Abnormal bleeding, PMS and PCOS Flashcards
What is primary vs secondary dysmenorrhoea?
PRIMARY
-Occurs within 1-2 years following menarche
-No underlying pelvic pathology
-Very common - up to 50% of women
-Caused by excessive production of endometrial prostaglandins
-Treated with NSAIDs or COCP (2nd line)
SECONDARY
-Occurs many years after menarche
-Caused by underlying pathology eg endometriosis, adenomyosis, PID, fibroids
-Pain starts 3-4 days before period
-May be associated with dyspareunia
-Refer to gynaecologist, treat cause
How are dysmenorrhoea, menorrhagia, polymenorrhoea and oligomenorrhoea defined?
DYSMENORRHOEA = excessive pain during the menstrual period
MENORRHAGIA = prolonged (>7 days) and/or heavy (>80ml) uterine bleeding
POLYMENORRHOEA = abnormally short intervals between regular menses (<21 days)
OLIGOMENORRHOEA = abnormally long intervals between regular menses (>35 days)
How is menorrhagia investigated and managed?
INVESTIGATIONS
-TVUS, endometrial biopsy, outpatient hysteroscopy
-FBC
TREATMENT
-Mirena coil (1st line)
-Mefenamic acid, tranexamic acid, NSAIDs, COCP
-Ablation / hysterectomy if finished family
What commonly causes oligomenorrhoea?
-PCOS
What is the difference between primary and secondary amenorrhoea?
PRIMARY
-Failure to start menstruating (>16 / >14 with no breast development)
-Examination and karyotyping
SECONDARY
-Periods stopping for >6 months (not pregnant)
-Can be caused by HPO axis disorders (athletes), ovarian insufficiency, uterine causes, genetic disorders eg Turner’s
What should post-menopausal bleeding be treated as and what is it instead normally caused by?
-Defined as bleeding >1 year after last period
-Should be investigated as ?endometrial carcinoma until proven otherwise
-Often due to atrophic vaginitis (menopausal changes)
What commonly causes post-coital bleeding?
-Cervical ectropion is most common cause (common in women on COCP)
-Cervicitis
-Cervical cancer
-Polyps
-Trauma
How are abnormal menstrual bleeding disorders diagnosed?
-1st priority = rule out pregnancy-related causes (eg miscarriage, molar pregnancy)
-Review medications
-Check for underlying cause (TFTs)
-Abdo and pelvic examinations
-Bloods - FBC, iron, ferritin, clotting
-Menstrual calendar / diary
-Consider endometrial biopsy, hysteroscopy, USS
How should abnormal bleeding be managed medically?
-Oral contraceptives
-Mefanamic acid (NSAID)
-Tranexamic acid (anti-fibrinolytic)
-IUS
How should abnormal bleeding be managed surgically?
-Dilation and curettage
-Hysterectomy
-Endometrial ablation
How does premenstrual syndrome present?
NB a common syndrome that is typically mild, but 5-10% report severe symptoms, and 5% report interference with work and relationships
-Abdominal bloating
-Weight gain
-Constipation
-Anxiety, stress, fatigue, irritability
-Breast tenderness
-Reduced visuospatial ability
-Depression
-Cravings for sugar or salt
How is PMS managed?
1st line = supportive therapy
-Exercise, diet modification, weight loss
-Smoking cessation
-Stress management
-CBT
Fluoxetine
-Low-dose SSRI to reduce mood symptoms
2nd line
-Estradiol patches + progesterone / mirena
-Sertraline
3rd line
-GnRH analogues, HRT
4th line
-Total hysterectomy
How is PCOS defined?
-Unexplained hyerandrogenic chronic involution in which secondary causes have been excluded
What are typical LH and FSH levels in PCOS?
-LH is chronically elevated
-FSH is chronically suppressed
-No rising and falling like in normal menstrual cycles
What are the effects of deranged LH and FSH levels?
-Increased LH
–Stimulates ovarian stroma and theca cells – increased production of androgens
–These are converted peripherally to oestrogen which perpetuates chronic anovulation
-Suppressed FSH
–New follicular growth is continuously stimulated but never to the point of full maturation + ovulation
-Increased circulating testosterone
–Due to decreased levels of sex hormone-binding globulin levels
