Abnormal bleeding (Gynae) Flashcards
What are key features on history which should be identified in women presenting with abnormal bleeding?
- Background
- Age - menopause status
- Contraception status
- Ever been diagnosed or investigated for any gynaecological issues?
- have you ever been pregnant or is it possible you are currently pregnant? - Normal menstrual cycle - length, regularity, heaviness, pain
- LMP - ? pregnant, perimenopausal, regularity.
WAS THIS NORMAL FOR YOU (important for early pregnancy bleeding) - Current bleeding issue - PCB, IMB, irregular cycle. Acute vs. chronic issue
- Associated features - pain (cyclical vs. constant vs. dyspareunia, abdo or pelvic), bowels, bladder, discharge
If indicated:
- Symptoms of PCOS - acne, hirutism, weight issue
- Symptoms of anaemia
- Bleeding history
- Eating, exercise, stress hx
- Brief sexual hx - current partner, gender, recently changed partners, previous STI, ever been screened?
- Pap smear
- Obstetrics - previous pregnancies - miscarriages, ectopics? Possibility currently pregnant?
- FHx - PCOS, endometriosis, bleeding or clotting disorders, gynae cancers
What are key examination and associated investigations to be performed?
Abdominal examination - palpable masses, tenderness or signs of peritonitis
Speculum examination - cervical pathology & assessment, vaginal or vulval source of bleeding, discharge, endocervical swabs, papsmear
Bimanual examination - uterine mass, adnexal mass, adnexal tenderness, cervical motion tenderness
Colposcopy - if recurrent or persistent or abnormal smear hx
What are the DDx for PCB?
Cervical pathology - malignancy, ectropion, polyps, cervicitis (chlamydia)
Atrophic vaginitis if post-menopausal
Chlamydia is the most common cause
What are the DDx for IMB?
Uterine causes - polyps, fibroids, endometritis and PID
Ectropion, cervicitis, cervical cancer
Endometrial hyperplasia, endometrial cancer
Contraception - skipping withdrawal bleed, inadequate pill dosage, progesterone only medication
Pregnancy and related complications
Trauma
What are the DDx for oligomenorrhoea/irregular periods?
PCOS
Endometriosis
Hyperprolactinaema - prolactinoma, drug induced
Other endo - diabetes, Cushing’s
Stress, nutrition, excess exercise, eating disorder
What are the the clinical features of fibroids?
Most commonly present as noticeable pelvic mass
May have associated pelvic pressure or obstructive symptoms - retention, bladder dysfunction, bowel dysfunction
Pelvic pain
Menorrphagia, IMB - increased endometrial SA, lining over fibroid may be incompletely shed
Subfertility, recurrent miscarriage
Smooth, firm, non-tender mass palpable on bimanual examination
Enlarged, bulky mobile uterus
What is the Ix of fibroids?
U/S +/- sonohysterography - confirm diagnosis and characterise type, exclude other masses
MRI - best imaging modality if complex case or work-up prior to surgery. Can distinguish between fibroid and sarcoma
FBE, Fe studies
What is the Rx of fibroids?
Rx anaemia
Symptomatic management
- anti-fibrinolytics, OCP, mirena, GnRH analogues
- cyclical NSAIDs
Management of fibroid
- Expectant - monitor with U/S ~6-12 mths to assess if rapidly growing/atypical features
- GnRH - can reduce size
- Surgery - myomectomy or hysterectomy
- Interventional radiology - MR guided U/S to shrink/’kill’ it or injection of particles to vessels to disrupt blood supply and cause necrosis
What are general pathological features of fibroids?
Grow during reproductive years, generally stop growing at menopause but don’t neccessarily shrink
Some grow, some stay the same and some regress- course is variable
Become more common as approaching menopause
Almost always benign but can be sarcoma
U/S - hypoechoic, may have cystic areas with necrosis, focal calcification
Path - white, whorled cut surface appearance, circular and well defined
What factors guide management of fibroids?
Womens preference, how impacting on life, fertility issues
Size of fibroid, if rapidly growing or suspicious features, type of fibroid (i.e. intramural makes myomectomy harder), pedunculated (myomectomy often easier)
What are the general features of polyps?
Overgrowth of an endometrial gland
Common cause of PMB
95% benign
Symptomatic or post-menopausal polyps more likely to be malignant than asymptomatic, especially in pre-menopausal
What are risk factors for polyps?
Oestrogen excess, tamoxifen, obesity
Lynch syndrome
Increasing age
What are the clinical features of polyps?
May be asymptomatic and found incidentally on U/S or pap smear (presence of endometrial cells)
Irregular bleeding and IMB most common symptoms
Can cause menorrhagia but usually light bleeding/spotting
Unlikely to have examination findings unless polyp is prolapsed and visible on speculum examination
What are the Ix and management options of polyps?
TV U/S +/- sonohysterography
All symptomatic polyps (pre and post-menopausal) and all post-menopausal (even if asymptomatic) must be removed and histologically evaluated for malignancy
Hysteroscopy with diathermy loop removal or polyp forceps removal
What is the definition of abnormal bleeding and what does it include?
Overarching term describing uterine bleeding which is abnormal in its amount of timing
Can be acute or chronic
Includes heavy menstrual bleeding, IMB and irregular bleeding (ovulatory dysfunction)
What is the definition of heavy menstrual bleeding?
How can it be distinguished from normal?
> 80ml menstrual bleeding
7 day duration
Any bleeding that is considered unacceptably heavy to the women
Abnormal if flooding, clots
Soaking/changing pads <2 hours
Increased absorbancy sanitary pads
What are the DDx for heavy menstrual bleeding?
Structural - PALM
Polyp, adenomyosis, leiomyoma, endometrial malignancy or hyperplasia
Non-structural - COIEN
Coagulopathy, ovulatory dysfunction, iatrogenic (contraception factors, anticoags), endometrial (normal ovulation but no other cause), non-otherwise specified
What are ovulatory dysfunction causes of abnormal bleeding?
Endocrine - PCOS, hypothyroid, hyperprolactinaemia Stress Sudden weight change - gain or loss Excess exercise, poor nutrition Eating disorder
What are causes of hyperprolactinaemia?
Prolactinoma
Dopamine influencing medications - metoclopramide, antipsychotics
What Ix would you perform for heavy menstrual bleeding?
FBE + Fe studies
TV U/S with endometrial thickness
Pap smear
If indicated Beta-hCG Coagulation profile and bleeding disorder work-up TFT Explorative laparoscopy Swabs for infection Urine MCS and PCR
What are the symptomatic medical Rx for heavy menstrual bleeding?
*Treat anaemia and underlying cause
- Non-hormonal - PG inhibitors (mefenamic acid), anti-fibrinolytics (tranexamic acid)
- Hormonal - 1st = COCP, 2nd = danazol, GnRH analogues
- Procedural - mirena
What are the surgical symptomatic Rx for heavy menstrual bleeding?
- Endometrial ablation
2. Hysterectomy
What is the most common cause of heavy menstrual bleeding?
Endometrial causes
How/what types of fibroids result in heavy menstrual bleeding?
If they expand the diameter or push into the cavity of the uterus they will cause heavy bleeding
Intramural and submucosal are the main fibroid types that cause heavy bleeding
What factors should be considered for coagulopathic causes of HMB?
Younger patients with HMB from onset of menarch are more likely than older women presenting later to have coagulopathy
- Should test young women for vW and platelet dysfunction
Older women may have acquired causes such as anticoagulation, chronic liver or renal disease or leukaemia
