Abnormal Menstrual Bleeding Flashcards

1
Q

What are the causes of persistent Abnormal Menstrual Bleeding?

A

Ovulatory
Vulval or labial (herpes, genital warts)
Vaginal (atrophic vaginitis, adenosis, tumours, trauma, foreign body, sexual abuse)
Cervical (cervicitis, cervical ectropion associated with contraception, cervical polyps, cancer)
Endometrial (Ca, fibroids)
Leiomyoma (fibroids)
Coagulopathies
Adenomyosis (uterine tissue growing in the uterus wall)

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2
Q

What are the recommended investigations for heavy menstrual bleeding?

A

UPT +/- serum hCG
CBC including ferritin
TSH
Coag and LFTs if hx suggests haemostasis defect (freq nose bleeds, easy bruising, HMB from menarche, FHx)
Pipelle – to rule out endometrial hyperplasia
STI screen
Consider punch biopsy of the vulva
Smear
Pelvic USS including endometrial thickness (if suspect a structural cause; rare <40yrs)

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3
Q

What are the risk factors for endometrial cancer?

A

> 45 yrs, or >35yrs and BMI >30, diabetes, HTN, exposure to unopposed OE2, nulliparity, infertility, PCOS, Maori/PI, FHx endometrial Ca, CRC, SI Ca, Ureter or renal Ca; taking tamoxifen

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4
Q

What is the management of HMB?

A

Fibroids < 3cm Mx by GP with Mirena, COC with >30/35mcg ethinylestradiol if wanting to be pregnant in the near future, Depot, TXA, cyclical progesterones (no contraception, least effective) days 5-25, NSAIDs

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5
Q

What are the causes of intermenstrual bleeding?

A

Ovulation,
STIs,
Endometrial or cervical poylps,
Progesterone only contraception,
Endometrial hyperplasia or malignancy,
C section scar defect

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6
Q

What investigations should be done for intermenstrual bleeding?

A

UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS including endometrial thickness if persistent or exam reveals any abnormalities

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7
Q

What is the management of Intermenstrual bleeding?

A

If using COC, consider increasing the ethinyloestradiol dose (to max 35mcg) or change the type of progesterone
If COC running packs together stop for 4 days then resume
Can be common to have unpredictable bleeding with progesterone only pills and it doesn’t always settle over time
Refer to gynae if Ix normal and still an issue

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8
Q

What are the causes of post-coital bleeding?

A

STIs,
Cervical ectropion or polyps, Atrophic vaginitis,
Cervical Ca,
Vaginal Ca,
Trauma

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9
Q

What investigations should be done for post-coital bleeding?

A

UPT +/- serum hCG
STI screen
Consider punch biopsy of the vulva
Smear
USS
Colposcopy if pelvic exam reveals any abnormality

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10
Q

What is the treatment for post-coital bleeding?

A

Depends on the cause e.g.
Atrophic vaginitis: vaginal lubricants or topical vaginal oestrogens
Remove any cervical polyps (GP if <1.5cm; otherwise refer gynae)
If results abnormal, persistent or recurrent post coital bleeding refer for colposcopy

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11
Q

What are common causes of post-menopausal bleeding?

A

Endometrial or vaginal atrophy (60-80%),
MHT (15-25%), Endometrial/cervical polyps 2-12%,
Endometrial hyperplasia (10%),
Endometrial cancer (10%), Cervical cancer <1%.

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12
Q

If on tamoxifen with post coital bleeding what tests are required?

A

Hysteroscopy and pelvic USS

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13
Q

If not recently started on MHT OR >6 months continuous MHT OR unscheduled bleeding if taking cyclical MHT what tests are required urgently?

A

High priority pelvic USS

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14
Q

If high suspicion of endometrial cancer what tests are required for post menopausal bleeding?

A

A pipelle and pelvic USS

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15
Q

What are the diagnostic criteria for PCOS?

A

Rotterdam criteria: 2 of oligomenorrhoea/anovulation; clinical or biochemical hyperandrogenism; polycystic ovaries on USS if >20 yrs old.

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16
Q

What is the management of PCOS?

A

Laser/creams/threading/plucking/waxing/electrolysis for excessive undesirable hair
Pharm takes 6-12 months to work
COCP at lowest effective dose 1st line (oestrogen 20-30mcg); if this is ineffective after 6 months add an anti androgen

17
Q

What is the pathophysiology of PCOS?

A

Reproductive and metabolic features are due to insulin resistance irrespective of BMI which promotes ovarian androgens and reduces SHBG which increases the free and total androgens

18
Q

What are the implications of PCOS?

A

Fertility reduced due to irregular periods
Anxiety/depression
Eating disorders
Body image issues
Increased CVD risk
Increased diabetes risk independent of BMI
OSA

19
Q

What is the treatment for poor fertility in PCOS?

A

If <4 cycles per year use medroxyprogesterone acetate to induce withdrawal bleeds if not on COCP

20
Q

What are the monitoring requirements for PCOS CVD risk?

A

assess lipids at baseline and regularly if BMI >25
Yearly BP, aim for BP <130/85

21
Q

What is the monitoring for diabetes in those with PCOS?

A

Assess HbA1c in all women at baseline and every 1-3 years depending on risk factors
OGTT recommended if BMI >25, Asian with BMI >23, FHx of IGT or gestational DM, FHx T2DM or high risk ethnicity
OGTT pre pregnancy, with fertility therapy, and at 25-28 weeks gestation
o Use contraception while on GLP-1 agonists or spironolactone (for hirsuitism)
o Metformin not recommended in pregnancy