 to 25 of each cycle
o To be given for 6 months after which patient should be
evaluated

“Not because the patient is profusely bleeding, you

immediately operate. Surgical management should always be
the last option. Try the medical option first, control the
bleeding, and make sure that there is no recurrence of the
problem."

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 GYNE 2.06 : AUB (Dr. Quillamor)

Progestins preferred over COCs if with contraindication o Sonohyterogram, HSG (Hysterosonography)

• History of thrombosis o Endometrial biopsy
• Advanced DM or liver disease ▪ Complex Atypical Hyperplasia, Endometrium
• Smokers >35 years of age o Hysteroscopy
• Uncontrolled hypertension
• Headaches with neurological manifestations
• Known/suspected breast, endometrial, vaginal, or cervical
cancer

B. J.T 55 y/o (from 2018A trans – not discussed)

History & PE
• This is a case of J.T., 55 yrs. old, G0, 2 yrs. post-menopause
• CC: postmenopausal, post-coital bleeding of 2 mos.
Past and Family Hx:
• (+) DM type 2
• (+) Hypertension
• Mother has DM
Personal History
Figure 9: Transvaginal ultrasound. Indicative of endometrial
• Pap smear: (-) for intraepithelial lesion/malignancy
hyperplasia, but endometrial malignancy should be ruled out.
P.E.
Advise patient to undergo endometrial biopsy.
• VS within normal
• BMI: 40 kg/m2 3. What is your diagnosis?
• Essentially normal systemic findings • Abnormal Uterine Bleeding, rule out malignancy AUB-M1
Speculum Examination 4. What is the appropriate management for the patient
• Vagina and cervix pink & smooth • Iron supplementation
• (-) lesion/discharge • For profuse bleeding: Tranexamic acid 1 g. 4x/day, 3-5 days
Pelvic Examination o Remember this is not a definitive treatment, This controls
• Normal external genitalia, smooth vagina bleeding and prepares patient for endometrial biopsy
• Cervix 3x2 cm, smooth and non-tender 5. When should this patient be referred to a gynecologist?
• Uterus retroverted and small • 4 to 6 weeks in between periods is considered normal during
• No adnexal masses, nodulations, parametria smooth and the transition. But if the cycles are less than 21 days, one
pliable should consult.
• Very heavy bleeding lasts for more than a week or if bleeding
1. What other pertinent data in the clinical history and physical occurs after being period-free for 6 months
examination should be elicited? • If spotting or bleeding occurs every week for 2 weeks or in
• Onset, frequency, duration, severity between periods.
• Family history of malignancy
• Intake of medication (HRT, OCP) SUMMARY
• History of anovulation
* With post-menopause. Remember PALM. More organic cases.  Appropriate evaluation should be done
 Major causes should be identified (remember PALM COIEN)
2.What laboratory examinations should be requested? Why?  Progestins play an important role
• CBC with BLOOD TYPING and RH TYPING  Patient education on nutrition and micronutrient
o Hgb: 102 g/dL supplementation must be a part of preconception preventive
o Hct: 0.30 management for those who desire to get pregnant
o Platelet: 250  The first thing that affects the patient is anemia which may
• Transvaginal Ultrasound affect the patient’s quality of life
o Uterus retroverted, with smooth contour and
homogenous (normal dimensions) REFERENCES
o Endometrium 1.8 cm thick, hyperechoic, with cystic
spaces (* Normal: 0.3 cm/3 mm, more than that is not
• Lentz Comprehensive Gynecology 6th Edition
normal)
• Dr. Quillamor’s Lecture and PPT
o No adnexal masses
o No fluid in the cul de sac • 2018 A/B Trans
• Confirmatory Tests
o HCG assay
o TSH, prolactin

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 GYNE 2.06 : AUB (Dr. Quillamor)

GUIDE QUESTIONS (approximately 12 weeks gestation size). Pregnancy test was

negative. What is the first step in diagnosis?
a. Hysterectomy
1. Which of the following agents used in cessation of menstruation
b. MRI
is decreased in anovulatory abnormal uterine bleeding?
c. Pelvic sonogram
a. Fibrin
d. Saline infusion sonohysterography
b. Thromboxane
13. A 40 y/o G3P3 complained of heavy menses of 10 days duration.
c. Matrix metalloproteinase
Past 3 menstrual cycles were heavy and lasted 3-4 days. She had
d. Vascular endothelial growth factor
been on insulin-sensitizer for 2 years with good glycemic control.
2. Which of the following is the least important in the evaluation of
PE and pelvic findings were within normal. Pelvic sonogram
abnormal uterine bleeding?
showed thickened endometrial stripe. What is the next step in the
a. Duration
management?
b. Amount
a. Endometrial biopsy
c. Frequency
b. High dose estrogen therapy
d. Pain
c. IV anti-fibrinolytics
3. Which of the following is an effect of estrogen on the
d. Saline infusion sonohysterography
endometrium?
14. A 30 y/o has heavy menstrual bleeding. Endometrial biopsy done
a. Leukocyte influx in the upper endometrial zones
at day 25 of cycle revealed proliferative endometrium. What is the
b. Regrowth of the endometrium
indicative of?
c. Subnuclear vacuolization of the gland linings
a. Anovulatory AUB
d. Upregulation of the inflammatory mediators
b. Endometrial atrophy
4. What event precedes menstruation?
c. Normal menstrual endometrium
a. Estrogen withdrawal
d. Ovulatory AUB
b. FSH peak
c. LH surge
d. Progesterone withdrawal BDBDA DDDC 4-8 days CCAA
5. What is the function of progesterone in normal menstruation?

“The best preparation is doing your

a. Increase in vascular growth
b. Opposes growth
c. Selective shedding
6. What is the hormone responsible for transformation of the
endometrium from proliferatory to secretory phase?
a. FSH
best today.”
b. LH
c. Estrogen
d. Progesterone
7. Who among the following is at highest risk for having abnormal
menstrual pattern?
a. An 18 y/o adolescent with menarche at 14 y/o
b. A health conscious reproductive-aged individual
c. A middle-aged long distance marathon runner
d. A 45 y/o with BMI of 35
8. Which of the following systemic diseases can present with
abnormal uterine bleeding?
a. Chronic hypertension
b. Hyperprothrombinemia
c. Hyperthyroidism
d. Liver cirrhosis
9. Which of the following information in a 14 y/o with heavy
menstrual bleeding will raise the possibility of an underlying
coagulation disorder?
a. Age of menarche
b. Duration of menses
c. Heavy menses since menarche
d. Intermenstrual bleeding
10. What is the acceptable duration of menses in a woman of
reproductive age?
11. Which condition can explain cyclic heavy menstrual bleeding in
the absence of a structural pathology, in a reproductive-aged
woman?
a. Diabetes
b. Endometrial atrophy
c. Endometrial hemostatic dysfunction
d. Hypothyroidism
12. A 35 y/o has cyclic heavy menstrual bleeding for the past 6
menstrual cycles associated with progressive dysmenorrhea. PE
showed pallor: BMI=25, BP=110/70, HR=100/min. Pelvic exam
revealed small, firm cervix and a homogenously enlarged uterus

8 of 8 || De New Group 7: DE GUZMAN, DE MESA, DELA CRUZ, DELOS REYES, DELOS SANTOS
Subject Trans Heads: ABAD | MAGRACIA