abnormal menstrual bleeding Flashcards
abnormal menstrual bleeding
menorrhagia (>80mls)
investigations
endometrial biopsy, over 45/persist IMB chlamydia (esp IMB, PCB) • only check thyroid / coagulation if other symptoms • pregnancy test • transvaginal (TV) ultrasound scan • hysteroscopy laparoscopy
age and menstrual bleeding probs
• early teens anovulatory cycles
(congenital anomaly)
(coagulation problems)
• teens to 40 chlamydia
contraception related
endometriosis / adenomyosis
fibroids
endometrial or cervical polyps
dysfunctional bleeding
• 40 to menopause perimenopausal anovulation
endometrial cancer
warfarin
thyroid dysfunction
FIGO classification
PALMCOEIN
Polyp adenomyosis leiomyoma malignancy coagulation eg won willebrands ovarian eg pcos/ perimenopausl anov cycles Endocrine Iatrogenic eg warfarin N- not yet classified
DUB
Abnormal bleeding but No structural /endocrine /neoplastic /infectious cause found for complaint (yet)
50% hysterectomies for menorrhagia are for DUB
endometriosis
endometrial type tissue outside uterine cavity
usually ovary, pouch of douglas, pelvic peritoneum
• Symptoms:
o premenstrual pain, dysmenorrhoea, deep dyspareunia, subfertility
• Signs:
o may be none, or tender nodules in rectovaginal septum, limited uterine mobility, adnexal mass
Diagnosis:
laparoscopy
‘chocolate cysts’, ‘powder burn’ on peritoneum
treatment: ♣ progestogen • oral/inject/Mirena IUS ♣ combined pill – 3 months at a time ♣ GnRH analogues • E.g. leuprorelin ♣ Historical – (danazol/gestrinone)
o Surgical
♣ excision of deposits from peritoneum/ovary
♣ diathermy / laser ablation of deposits
♣ hysterectomy AND oophorectomy
adenomyosis
endometrial tissue in myometrium
• Symptoms/signs:
o heavy painful periods
o bulky tender uterus
• Diagnosis
o Probably normal USS, laparoscopy, hysteroscopy
hysterectomy
fibroids
smooth muscle growths leiomyoma arising from myometrium
Common & usually asymptomatic
o May present with dysmenorrhoea, menorrhagia, pressure symptoms, pelvic pain
♣ If they enlarge the uterine cavity surface area, may cause menorrhagia
If sub mucous or polyp may cause intermenstrual bleeding
submucous-protrude into uterine cavity
intramural- within uterine wall
subserous- project out of uterus into peritoneal cavity
• Treatment
o Nothing
o Standard menorrhagia Rx if cavity not too distorted
o GnRH analogues – as temporary shrinkage prep (adjunct)
o Ulipristal oral antiprogestogen
o Transcervical resection
♣ submucous fibroids
o Myomectomy – risk of haemorrhage & hysterectomy
♣ Need caesarean if pregnancy after
o Uterine artery embolisation NICE approved
♣ Doesn’t always work well, risk of infection
o Hysterectomy
management for DUB
transexamic acid
-doesnt regulate cycle
progestogen -mirena progestogen IUD reduces bleeding treatment if family complete: -endometrial ablation -hysterectomy
menopause
average age 51 yrs
perimenopausal 5 years
o Hot flashes, breast tenderness, lower sex drive, fatigue, bloating, irregular periods, vaginal dryness, urine leakage, urinary urgency, mood swings, trouble sleeping
ovarian failure
-oestradiol falls
o FSH rises
o still some oestriol released from peripheral conversion of adrenal androgens in fat
Obesity increases oestrogen levels, higher risk of cancers (e.g. ovarian, endometrial)
menopausal symptoms
Vasomotor symptoms ‘hot flushes’
o Vaginal dryness/ soreness, low libido, muscle and joint aches, mood changes/ poor memory
• Menopause – silent change: osteoporosis o Reduced bone mass – DEXA scan T score o Fractured hip/ vertebra ♣ 1% women 50-69; significant morbidity + mortality o Increased risk if: ♣ ♣ thin ♣ Caucasian ♣ Smokers ♣ EtOH (ethanol) ♣ +ve FH
Prevention & treatment:
o ♣ Weight bearing exercise ♣ Adequate calcium & Vit D ♣ HRT ♣ Bisphosphonates (calcitonin, strontium, denosumab - monoclonal antibody to osteoclasts)
HRT and others
o Oestrogen only if no uterus (can cause endometrial overgrowth)
o Oestrogen + progestogen if uterus present
• Local vaginal oestrogen pessary/ring/cream
• Systemic transdermal / oral
• Combined Oestrogen and Progestogen HRT
o Cyclical combined: 14 days E + 14 days E+P
♣ Get a withdrawal bleed
♣ Use if still some ovarian function i.e. perimenopause
o Continuous combined 28 days E+P
♣ settle to amenorrhoea
♣ use if > 1yr after menopause
♣ much lower dose than COCP, fewer contraindications
• Selective Estrogen receptor Modulators (SERMs)
o E effect on selected organs (e.g. tibolone/ ospemifene)
• SSRI/SNRI antidepressants
o e.g. venlafaxine or Clonidine
o NOT helpful side effects/few benefit
• Risks & benefits
o No overall increased mortality for HRT users
amenorrhoea
primary amenorrhoea: never had a period
Affect 5 % girls
Secondary amenorrhoea: has had periods in past but none for 6 month
• Causes:
o Pregnancy / Breast feeding (not ovulating)
o Contraception related – current use or for 6-9 months after Depo-Provera
o Polycystic ovaries
o Early menopause
o Thyroid disease/ Cushing’s/ Any significant illness
o Raised prolactin/ medication related
o Hypothalamic – stress/ wt change/ exercise
o Androgen secreting tumour – testosterone >5mg
o Sheehan’s syndrome – pituitary failure
o Asherman’s syndrome – intrauterine adhesions
investigations: BP, BMI, hirsutism, acne,deep voice
abdo exam
urine pregnancy test, bloods
ultrasound
o Assume fertile and need contraception unless 2 yrs after confirmed menopause
o If premature menopause offer HRT till 50
Emotional support
o check for Fragile X syndrome
fragile x syndrome
♣ X-linked dominant inheritance – mutation in FMR1 gene
♣ Causes a range of developmental problems including learning disabilities and cognitive impairment, more severe in males
♣ Most males have characteristic physical features that become more apparent with age. These features include a long and narrow face, large ears, a prominent jaw and forehead, unusually flexible fingers, flat feet, and in males, enlarged testicles (macro-orchidism) after puberty.
