ENFOQUE PARA EL SANGRADO UTERINO ANORMAL EN LAS MUJERES EN EDAD REPRODUCTIVA NO EMBARAZADAS.docx

8/18/2019 ENFOQUE PARA EL SANGRADO UTERINO ANORMAL EN LAS MUJERES EN EDAD REPRODUCTIVA NO EMBARAZADAS.d…

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ENFOQUE PARA EL SANGRADO UTERINO ANORMAL EN LAS MUJERES EN EDADREPRODUCTIVA NO EMBARAZADAS

Autor Andrew Kaunitz M, MDEditores de secci!

Robert L Barbieri, MDDeborah Levine, MDSu"editorde arena J Falk, MD, FACOG

Re#isi! de $% $iter%tur% corrie!te % tr%#&s de' febrero de !"#$ % Este te(% )ue %ctu%$i*%d%e$ "& de A'o de !"($

INTRODUCCI+N ) *an'rado uterino anor+al -.A/ un t0r+ino 1ue *e refiere al *an'rado

+en*trual anor+al de la 2antidad, la dura2i3n, o el 4ro'ra+a/ e* una 1ue5a 'ine2ol3'i2a

2o+6n, re4re*entando un ter2io de la* vi*ita* a+bulatoria* a lo* 'ine23lo'o* 7 " 8$ A.B 4uede

*er 2au*ada 4or una a+4lia variedad de enfer+edade* lo2ale* 9 *i*t0+i2a* o rela2ionada 2on

+edi2a+ento* fi'ura " / 7 8$ La* etiolo':a* +;* 2o+une* en la* +u5ere* no e+barazada*

*on 4atolo':a* e*tru2turale* del 6tero 4or e5e+4lo, fibro+a*, 43li4o* endo+etriale*,

adeno+io*i*/, anovula2i3n, tra*torno* de la he+o*ta*ia, o neo4la*ia$

9 >=i*i3n 'eneral de la

etiolo':a 9 la evalua2i3n de *an'rado va'inal en +u5ere* e+barazada*> $/

TERMINOLOG,A ) .n *i*te+a revi*ado la ter+inolo':a de *an'rado uterino anor+al -.A/en +u5ere* en edad re4rodu2tiva no 'r;vida* fue introdu2ido en !"" 4or la Federa2i3n

?nterna2ional de Gine2olo':a 9 Ob*tetri2ia F?GO/ 7 @ 8$


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leio+io+a* uterino* =er > $/

43li4o* endo+etriale* =er >43li4o* endo+etriale*> $/

La adeno+io*i* =er >adeno+io*i* uterina> $/

Otra* le*ione* ) defe2to de 2i2atriz de 2e*;rea, +alfor+a2i3n arterioveno*a

di*fun2i3n ovulatoria A.B)O/ =er Hdi*fun2i3n ovulatoria *an'rado irre'ular/ > a

2ontinua2i3n 9 > Dia'n3*ti2o diferen2ial de la he+orra'ia del tra2to 'enital en la* +u5ere*

>, en la *e22i3nH di*fun2i3n ovulatoria H /$

Lo* tra*torno* he+orr;'i2o* =er >A4roIi+a2i3n al 4a2iente adulto 2on una di;te*i*

he+orr;'i2a>, en la *e22i3n >La +enorra'ia H /$

iatro'0ni2a 4or e5e+4lo, anti2oa'ulante*, anti2on2e4tivo* hor+onale*, di*4o*itivo*

intrauterino* 7D?.8/ ) A.B e* 2o+6n en la* +u5ere* 1ue lo* anti2on2e4tivo* de

4ro'e*t;'eno *olo, *obre todo al 4rin2i4io 9 lo* u*uario* 4ueden lle'ar a de*arrollar

a+enorrea$ =0a*e >Ge*ti3n de *an'rado no 4ro'ra+ado en +u5ere* 1ue u*an +0todo*

anti2on2e4tivo*> $/

eo4l;*i2a* hi4er4la*ia endo+etrial o 2ar2ino+a o *ar2o+a uterino/ =er >Cla*ifi2a2i3n 9 dia'n3*ti2o de

hi4er4la*ia de endo+etrio> 9 >el *ar2o+a uterinoE 2la*ifi2a2i3n, +anife*ta2ione* 2l:ni2a* 9

el dia'n3*ti2o> $/

La infe22i3n 9 la infla+a2i3n ) La endo+etriti*, enfer+edad infla+atoria 40lvi2a =er >La

endo+etriti* rela2ionado* 2on el e+barazo> 9 >enfer+edad infla+atoria 40lvi2aE

+anife*ta2ione* 2l:ni2a* 9 dia'n3*ti2o> $/

Lo* tra*torno* de la he+o*ta*ia endo+etrial lo2al v0a*e >Dia'n3*ti2o diferen2ial de la

he+orra'ia del tra2to 'enital en la* +u5ere*>, en la *e22i3n de Htra*torno* de he+o*ta*ia

endo+etriale* lo2ale*H $/

EVALUACI+N INICIAL )


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$/


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La edad 4ro+edio de la +eno4au*ia e* de &" ao* 7 N 8$ La +eno4au*ia *e define 2o+o "

+e*e* de a+enorrea en au*en2ia de otra* 2au*a* biol3'i2a* o fi*iol3'i2a*$ $/

La* +u5ere* 2on A.B 1ue no han tenido la a+enorrea durante " +e*e* deben *er

2on*iderado* ante* de la +eno4au*ia 2on el 4ro43*ito de la evalua2i3n, 4ero deben tener to+a

de +ue*tra* endo+etriale* *i lo* fa2tore* de rie*'o del 2;n2er de endo+etrio e*t;n 4re*ente*

tabla @ 9 la tabla ( /$ odo *an'rado 4o*+eno4;u*i2o e* anor+al, 9 re1uiere una evalua2i3n

4ara el 2;n2er de endo+etrio$ =er >he+orra'ia uterina 4o*+eno4;u*i2a> 9 >to+a de +ue*tra*

endo+etriale* H a 2ontinua2i3n/$

6E$ 3%cie!te est5 e("%r%*%d%2 ) odo* lo* 4a2iente* 2on A.B deben tener una 4rueba de

e+barazo$ La hi*toria de lo* 6lti+o* 4er:odo* +en*truale* *e deber:a 4oder 2ontar 4ara

obtener una idea de *i la +en*trua2i3n *e retra*a$ -in e+bar'o, la* 4rueba* de e+barazo deberealizar*e in2lu*o en +u5ere* 2on *an'rado va'inal re2iente, 9a 1ue e*to 4uede re4re*entar

una he+orra'ia durante el e+barazo en lu'ar de la +en*trua2i3n$ a+bi0n *e debe realizar en

la* +u5ere* 1ue indi1uen 1ue no tienen a2tividad *eIual 9 en lo* 1ue infor+an el u*o de

anti2on2e4tivo*$

La* +u5ere* 1ue e*t;n e+barazada* *on evaluada* 4rin2i4al+ente 4or 2au*a* rela2ionada*

2on el e+barazo de la he+orra'ia, 4ero la evalua2i3n debe in2luir la evalua2i3n de la*

etiolo':a* no rela2ionado* 2on el e+barazo *i e* a4ro4iado$ =er >De*2ri42i3n 'eneral de la

etiolo':a 9 la evalua2i3n de *an'rado va'inal en +u5ere* e+barazada*> $/

U!% e#%$u%ci! (5s 3ro)u!d% )


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'ine2ol3'i2a 9 ob*t0tri2a de la hi*toria, in2lu9endoE

La hi*toria +en*trual$ =er >La hi*toria +en*trual H a 2ontinua2i3n/$

i*toria *eIual ) 4rueba*

endo2rina* H a 2ontinua2i3n 9 > ato'0ne*i*, la e4ide+iolo':a 9 la* +anife*ta2ione*

2l:ni2a* de la enfer+edad 2el:a2a en adulto* >, a4artado de lo*> +anife*ta2ione* no

'a*trointe*tinale*H /$

La enfer+edad 2el:a2a$ =er >La 4ato'0ne*i*, e4ide+iolo':a 9 +anife*ta2ione*

2l:ni2a* de la enfer+edad 2el:a2a en adulto*>, en la *e22i3n H+en*trual 9 4roble+a*

re4rodu2tivo*H $/

Medi2a+ento* ) Lo* +edi2a+ento* 4ueden 2au*ar A.B en una variedad de +anera*E

"/ lo* anti2oa'ulante* 4ueden 2au*ar *an'rado uterino 4rofu*o o 4rolon'ado/ una

variedad de +edi2a+ento* 4uede 2au*ar hi4er4rola2tine+ia tabla # /, re*ultando en

oli'o+enorrea o a+enorrea$

4re'unta* adi2ionale* 1ue 4ueden a9udar a *u'erir una etiolo':a in2lu9enE

Fueron fa2tore*, tale* 2o+o el trau+a no 4re2i4itante* e+orra'ia rela2ionada 2on el

trau+a *u'iere una va'inal o 2ervi2al, uterino en lu'ar de, ori'en del *an'rado$

a9 *:nto+a* a*o2iado* Ba5o el dolor abdo+inal, fiebre, 9 P o flu5o va'inal 4odr:a

indi2ar una infe22i3n enfer+edad infla+atoria 40lvi2a 7?D8, endo+etriti*/$Di*+enorrea,

di*4areunia o infertilidad *u'ieren endo+etrio*i* 9 adeno+io*i* 4o*ible$ Lo* 2a+bio* en

la ve5i'a o la fun2i3n inte*tinal *u'ieren he+orra'ia uterina eItrauterino o un efe2to de

+a*a de una neo4la*ia$ Gala2torrea, 2alor o intoleran2ia al fr:o, hir*uti*+o, o *ofo2o*

*u'ieren un 4roble+a endo2rinol3'i2o$

http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H196131http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women/abstract/8http://www.uptodate.com.sci-hub.io/contents/copper-intrauterine-device-drug-information?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/management-of-unscheduled-bleeding-in-women-using-contraception?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/management-of-unscheduled-bleeding-in-women-using-contraception?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16090927http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16090927http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H10390722http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16850399http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16850399http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Nongastrointestinal+manifestations&anchor=H17#H17http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Nongastrointestinal+manifestations&anchor=H17#H17http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Nongastrointestinal+manifestations&anchor=H17#H17http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Menstrual+and+reproductive+issues&anchor=H33#H33http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Menstrual+and+reproductive+issues&anchor=H33#H33http://www.uptodate.com.sci-hub.io/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults?source=see_link&sectionName=Menstrual+and+reproductive+issues&anchor=H33#H33http://www.uptodate.com.sci-hub.io/contents/image?imageKey=ENDO%2F75914&topicKey=OBGYN%2F3263&rank=1~150&source=see_link&search=hemorragia+uterina+annormal+en+perimenopausicahttp://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H196131http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women/abstract/8http://www.uptodate.com.sci-hub.io/contents/copper-intrauterine-device-drug-information?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/management-of-unscheduled-bleeding-in-women-using-contraception?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/management-of-unscheduled-bleeding-in-women-using-contraception?source=see_linkhttp://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16090927http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16090927http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H10390722http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausica&selectedTitle=1~150#H16850399http://www.uptodate.com.sci-hub.io/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women?source=search_result&search=hemorragia+uterina+annormal+en+perimenopausic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-e ha realizado una enfer+edad re2iente, el e*tr0*, el e5er2i2io eI2e*ivo, o 4o*ible

tra*torno de la ali+enta2i3n


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volu+en 9 la dura2i3n de la he+orra'ia o *an'rado entre 2:2li2a 9

anovulatorio$ =er Hter+inolo':aH+;* arriba/$

La* 2au*a* +;* 2o+une* de MB *onE

leio+io+a* uterino* ) MB a*o2iado 2on leio+io+a* uterino* e* +;* 4robable 1ue

o2urra 2on leio+io+a* *ub+u2o*o*, 4ero leio+io+a* en otro* *itio* ta+bi0n 4uede

2au*ar A.B$ =er > $/

La adeno+io*i* ) adeno+io*i* uterina> $/

defe2to 2e*;rea 2i2atriz ) Alrededor de do* ter2io* de la* +u5ere* 1ue han tenido uno o

en 4arti2ular/ +6lti4le* 4arto* 4or 2e*;rea 4ueden tener un defe2to 2i2atriz de una

2e*;rea, 9 a4roIi+ada+ente un ter2io de la* +u5ere* 2on e*ta 2ondi2i3n la eI4erien2ia

2:2li2a, *an'rado 4o*t)+en*trual 7 " 8$

ra*torno he+orr;'i2o$ =er HH La* 4rueba* de 2oa'ula2i3n de aba5o$/

Otra* etiolo':a* a*o2iada* 2on MB in2lu9enE

La hi4er4la*ia endo+etrial o 2ar2ino+a o, en rara* o2a*ione*, el *ar2o+a uterino

4ueden e*tar a*o2iado* 2on MB, 4ero el 4atr3n de *an'rado t:4i2o 4ara e*ta*

2ondi2ione* e* *an'rado irre'ular o de*4u0* de la +eno4au*ia$ =er > 9 >anti2on2e4tivo intrauterinoE Di*4o*itivo*, 2andidato*, 9 la *ele22i3n> $/

43li4o* endo+etriale*, endo+etriti*, o 9 >endo+etriti*

4o*4arto> 9 >La endo+etriti* rela2ionado* 2on el e+barazo> $/

+alfor+a2i3n arterioveno*a uterina 2on'0nita o ad1uirida )


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2o+6n en "N" +u5ere* 2on hi4otiroidi*+o 1ue en "( 2ontrole* *ano* N frente a " 4or 2iento/,

4ero la 4ro4or2i3n de +u5ere* 2on e*te *:nto+a fue ba5a 7 @ 8$ =er >La* +anife*ta2ione*

2l:ni2a* del hi4otiroidi*+o>, a4artado de lo* >anor+alidade* re4rodu2tiva* H 9 H 4rueba*

endo2rina* H aba5o$/$

Otra* 2au*a* de MB *e enu+eran en la tabla tabla Q /$

E$ s%!.r%do i!ter(e!stru%$ ) *an'rado uterino inter+en*trual 4uede e*tar rela2ionado 2on

una variedad de etiolo':a* 2uadro "! /, in2lu9endoE

43li4o* endo+etriale*$ =er >43li4o* endo+etriale*> $/

*an'rado no 4ro'ra+ado debido a un +0todo anti2on2e4tivo$ =0a*e >Ge*ti3n de

*an'rado no 4ro'ra+ado en +u5ere* 1ue u*an +0todo* anti2on2e4tivo*> $/

La hi4er4la*ia endo+etrial o 2ar2ino+a o, en rara* o2a*ione*, el *ar2o+a

uterino$ =er > 9 >La

endo+etriti* rela2ionado* 2on el e+barazo> 9 >endo+etriti* 4o*4arto> 9 >ni2ho> de*4u0* del 4arto 4or 2e*;rea/ =er >, *e22i3n *obre

HLa* +anife*ta2ione* 2l:ni2a* > 9 > ano+al:a* 2on'0nita* 2ervi2ale* 9 le*ione* 2ervi2ale*

beni'no* >, a4artado de lo*> 43li4o* > 9 > ano+al:a* 2on'0nita* 2ervi2ale* 9 le*ione* 2ervi2ale*

beni'no* >, en la *e22i3n> La 2ervi2iti* > 9 > ano+al:a* 2on'0nita* 2ervi2ale* 9 le*ione*

2ervi2ale* beni'no* >, en la *e22i3n He2tro4i3nH /$

E$ s%!.r%do irre.u$%r 8dis)u!ci! o#u$%tori%9 ) *an'rado uterino irre'ular e* +;*2o+6n+ente a*o2iado 2on la di*fun2i3n ovulatoria A.B)O/$ La* +u5ere* 4ueden tener o

anovula2i3n, 1ue *e refiere a la au*en2ia de 2i2lo* ovulatorio*, o oli'oovula2i3n, en la 1ue *e

de*4lazan entre lo* 2i2lo* ovulatorio* 9 anovula2i3n$ =er >


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*an'rado

inter+en*trual H +;* arriba/$ La evalua2i3n de laboratorio 'eneral+ente no *e re1uiere 4ara

2onfir+ar la anovula2i3n, 4ero e* 6til 4ara eI2luir la enfer+edad de la tiroide* o la

hi4er4rola2tine+ia$ =er >4rueba* endo2rina* H a 2ontinua2i3n 9 > , en la *e22i3n> $/

(e!or #o$u(e! ) La* +u5ere* a ve2e* infor+an de 1ue lo* 4er:odo* 1ue *on re'ulare*,

4ero *e han vuelto inu*ual+ente li'era o de 2orta dura2i3n$


10/20


11/20

e*4ont;neoE Lo* fa2tore* de rie*'o, etiolo':a, +anife*ta2ione* 2l:ni2a*, dia'n3*ti2o 9

evalua2i3n> 9 > $/

La enfer+edad trofobl;*ti2a 'e*ta2ional, 1ue en al'uno* 2a*o* 4re*enta *e+ana* a ao*

de*4u0* de un e+barazo, ta+bi0n *e a*o2ia 2on *an'rado uterino 9 una 4rueba de e+barazo

4o*itiva$ =er >La +ola hidatidifor+eE $/

Recue!to s%!.u/!eo co(3$eto ) La* +u5ere* 2on *an'rado abundante o 4rolon'ado deben

*er evaluado* 2on un nivel de he+o'lobina 9 P o he+ato2rito 4ara la

ane+ia$ =0a*e >A4roIi+a2i3n al 4a2iente adulto 2on ane+ia> $/

Ade+;*, un re2uento de 4la1ueta* e* +u9 6til *i *e *o*4e2ha de un tra*torno de la

2oa'ula2i3n$ .n re2uento de 'l3bulo* blan2o* e* 6til *i *e *o*4e2ha de una infe22i3n$ Laenfer+edad infla+atoria 40lvi2a


12/20

'rave *e debe *o*4e2har 9 el 4a2iente debe *er evaluado 4or un tu+or *e2retor de

andr3'eno* de la 'l;ndula *u4rarrenal o de ovario 2uadro "@ /$ =er >ato'0ne*i* 9 la* 2au*a* de hir*uti*+o> $/

1or(o!% )o$/cu$o esti(u$%!te o $% 1or(o!% $utei!i*%!te ) hor+ona fol:2ulo

e*ti+ulante F-/ 9 la hor+ona luteinizante L/ *on liberada* 4or la 'l;ndula

4ituitaria$ -i *e *o*4e2ha una in*ufi2ien2ia ov;ri2a 4re+atura, una F- *0ri2a debe *er

realizada$ ara la* +u5ere* 2on *o*4e2ha de di*fun2i3n hi4otal;+i2a debido a la +ala

ali+enta2i3n o el e5er2i2io inten*o/, una F- 9 L *e deben realizar, a*: 2o+o

un e*tr3'eno P 4ro'e*tina 4rueba de retirada$ =er >La* +anife*ta2ione* 2l:ni2a* 9 la

evalua2i3n de la in*ufi2ien2ia ov;ri2a 4ri+aria e*4ont;nea in*ufi2ien2ia ov;ri2a

4re+atura/>, en la *e22i3n >dia'n3*ti2o> 9 > $/

E#%$u%ci! de $% )u!ci! o#u$%tori% ) La anovula2i3n *e dia'no*ti2a nor+al+ente

ba*;ndo*e en el 4atr3n de *an'rado 2ara2ter:*ti2a , en la *e22i3n

>, en la *e22i3n >La +enorra'ia> 9 >Dia'n3*ti2o diferen2ial de la

he+orra'ia del tra2to 'enital en la* +u5ere*>, en la *e22i3n HH Lo* tra*torno* he+orr;'i2o* $/

ra*torno* de la 2oa'ula2i3n nor+al+ente 4re*entan *an'rado tan 4e*ado de la +enar1uia o

en +u5ere* en edad re4rodu2tiva 4o*teriore*$ ara la enfer+edad de von Uillebrand, la

di*+inu2i3n de lo* nivele* de e*tr3'eno durante la *:nte*i* del fa2tor de von Uillebrand

i+4a2to tran*i2i3n a la +eno4au*ia$ , en la *e22i3n HLa* varia2ione* en lo* nivele*

de F=U en la *alud 9 la enfer+edad V $/

.n tra*torno de la 2oa'ula2i3n *e debe *o*4e2har *i la +en*trua2i3n 4rolon'ado* o

2o+enzaron en la +enar1uia, *e a*o2ia 2on una hi*toria fa+iliar de 2oa'ulo4at:a, el 4a2iente

tiene *i'no* de una di;te*i* he+orr;'i2a 4or e5e+4lo, +oretone* o *an'rado 4rolon'ado en

la* *u4erfi2ie* +u2o*a*/, o *i e*t; to+ando +edi2a+ento* a*o2iado* 2on un +a9or tenden2ia

al *an'rado 2uadro "( / 7 @)@( 8$

La* +u5ere* 1ue to+an warfarina deben tener lo* 4ar;+etro* de 2oa'ula2i3n evaluado* 4ara

ver *i el efe2to e*t; dentro de la ventana tera40uti2a$ Ade+;*, lo* 4a2iente* *e le* debe

4re'untar a2er2a de otro* +edi2a+ento* 2on o *in re2eta 1ue 4uedan afe2tar a la 2oa'ula2i3n

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o la fun2i3n 4la1uetaria$ =0a*e >A4roIi+a2i3n al 4a2iente adulto 2on una di;te*i*

he+orr;'i2a>, en la *e22i3n >.*o de +edi2a+ento*> $/

La evalua2i3n de lo* 4a2iente* 2on *o*4e2ha de un tra*torno de la 2oa'ula2i3n *e eIa+ina 4or

*e4arado$ =0a*e >A4roIi+a2i3n al 4a2iente adulto 2on una di;te*i* he+orr;'i2a>, en la

*e22i3n HLa* 4rueba* de laboratorioH $/

L%s 3rue"%s 3%r% desc%rt%r 1e(orr%.i% cer#ic%$ ) A +enudo e* dif:2il diferen2iar el

*an'rado 2ervi2al 9 uterino ba*ado en la hi*toria 9 eIa+en f:*i2o$ -i ha9 in2ertidu+bre *obre el

ori'en de la he+orra'ia, una evalua2i3n b;*i2a 4ara etiolo':a* de *an'rado 2ervi2al debe *er

realizada$ =er > 9>Cl:ni2a 9 dia'n3*ti2o de la* infe22ione* 4or

Chla+9dia tra2ho+ati*> $/

ENDOMETRIALES MUESTREO ) De*4u0* del e+barazo ha *ido eI2luido, to+a de +ue*tra*endo+etriale* *e debe realizar en la* +u5ere* 2on A.B 9 un +a9or rie*'o de hi4er4la*ia

endo+etrial o 2;n2er tabla @ 9 la tabla ( /$

La* indi2a2ione* 4ara la to+a de +ue*tra* endo+etriale* en +u5ere* en edad re4rodu2tiva 2on

A.B var:an *e'6n el 'ru4o de edad tabla @ /E

Ed%d ;< %=os 1%st% $% (e!o3%usi% )


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4or 2iento en lo* +a9ore* de @& a (( ao* 7 @#)@ 8$ Cla*ifi2a2i3n 9 dia'n3*ti2o de hi4er4la*ia de endo+etrio>, en la *e22i3n

H 7 @Q 8$ ara otro* ti4o* de A.B, el +0di2o debe utilizar *u 2riterio 2on re*4e2to al

*an'rado anor+al e* 4er*i*tente$

eo4la*ia endo+etrial e* 4o2o fre2uente en lo* adole*2ente* de entre "@ a " ao* !,!& 4or

2iento de lo* 2a*o* de 2;n2er de endo+etrio o2urrir en 4a2iente* 2on edade* de "& a "Q ao*

7 (! 8/, 4ero *e 4uede tran*for+ar en el entorno de la obe*idad 2on anovula2i3n *:ndro+e de

ovario 4oli1u:*ti2o 7-O8 / 7 (" 8$ , en la *e22i3n HLa* +u5ere*4re+eno4;u*i2a*H /$

La *o*4e2ha de la endo+etriti* e* otra indi2a2i3n 4ara la to+a de +ue*tra*

endo+etriale*$ ara la* +u5ere* 2on A.B durante el 4er:odo 4o*4arto o 4o*taborto, to+a de

+ue*tra* endo+etriale* 4uede revelar 4rodu2to* de la 2on2e42i3n retenido*$ =er >La

endo+etriti* 4o*t4arto> 9 >La endo+etriti* rela2ionado* 2on el e+barazo> 9>reten2i3n de

re*to*> $/

o+a de +ue*tra* endo+etriale* *e realiza t:4i2a+ente 2o+o una bio4*ia de la ofi2ina, 4ero

dilata2i3n 9 2ureta5e o bio4*ia diri'ida hi*tero*234i2a+ente)4uede llevar*e a 2abo *i el

*an'rado 4er*i*te de*4u0* de una bio4*ia de endo+etrio nor+al o *i ha9 otra* indi2a2ione*

4ara un 4ro2edi+iento 1uir6r'i2o$ =er >4ro2edi+iento* de to+a de +ue*tra*

endo+etriale*> 9 > $/

IMAGEN > 7ISTEROSCOPIA ) La de2i*i3n de 4ro2eder 2on i+;'ene* de la 4elvi* debenba*ar*e en el 5ui2io del +0di2o, de4endiendo de la edad del 4a2iente, la hi*toria 9 lo* *:nto+a*$

La ele22i3n de ha2er i+;'ene* e* 'uiado 4or vario* fa2tore*E

-i el abdo+en 9 P o lo* hallaz'o* del eIa+en 40lvi2o bi+anual in2lu9en un 6tero

a'randado o 'lobular o +a*a aneIial, la i+a'en e* ade2uada 4ara evaluar la 4re*en2ia

de leio+io+a*, adeno+io*i*, 9 la 4atolo':a aneIial$

?+a'in' *e 4uede o+itir, 4or lo +eno* en la evalua2i3n ini2ial, *i el *an'rado *e 4ien*a

1ue e* debido a una le*i3n ob*ervada en el eIa+en f:*i2o 43li4o endo2ervi2al/,

anovula2i3n, o la infe22i3n 7 ( 8$

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-i el eIa+en 40lvi2o e* nor+al, la* i+;'ene* ta+bi0n e* a4ro4iado *i lo* *:nto+a*

4er*i*ten a 4e*ar del trata+iento$

E$ecci! de $% (od%$id%d ) 40lvi2a e2o'raf:a e* el e*tudio de i+a'en de 4ri+era l:nea en

+u5ere* 2on A.B$


16/20

=enta5a* de la hi*tero*2o4ia *on 1ue hi*tero*2o4ia 4uede ofre2er a lo* 4a2iente* una +a9or

2o+odidad, *obre todo *i *e 4uede realizar en la +i*+a vi*ita 1ue la evalua2i3n

ini2ial$ hi*tero*2o4ia 1uir6r'i2a no *uele e*tar di*4onible en un 2on*ultorio +0di2o 9 4or lo tanto

no e* 4arte de la evalua2i3n ini2ial de la .AB$

Fa2tore* tale* 2o+o la 2o+odidad, la di*4onibilidad de e1ui4o* 9 4er*onal 2a4a2itado, 9 el2o*to del -?- 9 la hi*tero*2o4ia var:an en diferente* *itua2ione* 2l:ni2a*, 9 e*to* fa2tore* a

+enudo influ9en en la ele22i3n del e*tudio$

INFORMACI+N PARA PACIENTES ) Dia ofre2e do* ti4o* de +ateriale* edu2ativo* 4ara el

4a2iente, >Lo b;*i2o> 9 >$ M;* all; de lo b;*i2o> La* 4ieza* edu2a2i3n del 4a2iente Ba*i2* e*t;n

e*2rito* en un len'ua5e *en2illo, en el & W a # W 'rado de le2tura, 9 1ue re*4onde a la 2uatro o

2in2o 4re'unta* 2lave 1ue un 4a2iente 4odr:a tener *obre una 2ondi2i3n dada$ 9 la 4alabra 2lave */ de inter0*$/

Con2e4to* b;*i2o* de lo* te+a* ver >?nfor+a2i3n del 4a2ienteE 4er:odo* 4e*ado*

2on2e4to* b;*i2o*/> /

M;* all; de lo* te+a* Ba*i2* =er >?nfor+a2i3n del 4a2ienteE *an'rado uterino anor+al

a4arte de la* b;*i2a*/> 9 >?nfor+a2i3n del 4a2ienteE +en*trual abundante o 4rolon'ado

+enorra'ia/ a4arte de la* b;*i2a*/> 9 >?nfor+a2i3n del 4a2ienteE Au*en2ia de 4er:odo*

+en*truale* irre'ulare* o M;* all; lo* 2on2e4to* b;*i2o*/ > $/

RESUMEN > RECOMENDACIONES

*an'rado uterino anor+al -.A/ e* una 1ue5a 'ine2ol3'i2a 2o+6n$ A.B 4uede *er

2au*ada 4or una a+4lia variedad de enfer+edade* lo2ale* 9 *i*t0+i2a* o rela2ionada

2on +edi2a+ento* tabla " / 7 8$ La* 2au*a* +;* 2o+une* *on 2ondi2ione* a*o2iada*

2on el e+barazo, 4atolo':a uterina e*tru2tural 4or e5e+4lo, fibro+a*, 43li4o*

endo+etriale*, adeno+io*i*/, anovula2i3n, tra*torno* de la 2oa'ula2i3n, o

neo4la*ia$ =0a*e H?ntrodu22i3nH arriba 9 Hrevalen2ia 9 etiolo':aH +;* arriba/$


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4or lo 'eneral a*o2iada 2on la di*fun2i3n ovulatoria/, 9 a+enorrea$ =er >La hi*toria

+en*trual H +;* arriba/$

+ue*treo endo+etrial debe realizar*e en +u5ere* no e+barazada* 2on A.B 9 un +a9or

rie*'o de hi4er4la*ia endo+etrial o 2;n2er$ La* indi2a2ione* 4ara la to+a de +ue*tra*

endo+etriale* 4ueden variar *e'6n el 'ru4o de edad tabla @ 9 la tabla ( /$ =er Hto+a de

+ue*tra* endo+etriale*H +;* arriba/$

Lo* tra*torno* he+orr;'i2o*, en 4arti2ular la enfer+edad de von Uillebrand =UD/, *on

2o+une* en la* +u5ere* en edad re4rodu2tiva$ .n tra*torno *e debe *o*4e2har *i la

+en*trua2i3n 4rolon'ado* o 2o+enzaron la +enar1uia o *e a*o2ia 2on una hi*toria

fa+iliar de 2oa'ulo4at:a u otro* *i'no* de una di;te*i* he+orr;'i2a 4or e5e+4lo,

+oretone* 2on fa2ilidad o *an'rado 4rolon'ado en *u4erfi2ie* +u2o*a*/$ Ade+;*, lo*

anti2oa'ulante* 4ueden 2au*ar *an'rado uterino 4rofu*o o 4rolon'ado$ =er HH La*

4rueba* de 2oa'ula2i3n anterior+ente/$

La anti2on2e42i3n hor+onal o un di*4o*itivo intrauterino D?./ 4ueden 2au*ar

A.B$ =er >i*toria 'eneral H +;* arriba/$

oda* la* +u5ere* 2on A.B deben tener una hi*toria 2o+4leta 9 un eIa+en f:*i2o$ -edebe obtener infor+a2i3n *obre la fre2uen2ia, dura2i3n 9 volu+en de A.B, a*: 2o+o la

4re*en2ia de lo* *:nto+a* a*o2iado* 9 lo* fa2tore* 1ue 4re2i4itan$ =er Hi*toriaH arriba

9 H +;* arriba/$

La +a9or:a de la* +u5ere* en edad re4rodu2tiva 2on A.B deben *er evaluado*

ini2ial+ente 2on la* *i'uiente* 4rueba*E la 'onadotro4ina 2ori3ni2a hu+ana hCG/,

re2uento *an'u:neo 2o+4leto, he+o'lobina 9 P o he+ato2rito$ Lo* eI;+ene* adi2ionale*

4ueden *er realizado* 4ara evaluar etiolo':a* 4arti2ulare*$ =er HH La* 4rueba*

ini2iale* anteriore* 9 >4rueba* adi2ionale*> +;* arriba/$

i+a'en 40lvi2a e* 6til *i una le*i3n e*tru2tural 43li4o* endo+etriale*, +io+a*,

adeno+io*i*, o una +a*a aneIial/ *e *o*4e2ha ba*an en la hi*toria 9 eIa+en f:*i2o no*e re1uiere en 2ada +u5er 2on A.B$


18/20

($ K5erulff K,


19/20

!$ al4erin R, -2hneider D, Ma9+on R, et al$ +alfor+a2i3n arterioveno*a de un le'radouterinoE re4orte de @ 2a*o*$ J Re4rod Med !!N &E ((&$

"$ i2hol*on AA, urnbull LU, AM Coad9, Guthrie K$ Dia'n3*ti2o 9 trata+iento de la*+alfor+a2ione* arterio)veno*a* uterino*$ Clin Radiol "QQQ &(E #&$

$ Kakuno Z, A+ino , Kanoh M, et al$ Altera2ione* +en*truale* en diver*a*enfer+edade* de la tiroide*$


20/20

@N$ Reed -D, ewton KM, Clinton UL, et al$ La in2iden2ia de hi4er4la*ia endo+etrial$ A+ JOb*tet G9ne2ol !!Q !!E #N$e"$

@$ htt4EPP*eer$2an2er$'ov$*2i)hub$ioP*tatfa2t*Pht+lP2or4$ht+l 2on*ultado el ! de di2ie+brede !""/$

@Q$ Lethab9 A, -u2klin' J, Barlow D, et al$ era4ia de ree+4lazo hor+onal en +u5ere*4o*t+eno4;u*i2a*E hi4er4la*ia endo+etrial 9 *an'rado irre'ular$ Ba*e de Dato* Co2hrane -9*tRev !!( E CD!!!(!$

(!$ htt4EPP*eer$2an2er$'ov$*2i)hub$ioP*tatfa2t*Pht+lP2or4$ht+l 2on*ultado el "" de*e4tie+bre de !"@/$

("$ AJ +arr3n, Ue*tin -, Broaddu* RR, -2h+eler K$ 4ro'e*tina di*4o*itivo intrauterinoen un adole*2ente 2on 'rado de 2;n2er de endo+etrio$ G9ne2ol !" ""QE (@$

($ Doubilet M$

ENFOQUE PARA EL SANGRADO UTERINO ANORMAL EN LAS MUJERES EN EDAD REPRODUCTIVA NO EMBARAZADAS.docx

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Transcript of ENFOQUE PARA EL SANGRADO UTERINO ANORMAL EN LAS MUJERES EN EDAD REPRODUCTIVA NO EMBARAZADAS.docx