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Gynaecology > 1: Menstruation: Dysfunctional Uterine Bleeding, Menorrhagia, Dysmenorrhoea > Flashcards

1: Menstruation: Dysfunctional Uterine Bleeding, Menorrhagia, Dysmenorrhoea Flashcards

1
Q

What is dysfunctional uterine bleeding now referred to

A

Abnormal Uterine Bleeding (AUB)

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2
Q

What is dysfunctional uterine bleeding now referred to

A

Abnormal Uterine Bleeding (AUB)

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3
Q

Define abnormal uterine bleeding

A

Abnormal genital tract bleeding in absence of systemic, genital tract pathology or pregnancy

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4
Q

What can abnormal uterine bleeding include in presentation

A
  • IM Bleeding
  • Post-coital bleeding
  • Post-menopausal bleeding
  • Heavy menstural bleeding
  • More than 7-9d difference between cycle length
  • Cycle <24d or >38d
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5
Q

When should abnormal uterine bleeding only be used

A

AUB is a diagnosis of exclusion and should only be made when other pathology has been excluded

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6
Q

According to FIGO how can causes of AUB be divided

A
  1. Structural

2. Non-structural

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7
Q

What is a menumonic to remember structural causes of AUB

A

PALM

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8
Q

What are structural causes of AUB

A

Polyps
Adenomyosis
Leiomyomas
Malignancy

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9
Q

What is a mnemonic to remember non structural causes of AUB

A

COIEN

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10
Q

What are the non-structural causes of AUB

A 
Coagulopathies 
Ovulatory dysfunction
Iatrogenic 
Endometrial 
Not yet classified
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11
Q

What is the main symptom of AUB

A

Menorrhagia

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12
Q

What % of women with menorrhagia have AUB

A

50-60% women with DUB will have menorrhagia

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13
Q

What is the commonest symptom of dysfunctional uterine bleeding

A

Menorrhagia

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14
Q

Define menorrhagia

A

Heavy menstrual bleeding that impacts a women quality of life

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15
Q

Explain the old definition of menorrhagia and problem with this

A

It used to be defined as >80ml blood loss per cycle. However, this could not be measured

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16
Q

What % women suffer with menorrhagia

A

3%

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17
Q

What is 60% of menorrhagia caused by

A

DUB

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18
Q

What are 7 causes of menorrhagia

A
  1. DUB
  2. IUD
  3. Hypothyroidism
  4. Coagulopathies
  5. Fibroids
  6. Adenomyosis
  7. Endometriosis
  8. Pelvic infection
  9. Polyps
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19
Q

What is the most common coagulation disorder to cause menorrhagia

A

Von Wille brand disease

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20
Q

If a women >45 has menorrhagia what should be suspected

A

Endometrial cancer

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21
Q

Explain presentation of menorrhagia

A

Heavy or prolonged menstrual bleeding

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22
Q

Why may a women with menorrhagia present to health care

A

Change in periods or impact on QOL

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23
Q

What are associated symptoms of menorrhagia

A

Anaemia: pale, breathlessness, fatigue

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24
Q

What may enlarged uterus and menorrhagia indicate

A

Fibroids, adenomyosis

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25
Q

At the bedside, what should all women with menorrhagia have

A

Pregnancy test

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26
Q

What are two other bedside tests for menorrhagia

A

STI

Cervical smear

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27
Q

What are 3 blood tests for menorrhagia

A

FBC
Coagulation screen
TFTs

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28
Q

When is a coagulation screen performed

A

If suspect coagulopathy: easy bruising, gum bleeding

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29
Q

Explain investigation in women under 45-years

A

Women under 45, need no further investigation of menorrhagia as there is a low risk of endometrial pathology

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30
Q

Explain investigation in women over 45-years for menorrhagia

A

Women over 45 should be investigated - due to increased risk of endometrial cancer

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31
Q

When is TV-US indicated

A

Women over 45 with menorrhagia, IM bleeding, Post-menopausal bleeding

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32
Q

When is pipette endometrial biopsy performed

A

Menorrhagia resistant to pharmacological management

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33
Q

When is hysteroscopy and endometrial biopsy performed

A

Abnormality (endometrial thickening) found on TV-US

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34
Q

How should menorrhagia be managed if underlying cause

A

treat underlying cause

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35
Q

If no treatable underlying pathology, what is first-line for menorrhagia

A

levonorgestrel-releasing system (IUS)

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36
Q

Name a levonorgestrel-releasing system

A

Mirena Coil

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37
Q

What is the role of mirena coil

A

Releases progesterone - causes thinning of the endometrium. Also can be used as a contraceptive

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38
Q

How long can mirena coil be kept in

A

5-years

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39
Q

What are SE of mirena coil

A

Irregular bleeding in first 4-6m

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40
Q

What is second-line for menorrhagia

A

Mefenamic acid
Tranexamic acid
COCP

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41
Q

What does choice between tranexamic acid, mefenamic acid and cocp depend on

A
  • Women’s choice about wanting to conceive

- Presence of dysmenorrhoea

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42
Q

What is the MOA of tranexamic acid

A

Anti-Fibrinolytic

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43
Q

How is tranexamic acid taken

A

PO up to 4d during bleeding

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44
Q

When is tranexamic acid preferred

A

If not trying to conceive - as it is non-hormonal

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45
Q

What is mefanamic acid

A

NSAID

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46
Q

How is mefenamic acid taken

A

During bleeding

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47
Q

When is mefenamic acid most useful

A

If associated dysmenorrhoea - as it also has analgesic properties

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48
Q

What is problem with COCP as second-line

A

Cannot be used if women is trying to conceive

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49
Q

What is third-line for menorrhagia

A

Oral northisterone

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50
Q

What is oral northisterone a type of

A

Progesterone

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51
Q

explain how oral norhisterone is taken for menorrhagia

A

Taken for 5-7 days during the cycle

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52
Q

what is the problem with northisterone in menorrhagia

A

It is not effective as a contraceptive when taken for 5-7d

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53
Q

what can be given as alternative to oral northisterone

A

Depo or Implant

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54
Q

what can be used as last-line for management of menorrhagia

A

Surgery

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55
Q

when is surgery for menorrhagia indicated

A

Medical-treatment failed

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56
Q

what are the two main types of surgery for menorrhagia

A

Endometrial ablation

Hysterectomy

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57
Q

what is the main surgery for menorrhagia

A

Endometrial ablation

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58
Q

what is endometrial ablation

A

Uses diathermy to remove endometrium

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59
Q

when is endometrial ablation used

A

Women who do not want to conceive

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60
Q

what do women need to continue after endometrial ablation and why

A

Contraception - as women is still ovulating and if fertilised increases risk of ectopic pregnancy

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61
Q

what is the definitive treatment for menorrhagia

A

Hysterectomy

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62
Q

what is sub-total hysterectomy

A

Removal of uterus

Cervix remains intact

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63
Q

what is total hysterectomy

A

Removal uterus and cervix

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64
Q

Define abnormal uterine bleeding

A

Abnormal genital tract bleeding in absence of systemic, genital tract pathology or pregnancy

How well did you know this?
1
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2
3
4
5
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65
Q

What can abnormal uterine bleeding include in presentation

A
  • IM Bleeding
  • Post-coital bleeding
  • Post-menopausal bleeding
  • Heavy menstural bleeding
  • More than 7-9d difference between cycle length
  • Cycle <24d or >38d
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

When should abnormal uterine bleeding only be used

A

AUB is a diagnosis of exclusion and should only be made when other pathology has been excluded

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

According to FIGO how can causes of AUB be divided

A
  1. Structural

2. Non-structural

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

What is a menumonic to remember structural causes of AUB

A

PALM

69
Q

What are structural causes of AUB

A

Polyps
Adenomyosis
Leiomyomas
Malignancy

70
Q

What is a mnemonic to remember non structural causes of AUB

A

COIEN

71
Q

What are the non-structural causes of AUB

A 
Coagulopathies 
Ovulatory dysfunction
Iatrogenic 
Endometrial 
Not yet classified
72
Q

What is the main symptom of AUB

A

Menorrhagia

73
Q

What % of women with menorrhagia have AUB

A

50-60% women with DUB will have menorrhagia

74
Q

What is the commonest symptom of dysfunctional uterine bleeding

A

Menorrhagia

75
Q

Define menorrhagia

A

Heavy menstrual bleeding that impacts a women quality of life

76
Q

Explain the old definition of menorrhagia and problem with this

A

It used to be defined as >80ml blood loss per cycle. However, this could not be measured

77
Q

What % women suffer with menorrhagia

A

3%

78
Q

What is 60% of menorrhagia caused by

A

DUB

79
Q

What are 7 causes of menorrhagia

A
  1. DUB
  2. IUD
  3. Hypothyroidism
  4. Coagulopathies
  5. Fibroids
  6. Adenomyosis
  7. Endometriosis
  8. Pelvic infection
  9. Polyps
80
Q

What is the most common coagulation disorder to cause menorrhagia

A

Von Wille brand disease

81
Q

If a women >45 has menorrhagia what should be suspected

A

Endometrial cancer

82
Q

Explain presentation of menorrhagia

A

Heavy or prolonged menstrual bleeding

83
Q

Why may a women with menorrhagia present to health care

A

Change in periods or impact on QOL

84
Q

What are associated symptoms of menorrhagia

A

Anaemia: pale, breathlessness, fatigue

85
Q

What may enlarged uterus and menorrhagia indicate

A

Fibroids, adenomyosis

86
Q

At the bedside, what should all women with menorrhagia have

A

Pregnancy test

87
Q

What are two other bedside tests for menorrhagia

A

STI

Cervical smear

88
Q

What are 3 blood tests for menorrhagia

A

FBC
Coagulation screen
TFTs

89
Q

When is a coagulation screen performed

A

If suspect coagulopathy: easy bruising, gum bleeding

90
Q

Explain investigation in women under 45-years

A

Women under 45, need no further investigation of menorrhagia as there is a low risk of endometrial pathology

91
Q

Explain investigation in women over 45-years for menorrhagia

A

Women over 45 should be investigated - due to increased risk of endometrial cancer

92
Q

When is TV-US indicated

A

Women over 45 with menorrhagia, IM bleeding, Post-menopausal bleeding

93
Q

When is pipette endometrial biopsy performed

A

Menorrhagia resistant to pharmacological management

94
Q

When is hysteroscopy and endometrial biopsy performed

A

Abnormality (endometrial thickening) found on TV-US

95
Q

How should menorrhagia be managed if underlying cause

A

treat underlying cause

96
Q

If no treatable underlying pathology, what is first-line for menorrhagia

A

levonorgestrel-releasing system (IUS)

97
Q

Name a levonorgestrel-releasing system

A

Mirena Coil

98
Q

What is the role of mirena coil

A

Releases progesterone - causes thinning of the endometrium. Also can be used as a contraceptive

99
Q

How long can mirena coil be kept in

A

5-years

100
Q

What are SE of mirena coil

A

Irregular bleeding in first 4-6m

101
Q

What is second-line for menorrhagia

A

Mefenamic acid
Tranexamic acid
COCP

102
Q

What does choice between tranexamic acid, mefenamic acid and cocp depend on

A
  • Women’s choice about wanting to conceive

- Presence of dysmenorrhoea

103
Q

What is the MOA of tranexamic acid

A

Anti-Fibrinolytic

104
Q

How is tranexamic acid taken

A

PO up to 4d during bleeding

105
Q

When is tranexamic acid preferred

A

If not trying to conceive - as it is non-hormonal

106
Q

What is mefanamic acid

A

NSAID

107
Q

How is mefenamic acid taken

A

During bleeding

108
Q

When is mefenamic acid most useful

A

If associated dysmenorrhoea - as it also has analgesic properties

109
Q

What is problem with COCP as second-line

A

Cannot be used if women is trying to conceive

110
Q

What is third-line for menorrhagia

A

Oral northisterone

111
Q

What is oral northisterone a type of

A

Progesterone

112
Q

explain how oral norhisterone is taken for menorrhagia

A

Taken for 5-7 days during the cycle

113
Q

what is the problem with northisterone in menorrhagia

A

It is not effective as a contraceptive when taken for 5-7d

114
Q

what can be given as alternative to oral northisterone

A

Depo or Implant

115
Q

what can be used as last-line for management of menorrhagia

A

Surgery

116
Q

when is surgery for menorrhagia indicated

A

Medical-treatment failed

117
Q

what are the two main types of surgery for menorrhagia

A

Endometrial ablation

Hysterectomy

118
Q

what is the main surgery for menorrhagia

A

Endometrial ablation

119
Q

what is endometrial ablation

A

Uses diathermy to remove endometrium

120
Q

when is endometrial ablation used

A

Women who do not want to conceive

121
Q

what do women need to continue after endometrial ablation and why

A

Contraception - as women is still ovulating and if fertilised increases risk of ectopic pregnancy

122
Q

what is the definitive treatment for menorrhagia

A

Hysterectomy

123
Q

what is sub-total hysterectomy

A

Removal of uterus

Cervix remains intact

124
Q

what is total hysterectomy

A

Removal uterus and cervix

125
Q

define dysmenorrhoea

A

painful periods

126
Q

how can dysmenorrhoea be categorised

A
  • Primary dysmenorrhoea

- Secondary dysmenorrhoea

127
Q

what is primary dysmenorrhoea

A

Painful periods with no underlying pelvic abnormality

128
Q

what is secondary dysmenorrhoea

A

Painful periods with underlying pelvic pathology

129
Q

when does primary dysmenorrhoea tend to occur

A

Earlier in life - as no associated pelvic conditions

130
Q

when does secondary dysmenorrhoea tend to occur

A

Later in life

131
Q

what are 5 causes of secondary dysmenorrhoea

A
  1. Fibroids
  2. Adenomyosis
  3. Pelvic Adhesions
  4. Asherman’s syndrome
  5. PID
  6. LLETZ causing cervical stenosis
132
Q

give 5 risk factors for primary dysmenorrhoea

A
  1. Nulliparous
  2. Early menarche
  3. Dysmenorrhoea
  4. Long menstrual phase
  5. Smoking
133
Q

Explain clinical presentation of primary dysmenorrhoea

A
  • Crampy lower abdominal pain that may radiate to the back or anterior thigh
134
Q

How long dose primary dysmenorrhoea last

A
  • Worse at the onset of periods

- Each episode may last 48-72h

135
Q

What can primary dysmenorrhoea be associated with

A
  • Nausea
  • Vomiting
  • Dizziness
136
Q

How does secondary dysmenorrhoea present

A
  • More constant pain

- Associated with deep dyspareunia

137
Q

What is primary dysmenorrhoea as a differential

A

Primary dysmenorrhoea is a differential of exclusion - hence secondary causes should be identified and managed first

138
Q

Explain pathophysiology of primary dysmenorrhoea

A
  • If the ova is not fertilised to corpus luteum will regress
  • This will cause a drop in progesterone and oestrogen
  • Drop in progesterone causes endometrial cells to secrete prostaglandins
  • Prostaglandins cause myometrial contraction and vasoconstriction of spiral arteries
  • vasoconstriction of spiral arteries causes ischaemic necrosis of the endometrium
139
Q

What is primary dysmenorrhoea due to

A

Excess secretion of PGF2a and PGE from endometrial cells

140
Q

How is dysmenorrhoea investigated

A

Examination
STI Screen (Exclude PID)
TV-US (Exclude fibrosis, adenomyosis, polyps)

141
Q

What are 3 conservative measures to manage dysmenorrhoea

A
  1. Smoking cessation
  2. Hot water bottle
  3. TENS
142
Q

What is first-line pharmacological method for primary dysmenorrhoea

A
  1. Analgesia (NSAIDs)
143
Q

Why are NSAIDs preferred to paracetamol for dysmenorrhoea

A

NSAIDs inhibit prostaglandin production - part of pathology

144
Q

What is second-line for dysmenorrhoea

A

COCP

145
Q

What is intermenstrual bleeding also known as

A

Metotorrhagia

146
Q

What is intermenstrual bleeding

A

Bleeding between menses

147
Q

What % of AUB is due to intermenstrual bleeding

A

25

148
Q

What is the main differential for intermenstrual bleeding

A

Cervical cancer

149
Q

What is a more common cause of intermenstrual bleeding in young women

A

Cervical ectropion

150
Q

What are other causes of intermenstrual bleeding

A 
Cervical cancer
Cervical polyps 
Infection 
Cervical ectropion 
Hormonal contraceptives (POP, Injection) 
Atrophic vaginitis 
Pregnancy
151
Q

What infections may cause intermenstrual bleeding

A

Chlamydia

PID

152
Q

What is intermenstrual bleeding

A

bleeding between menses

153
Q

What should be ordered initially for intermenstrual bleeding

A
  • Pregnancy Test
  • STI screen
  • Cervical smear test
154
Q

If no cause identified in blood tests, what should be done to investigate intermenstrual bleeding

A

Colopscopy

TVUS

155
Q

when should an individual be referred to gynaecology under 2W rule

A

If risk factors for cervical cancer and IM bleeding

156
Q

what are 4 risk factors for cervical cancer

A
  1. FH
  2. Tamoxifen
  3. Heavy IM bleeding
  4. > 45-years
157
Q

how is intermenstrual bleeding managed

A

Treat underlying cause

158
Q

what is post-coital bleeding

A

bleeding after sexual intercourse

159
Q

what are 5 causes of post-coital bleeding

A
  1. Infection
  2. Cervicitis
  3. Cervical cancer
  4. Vaginal cancer
  5. Cervical ectropion
  6. Cervical polyps
160
Q

what are two infectious causes of post-coital bleeding

A

Chlamydia

Gonorrhoea

161
Q

what is cervical ectropion

A

Tissue from the endocervix is in the region of the ectocervix

162
Q

what is cervicitis

A

Inflammation of the cervix

163
Q

what may cause cervicitis

A

Chalmydia (most-common)

BV

164
Q

when may vaginal cancer cause post-coital bleeding

A

In older patients

165
Q

how will cervical cancer appear on examination

A

Contact bleeding

166
Q

what presentation often occurs with post-coital bleeding

A

Inter-menstrual bleeding

167
Q

what are 3 investigations for post-coital bleeding

A
  1. STI
  2. Cervical smear
  3. Colposcopy
168
Q

when should colposcopy be performed

A

If persistent post-coital bleeding with no previously identified cause

Gynaecology (22 decks)

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