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GASH > Abnormal bleeding > Flashcards

Abnormal bleeding Flashcards

1
Q

Clinical and objective definition of menorrhagia

A

Clinical: excessive loss that interferes with woman QoL

Objective: blood loss >80ml (=amount a healthy woman can lose before becoming iron deficient - 60% of women with menorrhagia develop anaemia)

Nb. heavy menstrual bleeding is more common in teenagers (fits few years after menarche)

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2
Q

Aetiology of menorrhagia - think PERIODS (clue: R is shit)

A

P E R I O D S

PID / Polyps(30%)
Endometrial Ca/Endometriosis
'Really bad hypothyroidism'
Intra-uterine contraception (copper)
Ovarian Cancer
Dysfunctional uterine bleeding
Submucosal fibroids (30%)
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3
Q

Useful area of focus for menorrhagia Hx

A

Timing

Amount:
Do they have to use double protection (tampons + pads)
Flooding + passing of large clots

Method of contraception

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4
Q

Red flag symptoms in menorrhagia

A

Weight loss
Dysuria
PCT
Dyspanuria

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5
Q

Examination for menorrhagia

A

Anaemia
Bimanual exam - irregular enlargement of the uterus (fibroids)
Tenderness with no enlargement - adenomyosis
Speculum - polyp may be visible

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6
Q

Investigations for menorrhagia

A

Keep a menstrual diary - record no. of pads/tampons and days bleeding

Bloods: FBC, TFT, coagulation

Speculum + cervical smear (if cervix looks suspicious/smear not up to date)

STI test - important if IMP, PCB or irregular bleeding

Trans-vaginal USS - assess endometrial thickness, detects uterine fibroids/ovarian mass/polyps

Hysteroscopy

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7
Q

Fast track referral and endometrial biopsy if:

A 
Endometrial thickness is >10mm (should be <5mm in post-menopausal women)
>45 y/o
IMB
Recent onset menorrhagia
Unresponsive to treatment
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8
Q

When choosing management for menorrhagia you should consider:

A 
Reproductive wishes
Contraceptive needs
Fitness for surgery
CI to medications
Associated Sx e.g. pain
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9
Q

What conservative management is there for menorrhagia?

A

No treatment - other than iron supplements

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10
Q

Medical management choices for menorrhagia for women wanting to conceive?

A
  1. Tranexamic acid - taken during menstruation, decreases bleeding by 50%
  2. NSAIDS (mefanemic acid) - inhibits PG –> reduces menstruation by 30%
    Nb. good for dysmenorrhoea!
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11
Q

Medical management choices for menorrhagia for women not wanting to conceive?

A
  1. Mirena coil (IUS) = first line for menorrhagia!
    Reduces menstrual flow by >90%
  2. Progestogens (high dose pill/injection/implant) - will cause amenorrhoea
    Periods will resume afterwards
  3. Combined contraceptive pill - reduces bleeding by 1/3rd
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12
Q

Surgical options to treat menorrhagia?

A
  1. Removal of polyps/fibroids
  2. Endometrial ablation –> amenorrhoea/lighter periods + sub fertility
  3. Hysterectomy - removal of the uterus
  4. Uterine artery embolization - cuts of blood supply to fibroids (effects on fertility largely unknown - if wanting to conceive try something else)
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13
Q

Aetiology of IMB

A

PALM COEIN

Poylp
Adenomyosis
Leiomyoma
Malignancy

Coagulopathy
Ovulatory dysfunction (i.e. an ovulation)
Iatrogenic
Endometriosis 
No cause found
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14
Q

Investigations for IMB?

A

Speculum - may show polyp

Smear - identify abnormal cells

TV USS:
1. Women >35
2. Women <35 who do not respond to treatment
Detection of fibroids and ovarian masses

Endometrial biopsy:
If endometrium is thickened
If polyp suspected
>40 y/o
Ablation surgery/IUS to be used
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15
Q

If no anatomical cause is found for IMB what is the cycle deemed to be?

A

Anovulatory

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16
Q

Management of IMB?

A

First line = IUS or COCP
COCP induces lighter and regular periods

  1. Progestogens - high levels induce amenorrhoea
  2. surgery - same as menorrhagia (Nb ablation unlikely as may still have irregular periods)
17
Q

What is important to exclude when PCB occurs?

A

Endometrial cancer

18
Q

Differential diagnosis for PCB?

A

Cervical: polyp, cervicitis, ectropion, cancer

Endometrial: polyp, fibroid

19
Q

Management of PCB?

A

Inspection of cervix + smear test

  1. Remove polyp
  2. Cryotherpay of ectropion (if smear clear and ectropion found)
20
Q

Causes of dysmenorrhoea?

A

Primary = idiopathic/ thought to be increased prostaglandins (usually occurs in first two years of menarche)

Secondary:
Endometriosis + adenomyosis 
PID
Fibroids
Pelvic adhesions 
Cervical stenosis (e.g. post LLETZ)
Asherman's
IUD
Congenital abnormality
21
Q

Investigations into dysmenorrhea

A

STI screen

TV USS - endometrioma, PID, fibroids, congenital ab

Laproscopy

Nb. If secondary dysmenorrhoea, refer to gynae

22
Q

Management of primary dysmenorrhoea?

A

NSAIDS (mefanmic acid / ibuprofen)
COCP
Mirena Coil

23
Q

Causes of primary amenorrhoea?

A

Turner’s syndrome (45X)
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of genital tract - mullerian agenesis

24
Q

Causes of secondary amenorrhoea?

A 
Hypothalamic hypogonadism
PCOS
Hyperprolactinaemia
POF
Thyrotoxicosis 
Sheehan's syndrome
Asherman's
25
Q

Oligomenorrhoea

A

Infrequent periods - 35 –> 6 months in frequency

26
Q

Hypothalamic hypogonadism

A

Common - usually psychiatric causes (anorexia nervosa or over exercising)
GnRH is reduced (prevents menstruation happening)
Bone density reduced (due to reduction of oestrogen)

27
Q

Hyperprolactinaemia

A

Pituitary hyperplasia/benign adenoma

Treatment = bromocriptine

28
Q

Hyper/hypothyroidism

A

Hypo –> raised prolactin –> amenorrhoea

29
Q

How should you treat premature ovarian failure?

A

HRT or COCP

30
Q

Asherman’s syndrome

A

Intra-uterine adhesions (usually iatrogenic causes - overzealous uterine curettage)

31
Q

Mullerian Agensis

A

Congenital malformation - mullerian ducts fail to form (absent uterus and variable malformations of vagina)

32
Q

Sheehan’s syndrome

A

Hypopituitarism - ischaemic necrosis (blood loss)

33
Q

Outflow tract problems that cause amenorrhoea?

A 
Genital tract abnormalities
Asherman's
Mullerian agenesis 
Transverse vaginal septum
Imperforate Hyman
34
Q

Investigation into amenorrhoea?

A 
PREGNANCY TEST
Gonadotrophins (low = hypothalamic, raised = ovarian)
Prolactin 
Androgen levels (PCOS)
Oestadoil 
TFT

GASH (13 decks)

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