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Role of Ultrasound in the Evaluation of Abnormal Vaginal Bleeding in Nonpregnant Patients in Reproductive Age

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Role of Ultrasound in the Evaluation of Abnormal Vaginal Bleeding in Nonpregnant Patients in Reproductive Age 10.5005/jp-journals-10009-1233 BaileyLIFELONG Wilson, LEARNINGSanja Kupesic Plavsic Role of Ultrasound in the Evaluation of Abnormal Vaginal Bleeding in Nonpregnant Patients in Reproductive Age Bailey Wilson, Sanja Kupesic Plavsic ABSTRACT prolonged bleeding at irregular intervals. Polymenorrhea Abnormal uterine bleeding is defined as any alteration in the describes periods that occur more frequently than every 21 volume, pattern or duration of menstrual blood flow. Abnormal days, while oligomenorrhea describes periods that occur uterine bleeding can be due to a number of organic and every 35 days or more.4 dysfunctional causes. This article presents different case The menstrual cycle results from the choreographed scenarios of nonpregnant reproductive age patients presenting with abnormal genital tract bleeding. These cases will allow the actions of the hypothalamus, pituitary gland, ovaries and reader to identify differential diagnoses related to each scenario the uterus and its endometrial lining. Alterations in any of and to understand ultrasound findings typical for nonpregnant these factors can result in abnormal uterine bleeding. Causes patients presenting with abnormal vaginal bleeding. The role of of abnormal genital tract bleeding can include neoplastic B-mode and color Doppler ultrasound in the evaluation of abnormal uterine bleeding is described. Standard treatment growth within the uterus, hormonal dysfunction, infection, methods are also listed for each case. coagulopathy, endometrial abnormality and ovarian Keywords: Menorrhagia, Anovulatory cycle, Ovulatory cycle, dysfunction. In this article we will review the principles of B-mode ultrasound, Color Doppler ultrasound. ultrasound diagnosis of abnormal genital tract bleeding in How to cite this article: Wilson B, Plavsic SK. Role of reproductive age and apply it to the presented case studies. Ultrasound in the Evaluation of Abnormal Vaginal Bleeding in After completion of this case-based discussion the learners Nonpregnant Patients in Reproductive Age. Donald School J will be able to identify the differential diagnosis for Ultrasound Obstet Gynecol 2012;6(1):112-120. reproductive age abnormal genital tract bleeding, list the Source of support: Nil ultrasound findings typical for patients presenting with Conflict of interest: None declared anovulation, polycystic ovarian syndrome, functional cyst, breakthrough bleeding, submucosal fibroid, endometrial INTRODUCTION polyp and adenomyosis, and to identify the role of B-mode and color Doppler ultrasound in the diagnosis and treatment Abnormal genital tract bleeding can involve heavy or of these clinical entities. prolonged periods, frequent periods, intermenstrual bleeding, light periods, infrequent periods or the complete absence of CASE STUDIES periods.1 It is estimated that the prevalence of abnormal vaginal bleeding among women of reproductive age is as high Anovulation 2 as 30%. Being the single most common reason for A 23-year-old nulliparous obese female presents gynecological referral in the United States, it is estimated complaining of irregular menstrual periods since menarche that the annual direct and indirect economic costs of abnormal which began at age 12. Her last menstrual period was uterine bleeding in the United States in 2007 were 4 months ago. She also states that she suffers from severe 1,2 approximately $1 billion and $12 billion respectively. acne, which began at about the same time as her first period. Women with heavy periods work an estimated 3.6 fewer Overtime, she has also noticed a slow growth of hair on her weeks per year and lose an estimated $1,692 annually in wages face, chin and abdomen. 3 compared with other women in the general workforce. It is, She denies changes in her voice, changes in vision, thus, very important to recognize the underlying causes and headaches or nipple discharge. Her medical history is mechanisms for abnormal genital tract bleeding and to assess noncontributory. She states that she is not taking any and manage care appropriately. medication and is not sexually active. The female menstrual cycle consists of cyclic uterine On physical examination, she is markedly obese. Her bleeding that occurs approximately every 28 days, with a BMI measures 31. She has visible facial hair and abdominal normal range of 21 to 35 days. Normal uterine bleeding hair. On pelvic examination, no adnexal masses are noted. lasts 3 to 5 days with about 30 to 50 ml of blood loss per Laboratory studies revealed negative beta-hCG, normal cycle. Menorrhagia is the term used to describe heavy or TSH, normal prolactin and normal lipid profiles. Her FSH prolonged periods. Metrorrhagia is the term used to describe on day of 3 of the menstrual cycle was normal; however, intermenstrual bleeding. Menometrorrhagia is excessive or her LH was elevated. Her free testosterone was also elevated. 112 JAYPEE DSJUOG Role of Ultrasound in the Evaluation of Abnormal Vaginal Bleeding in Nonpregnant Patients in Reproductive Age with a thickened endometrium (Figs 1A to C). She is given medroxyprogesterone acetate and she reports that menstruation began 4 days later. A diagnosis of polycystic ovarian syndrome is made. She is advised to control her weight with diet and exercise. She is also given oral contraceptive pills to promote cyclic, predictable, menstrual periods. She is advised that if she wants to become pregnant at some point, she will need to stop the oral contraceptive pills and begin treatment with clomiphene citrate to induce ovulation.5 Cervicitis and Pelvic Inflammatory Disease (PID) A 26-year-old nulliparous woman presents complaining of Fig. 1A: Three-dimensional ultrasound/surface rendering of an a 6-week history of thick, yellow vaginal discharge as well ovary in a 23-year-old patient presenting with oligomenorrhea and hirsuitism. Note: More than 10 follicles at the periphery of enlarged as vaginal bleeding after intercourse. She also states that ovarian stroma intercourse is sometimes painful. She has multiple sexual partners and has been sexually active since age 14. She does not use any contraceptive methods. Her last menstrual period was 2 weeks ago and was normal. She denies fever, headaches, nausea, vomiting, abdominal pain, pelvic pain or dysuria. Her medical history is unremarkable. She is not currently on any medications. On physical examination, she does not appear to be in any acute distress, and her physical examination findings are within normal limits. However, speculum examination reveals a mucopurulent yellow discharge. Upon bimanual pelvic examination, she exhibits cervical motion tenderness and bilateral adnexal fullness. Laboratory studies revealed negative beta-hCG. Cervical cultures and DNA probes revealed coinfection with Fig. 1B: Transvaginal color Doppler ultrasound of the same Neisseria gonorrhea and Chlamydia trachomatis. patient. Note: Dilated intraovarian vessels Transvaginal B-mode and color Doppler ultrasound demonstrate dilated and fluid filled tubes (Figs 2A and B). She is given 1 gm azithromycin to treat both the Neisseria and the chlamydial infections. Her current partner is also treated and she is counseled on safe sex practices and condom use.6 Submucosal Fibroid A 42-year-old G4P3013 female complains of menorrhagia and dysmenorrhea for the past 6 months of her menstrual periods. Her periods occur every 28 days and used to last for 5 days, but are now lasting up to 10 to 14 days at a time. She states that she feels constantly tired and has episodes of dizziness and headaches throughout the days that she Fig. 1C: Three-dimensional image of diffusely thickened and bleeds. She takes ibuprofen for the headaches and the hyperechogenic endometrium in the same patient presenting with dysmenorrhea without relief. abnormal uterine bleeding She denies shortness of breath, chest palpitations and Pelvic ultrasound is performed and reveals polycystic blurry vision. She also denies nausea, vomiting, abdominal ovaries with a ‘string-of-pearls’ appearance and a uterus pain, diarrhea and constipation. Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2012;6(1):112-120 113 Bailey Wilson, Sanja Kupesic Plavsic 98.6° F. Her lungs are clear to auscultation bilaterally. Her abdomen is soft and nontender. On pelvic examination, the uterus is enlarged and no adnexal masses are palpated. Laboratory studies revealed negative beta-hCG. Her hemoglobin level is 9.5 gm/dl and her hematocrit is 25%. Transvaginal ultrasound showed a hypoechoic fibroid measuring 4 × 3 cm, originating from the inner layer of the myometrium (Fig. 3). Saline-infusion sonography revealed similar findings. Endometrial biopsy revealed secretory transformed endometrium. A diagnosis of uterine submucosal leiomyoma is made. She is given a GnRH agonist to attempt to shrink the leiomyoma prior to therapeutic hysteroscopy. Fig. 2A: Transvaginal ultrasound of dilated and fluid filled tube in a patient presenting with vaginal discharge and postcoital bleeding von Willebrand’s Disease A 15-year-old nulliparous female complains of menorrhagia, headaches, dizziness, shortness of breath and chest palpitations. She goes through a tampon every hour when she is menstruating and she feels so weak during her periods that she has to miss her high school classes. She says that these perimenstrual symptoms have been going on for quite a while, but that she feels these to be getting worse lately. Menarche began at age 13 and the patient states that she remembers her period to be consistently heavy
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