Abnormal uterinblødning og tidlige graviditetsutfordringer

Question 1

Hvordan foregår den normale menstruasjonssyklusen?

Answer 1

Menstruation is the cyclic, orderly sloughing of the uterine lining, in response to the interactions of hormones produced by the hypothalamus, pituitary, and ovaries.

The menstrual cycle may be divided into two phases: (1) follicular or proliferative phase, and (2) the luteal or secretory phase.

The length of a menstrual cycle is the number of days between the first day of menstrual bleeding of one cycle to the onset of menses of the next cycle. The median duration of a menstrual cycle is 28 days with most cycle lengths between 25 to 30 days.

Patients who experience menstrual cycles that occur at intervals less than 21 days have FREQUENT menstruations, while patients who experience prolonged menstrual cycles greater than 35 days, have INFREQUENT menstruations.

The typical volume of blood lost during menstruation is approximately 30 mL. Any amount greater than 80 mL is considered abnormal. The menstrual cycle is typically most irregular around the extremes of reproductive life (menarche and menopause) due to anovulation and inadequate follicular development.
The luteal phase of the cycle is relatively constant in all women, with a duration of 14 days. The variability of cycle length is usually derived from varying lengths of the follicular phase of the cycle, which can range from 10 to 16 days.

Question 2

Hva er mekanismen bak menstruasjon?

Answer 2

Question 3

Hvor lenge varer en mesntruasjonssyklus?

Answer 3

The luteal phase is usually stable at 14 days.

Question 4

Hvilke alderrelaterte syklusforandringer skjer?

Answer 4

Question 5

Jmf. FIGO (2011), hvilken terminologi skal man bruke ved abnormal uterinblødninger (AUB)?

Answer 5

Question 6

Hvilken gammel terminologi brukes om AUB?

Answer 6

Menorrhagia, metrorrhagia, menometrorrhagia, DUB (dysfunctional uterine bleeding). ICD 10 (currently revised): N91, N92, N93
Mahdra M et al, 2014:

Disadvantage;
No specific underlying pathology, unclear if relating to symptoms or clinical diagnosis, wide variety of interpretation, different definitions for DUB USA /UK

1. Consequences of old terminology:
   Different underlying diagnoses same terminology or ICD 10 code
2. Imprecise estimates of disease prevalence.
3. Suboptimal resource allocation.
4. Systematic reviews/metaanalysis inadvertedly recommend interventions with less benefit/more harm. Number of subjects in clinical trials greater than necessary.

Question 7

Hvilke årsaker gir AUB?

Answer 7

PALM-COEIN!

Malignancy (predominantly cervix and endometrial, but also vaginal and ovarian) and hyperplasia should be considered in women of all ages.

NB: Coagulopathy can be caused by anticoagulation!

Endometria dysfunction: Diagnosis of exclusion. Disturbances of fibrinolytic systems, prostaglandins, other vasoactive mediators

Iatrogenic: Sex steroid administration, IUD, or other drug effects

Not otherwise classified: Arteriovenous malformations

Question 8

Hva er stor menstruasjonsblødning jmf. (NICE guidelines 44, 2007)?

Answer 8

Not necessarily > 80 ml.

1/3 fertile women complain of heavy menstrual bleeding (HMB).

Associated decrease QoL comparable to chronically ill.

Cost of treatment in USA comparable to annual gas/electricity in Europe

Question 9

Hva er de vanligste årsakene til irregulære, store blødninger hos kvinner?

Answer 9

Question 10

Hvilke anamnestiske spørsmål er akt. ved AUB?

Answer 10

Question 11

Hvilke us. bør gjøres ved AUB?

Answer 11

Endometrial sampling in all women over age 40 with AUB; in younger women if risk factors for hyperplasia/malignacy are present.

D+C is rarely indicated today; it requires general anestetics and the sampling has been shown to be less representative than when aquired via hysteroscopy.

Hysteroscopy is usually performed without or with local anestesia.

Question 12

Hvilket verktøy kan man anbefale kvinner som menstruerer?

Answer 12

Question 13

Hvilke diff.diagnoser har man ved inspeksjon av cervix?

Answer 13

Erytroplaki er en klinisk betegnelse på en rød flekk i en slimhinne, vanligvis i munnen eller områdene for kjønnsorganene. Flekken skyldes ikke mekanisk, kjemisk eller termisk skade og heller ikke betennelse eller en tilstand knyttet til blodårene. Den er uttrykk for forandringer i slimhinnens epitel som ofte viser seg å være et forstadium til kreft. Erytroplaki er en utelukkingsdiagnose, og det bør tas vevsprøve og utføres kirurgisk fjerning (SNL).

Question 14

Hvordan utfører man en endometriebiopsi?

Answer 14

This gives a Histology specimen (it shows the architecture of the endometrium, NOT only cytology as the cervical smear.

Question 15

Hva ser man etter på UL av uterus?

Answer 15

With transvaginal ultrasound, the size and configuration of the uterus is evaluated.

Benign and malignant neoplasias of the myometrium can be visualized.

The endometrial thickness, border and structures is evaluated.

The ovaries are inspected for cysts and neoplasia.

Question 16

Hva visuliserer man med et hysteroskop?

Answer 16

Question 17

Baser på sykehistorien, hvordan kan man bruke PALM-COEIN?

Answer 17

Question 18

Hvordan behandler man hhv. disse tilstandene:
- Erytroplaki
- Cervikale polypper
- Cervix neoplasi

Answer 18

Question 19

Hvilke behandlingsalternativer har man ved AUB?

Answer 19

Question 20

Hvordan er effektiviteten til de ulike alt. ved stor menstruasjonsblødning?

Answer 20

Question 21

Hvordan er det typiske blødningsmønsteret før/etter innsetting av en hormonell IUCD?

Answer 21

Hormon containing IUD (Mirena, Jaydess) can be a very effective first line treatment for for HMB. It is also indicated for the treatment of dysmenorrhoe. There are very few contraindications for the use.

Question 22

Hvordan kan man behandle irregulære, kraftige menstruasjonsblødninger?

Answer 22

This treatment is indicated in particular, if endometrial hyperplasia is suspected or demonstrated (histology from the pipelle aspirat).

https://www.felleskatalogen.no/medisin/provera-pfizer-563078#egenskap

Question 23

Hvilke metoder kan man bruke ved endometriell ablasjon?

Answer 23

Question 24

Hvordan kan man konservativt behandle fibrom i uterus som gir kraftige blødninger?

Answer 24

Question 25

Hvilken kirurgisk/radiologisk teknikk kan brukes mot fibromer?

Answer 25

This is performed at the radiology department under local anestetics.

Less risk for serious complications for the patient.

Very effective for the treatment of bleeding problems caused by uterine myoma , in about 80-90 % hysterectomy is avoided.

The myoma shrinks by about 50% by 6-12 months. However, less effective for pressure symptoms caused by uterine myoma.

Question 26

Hvilke varienter av hysterektomi kan utføres ved ABU?

Answer 26

Vaginal and laparoskopic hysterectomy causes less complications and is associated with shorter hospital stay and recovery.

Vaginal hysterectomy can be performed, but it depends on the size and mobility of the uterus and if there is suspected other pathology (ovaries/peritoneum).

Question 27

Hvordan behandler man store menstruasjonsblødninger i perimenopausen?

Answer 27

Question 28

Hva er forskjellen mellom HRT og COC behandling?

Answer 28

Question 29

Hva er årsaken til postmenopausale blødninger?

Answer 29

Question 30

Hvordan us. man postmenopausale kvinner med blødning?

Answer 30

Question 31

Hvordan behandler man kvinner med postmenopausal blødning?

Answer 31

Femarelle – et kosttilskudd for livskvalitet i overgangsalderen.

Femarelle …… innhold av allopregnanolon (AP), en endogen nevrosteroid. Det er ikke påvist klart bedre effekt en placebo.

Question 32

Hvilken risiko har polypper i cervix/uterus til å bli maligne?

Answer 32

TCPR can be performed without any anestetics policlinically with small, 3 mm hysteroscopes, or as daysurgery with local anestetics and sedation. Rarely general anestetics is required.

Tamoxifen is a selective estrogen receptor modulator (SERM) medication used to treat breast cancer in men and women and as a prophylactic agent against breast cancer in women.

Question 33

Hva vil korrekt behandling av AUB kunne føre til?

Answer 33

https://www.clinicalkey.com/student/content/toc/3-s2.0-C20200017846

https://www.sundhed.dk/sundhedsfaglig/opslag-og-vaerktoejer/laereboeger/obstetrics-gynecology/gynecology/

https://www.legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/veiledere/veileder-i-gynekologi/gynekologiske-blodningsforstyrrelser/

Question 34

Hvilke anamnestiske opplysninger må man spørre om ved blødninger/smerte hos kvinner som er gravide?

Kortkommet graviditet

Answer 34

Question 35

Hvilke us. bør gjøres hos gravide med blødninger/smerte?

Kortkommet graviditet

Answer 35

Question 36

Hva ser man etter på transvaginal UL hos kvinner som er gravide med blødninger/smerte?

Kortkommet

Answer 36

Question 37

Hvilke lab.prøver er akt. hos kvinner i tidlig graviditet med blødninger/smerte?

Answer 37

Question 38

Hvordan behandler man ektopiske graviditeter?

Answer 38

Question 39

Hvilke typer spontanaborter deler man inn i, og hva er behandlingen?

Answer 39

https://www.clinicalkey.com/student/content/toc/3-s2.0-C20200017846

https://www.sundhed.dk/sundhedsfaglig/opslag-og-vaerktoejer/laereboeger/obstetrics-gynecology/gynecology/