1- Menstrual disorders (conditions) Flashcards
menarche
first period
menopause
end of periods
amenorrhea
abscence of periods
primary amenorrhea
never had a period
secondary ammenorrhea
the cessation of menstruation for 3–6 months in women with previously normal and regular menses
Dysmenorrhoea
painful menstruation
menorrhagia
heavy/ prolonged bleeding
oligomenorrhoea
infrequent periods
oligomenorrhoea
infrequent periods
intermenstrual bleeding
(between periods)
o Post coital (after sex)
o Breakthrough (irregular bleeding on hormonal contraception)
Amenorrhea vs abnormal uterine bleeding
abnormal uterine bleeding
- Menorrhagia
- Dysmenorrhea
- Intermenstrual
- Post coital
- Break through
causes of AUB
PALM COEIN (FIGO)
Structural
- Polyp
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy/ hyperplasia
Non-structural
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial
- Iatrogenic
- Not yet classified (DUB)
menorrhagia background
heavy or prolonged bleeding
- interfers with womans physical, emotional and social QoL
parameters of menorrhagia
- > 8 days
- > 80mL/cycle
- more frequent than 24 days
- intermenstrual bleeding or postcoital spotting
causes of me norrhagia
- Idiopathic
- Fibroids (non cancerous growths)
- Endometriosis
- Blood clotting (von willebrand disease) disorders/ warfarin
- Contraceptive pill
- Hypothyroidism
- PID
- Endometriosis
presentation of menorrhagia
o May pass clots and/or experience flooding (having to change pads frequently) or having to wear pads and tampons simultaneously.
investigations for menorrhagia
- pelvic examination with speculum and bimanual (unless young and not sexually active)
to assess for fibroids, ascites and cancers- FBC- iron def anaemia
- pelvic and transvaginal US
- coagulation screen
- thryoid function tests
- swabs if evidence of infection
management of menorrhagia
First line:
- Mirena (often not first line in practice due to what women wants)
Second line:
- Tranexamic acid
- NSAIDS such as mefenamic acid
- COCP/POP
Third line: endometrial ablation and hysterectomy
*remember that coppper coil can cause menorrhagia
important questions to ask in a history for gynaecological problemms
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
dysmenorrhoea background
o Low anterior pelvic pain which occurs in association with periods
o Primary- period pains since start of period
o Secondary- occurring later, with previously normal periods
causes of dysmenorrhoea
- Excess or imbalance of prostaglandins in menstrual fluid, which causes vasoconstriction in the uterine vessels, causing uttering contractions which produce pain
-Prostaglandins may explain: diarrhoea, nausea, headache etc - Endometriosis
- PID
- Fibroids
- Copper IUD -> may hurt for a few months after fitting
- Childbirth reduces dysmenorrhoea
investigations for dysmenorrhea
o Good history
o Speculum exam of cervix
o High vaginal swap
o Pelvic/ transvaginal US
presentation of dysmenorrhea
o 1-2 days before or with onset of menses
o Improves 12-72 h
o Crampy and intermittently intense, or continuous dull ache
o Lower abdomen and suprapubic area
mangement of dysmenorrhea
- Lifestyle- stop smoking, exercise
- NSAIDs
- Hormonal treatment
COCP
Dep-povera
Coil - Surgery
Laparoscopic uterine nerve ablation
hysterectomy in rare cases
endometriosis physiology
where there is ectopic endometrial tissue outside the uterus.
- lump of endometrial tissue outside the uterus = endometrioma e.g. chocolate cysts in the ovaries
cause of endometriosis
a number of theories
- retrograde menstruation
- due to misplacement of embryonic cells
- spread of endometiral cells through lymphatics like cancers
- metaplasia of cells
retrograde menstruation
One notable theory for the cause of ectopic endometrial tissue is that during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity.
presentation of endometriosis
pelvic pain
- cells of endometrial tissue outside the uterus respond to hormones in the same way as endometiral tissue in the uterus
- during menstruation the endometrial tissue in the uterus sheds its lining and bleeds, the same happens elsewhere in the boyd
- this causes irritation and inflammation of tissues around the sites of endometriosis
key features
- cyclical
- dull, heavy or burning pain
- during emnstruation
why can people with endometriosis present with blood in urine or stools
due to deposits of endometriosis in the bladder or bowel
adverse reaction to endometriosus
adhesions due to localised bleeding and inflammation
- leads to chronic, non-cyclical pain that can be sharp, stapping or pulling and associasted with nausea
endometriosis and fertility
Endometriosis can lead to reduced fertility. Often it is not clear why women with endometriosis struggle to get pregnant. It may be due to adhesions around the ovaries and fallopian tubes, blocking the release of eggs or kinking the fallopian tubes and obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.
investigating endometriosis
- examination
- pelvic uS
- laparoscopic surgery
examination of a pt with endometriosis
- Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
- A fixed cervix on bimanual examination
- Tenderness in the vagina, cervix and adnexa
pelvic US and endometriosis
may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.
laparoscopic surgery and endometriosis
gold standard for diagnosis
- biopsy and stage
- surgeon can also remove deposits of endometriosis and improve symptoms
staging of endometirosis
American Society of Reproductive Medicine (ASRM) has a staging system
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
management of endometriosis
Initial management involves:
- Establishing a diagnosis
- Providing a clear explanation
- Listening to the patient, establishing their ideas, concerns and expectations and building a partnership
- Analgesia as required for pain (NSAIDs and paracetamol first line)
Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:
* Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
* Progesterone only pill
* Medroxyprogesterone acetate injection (e.g. Depo-Provera)
* Nexplanon implant
* Mirena coil
* GnRH agonists
Surgical management options:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy
- Laparoscopic treatment may improve fertility. *Hormonal therapies may improve symptoms but not fertility.
Risk factors for endometriosis
o Nulliparity (a woman has never given birth to a child, or has never carried a pregnancy)
o Early menarche
o Short cycles
o Heavy bleeding
o Low BMI
where is endometrial most commonly found
- Ovaries
o Endometrioma= chocolate cyst - Bladder
- Rectum
- Peritoneal lining and pelvic side walls
fibroids
benign tumours of the smooth muscle of the uterus.
They are also called uterine leiomyomas
- oestrogen sensitive
- very common in women in later reproductive years
RF for fibroids
- older
- black women
types of fibroids
- Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk.
fibroids presentation
Fibroids are often asymptomatic. They can present in several ways:
- Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
- Prolonged menstruation, lasting more than 7 days
- Abdominal pain, worse during menstruation
- Bloating or feeling full in the abdomen
- Urinary or bowel symptoms due to pelvic pressure or fullness
- Deep dyspareunia (pain during intercourse)
- Reduced fertility
investigations for fibroids
- submucosal fibroids: hysteroscopy
- larger fibroids: pelvic US
- MRI scanning - can give info about size, shape and blood supply
management of fibroids **<3cm **
same as menorrhagia
- Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
- Symptomatic management with NSAIDs and tranexamic acid
- Combined oral contraceptive
- Cyclical oral progestogens
Surgical options for smaller fibroids:
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
management of larger fibroids
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. - Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
Uterine Artery Embolisation
- Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists.
- The radiologist inserts a catheter into an artery, usually the femoral artery.
- This catheter is passed through to the uterine artery under X-ray guidance.
- Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.
- This starves the fibroid of oxygen and causes it to shrink.
surgical options for fibroids: myomectomy
involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery).
Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.
surgical option for fibroids: endometrial ablation
- can be used to destroy the endometrium. Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation.
- this involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.
surgical option for fibroids : hysterectomy
Involves removing the uterus and fibroids. Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach. The ovaries may be removed or left depending on patient preference, risks and benefits.
complications of fibroids
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
red degeneration of fibroids
ishaemia, infarction and necrosis of fibroid due to disrupted blood supply
- more likely in large fibroids >5cm during 2nd and 3rd trimester of pregnancy
- this may be because the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic.
- may also occur due to kinking of blood vessels as the uterus changes shape and expands
presentation of red degeneration of fibroids
- severe abdominal pain
- low-grade fever
- tachycardia
- often vomiting.
Management is supportive, with rest, fluids and analgesia.
polyps vs fibroids
fibroids are made of muscle cells and connective tissue, whereas polyps are made up of the tissue that lines the uterus, also known as endometrial tissue.
polyps vs fibroids
fibroids are made of muscle cells and connective tissue, whereas polyps are made up of the tissue that lines the uterus, also known as endometrial tissue.
Uterine polyps
are growths in the inner lining of your uterus (endometrium).
- usually benign but may cause problems with menstruation and fertility
- can grow as large as a golf ball
RF for polyps
- 40s and 50s
- overweight
- high BP
- taking tamoxifen
- HRT with high dose of oestrogen
presentation of uterine polyps
abnormal bleeding including:
- irregular menstrual periods
- post menopausal bleeding
- post coital
- intermenstrual
Other problems: infertility
usually not painful
physical examination of polyp
Polyps can sometimes prolapse, or slip, through your cervix. The cervix is the opening between your vagina and your uterus. In these instances, your provider may be able to see the polyp during a physical exam.
investigations of polyps
- pelvic examination
- transvaginal US
- hysteroscopy
- endometrial biopsy
- curettage
management of endometrial polyps
- Medication: GnRH agonist e.g. goserlin helps with symptoms, but symptoms return when the medication stops being taken
- Surgical: uterine polypectomy
uterine polypectomyr
removal of polyps during hysteroscopy
- can also send to histology to look for malignancy
endometrial hyperplasia
precancerous condition involving thickening of the endometrium
- risk factors, presention and investigationsa re similar to endometiral cancer
prognosis of endometrial hyperplasia
Most cases of endometrial hyperplasia will return to normal over time. Less than 5% go on to become endometrial cancer. T
two types of endometrial hyperplasia
- Hyperplasia without atypia
- Atypical hyperplasia
endometiral hyperplasia risk factor
same as endometrial cancer
Situations where there is increased exposure of unopposed oestrogen are:
- Increased age
- Earlier onset of menstruation
- Late menopause
- Oestrogen only hormone replacement therapy
- No or fewer pregnancies
- Obesity
- Polycystic ovarian syndrome
- Tamoxifen
Postcoital Bleeding
Postcoital bleeding (PCB) refers to bleeding after sexual intercourse. This is a red flag that should make you consider cervical and other cancers, although other causes are more common. Often no cause is found. The key causes are:
- Cervical cancer, ectropion or infection
- Trauma
- Atrophic vaginitis
- Polyps
- Endometrial cancer
- Vaginal cancer
