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Sexual Health + Obs & Gynae > Abnormal vaginal bleeding > Flashcards

Abnormal vaginal bleeding Flashcards

1
Q

What is abnormal uterine bleeding (AUB)?

A

Refers to any variance of a normal menstrual cycle in regards to frequency, regularity, duration, and volume.

AUB is common and can have a significant impact on quality of life.

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2
Q

Examples of abnormal uterine bleeding (AUB)?

A

Heavy menstrual bleeding (HMB)
- excessive menstrual loss

Intermenstrual bleeding (IMB)
- bleeding in-between periods

Post-coital bleeding (PCB)
- bleeding after sex

Post-menopausal bleeding (PMB)
- bleeding after the menopause (12 months after the last menstrual period)

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3
Q

How do you divide causes for abnormal uterine bleeding (AUB)? Give examples of causes?

A

PALM COEIN

Structural cause:
- Polyps
- Adenomyosis
- Leiomyoma
- Malignancy or hyperplasia

Non-structural causes:
- Coagulopathy
- Ovulatory disorder
- Endometrial
- Iatrogenic
- Not yet classified

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4
Q

What are polyps? Where does it commonly occur?

A

Refers to mucosal outgrowth that is small and benign (<1 cm).

Commonly occurs in endometrium and cervix.

Very low rate of malignancy.

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5
Q

What is the gold standard treatment for polyps?

A

Removal -polypectomy

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6
Q

Presentation of a pt who has polyps?

A
  • mostly asymptomatic
  • heavy menstrual bleeding (HMB)
  • intermenstrual bleeding (IMB)
  • post-coital bleeding (PCB)
  • post-menopausal bleeding (PMB)
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7
Q

What is adenomyosis?

A

Refers to endometrial tissueinside themyometrium(muscle layer of the uterus).

Common in women of reproductive age in the later years and those who had at least two or more pregnancies.

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8
Q

Presentation of a pt who has adenomyosis?

A
  • heavy menstrual bleeding (HMB)
  • dysmenorrhoea (painful periods)
  • pelvic pain
  • dyspareunia (pain during sexual intercourse)
  • may have infertility or pregnancy-related complications
  • may have enlarged and tender uterus
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9
Q

How is adenomyosis diagnosed?

A

1st line: transvaginal USS (or MRI or transabdominal USS)

Gold standard: histological examination of the uterus after a hysterectomy (but not suitable)

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10
Q

How is adenomyosis managed?

A

Depends on symptoms, age, and plans for pregnancy.

If pt does not want contraception:
- tranexamic acid (antifibrinolytic; given when no associated pain; reduces bleeding)
- mefenamic acid (NSAID, given when there is associated pain; reduces bleeding and pain)

If pt wants contraception:
- 1st line: mirena coil
- COCP
- cyclical oral progestogens

Other options:
- GnRH analogues
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy

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11
Q

What is endometriosis?

A

Refers to endometrial-like tissue found outside of the uterus.

It is an oestrogen-dependent, chronic inflammatory disease.

Affects 2-10% of women of reproductive age.

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12
Q

Presentation of endometriosis?

A
  • Can be asymptomatic
  • Cyclical abdominal or pelvic pain
  • Deep dyspareunia
  • Dysmenorrhoea (painful periods)
  • Heavy menstrual bleeding
  • Dyschezia -difficulty passing stool, straining
  • Infertility
  • Cyclical bleeding from other sites, such as haematuria
  • Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
  • A fixed cervix on bimanual examination
  • Tenderness in the vagina, cervix and adnexa
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13
Q

How is endometriosis diagnosed?

A

Gold standard: Laparoscopy

Pelvic USS (often unremarkable, may reveal large endometriomas (lump of endometrial tissue) and chocolate cysts (endometriomas in the ovaries).

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14
Q

How is endometriosis managed?

A

Medical:
1st line: analgesia (NSAIDs or paracetamol)

Hormonal therapies:
- COCP
- medroxyprogesterone acetate
- gonadotrophin-releasing hormone agonists

Surgical:
- Diathermy of lesions
- Ovarian cystectomy (for endometriomas)
- Adhesiolysis
- Bilateral oophorectomy (sometimes with a hysterectomy)

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15
Q

What is leiomyoma (aka fibroids)?

A

Refer to benign tumours of thesmooth muscleof the uterus.

They can develop in or around the uterus.

Common in 70-80% in women age >50.

Fibroids depend on oestrogen and progesterone.

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16
Q

What are the types of leiomyoma (fibroids)?

A

Intramural
- means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.

Subserosal
- means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.

Submucosal
- means just below the lining of the uterus (the endometrium).

Pedunculated
- means on a stalk.

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17
Q

Presentation of leiomyoma (fibroids)?

A
  • May be asymptomatic
  • Menorrhagia
  • Prolonged menstruation, lasting more than 7 days
  • Abdominal pain, worse during menstruation
  • Bloating or feeling full in the abdomen (distension)
  • Urinary or bowel symptoms (due to pressure on bowel and bladder)
  • Deep dyspareunia
  • Reduced fertility
  • Palpable pelvic mass or enlarged firm non-tender uterus
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18
Q

Investigations for fibroids?

A

Trans-vaginal USS
MRI
Biopsy

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19
Q

How are fibroids managed?

A

Non-surgical tx for fibroids causing abnormal bleeding and under 3cm in size with no uterine distortion:
- NSAIDs
- anti-fibrinolytics
- COCP
- Mirena

Surgical tx for fibroids causing symptoms due to their mass effect:
- myomectomy
- ablation
- uterine artery embolisation
- hysterectomy

20
Q

What is endometrial cancer?

A

Refers to cancer of theendometrium, the lining of theuterus.

21
Q

What is endometrial hyperplasia?

A

Refers to aprecancerouscondition involving thickening of the endometrium.

22
Q

Risk factors for endometrial cancer?

A
  • Increased age
  • Early menarche
  • Late menopause
  • Oestrogen only hormone replacement therapy
  • No or fewer pregnancies
  • Obesity
  • PCOS
  • Tamoxifen
23
Q

What type of bleeding occurs in endometrial cancer?

A

Post menopausal bleeding
Heavy menstrual bleeding
Intermenstrual bleeding

24
Q

What is the criteria for 2ww urgent referral for suspected endometrial cancer?

A

Post menopausal bleeding (>12 months after menstruation has stopped) -pt not on HRT

Unscheduled bleeding for 4-6 months after starting HRT

Abnormal abdominal/pelvic US suggestive of endometrial cancer

25
Q

What is the criteria for 2ww investigation for suspected endometrial cancer?

A

Age >55

Unexplained vaginal discharge -presenting for the first time/thrombocytosis/report haematuria

Visible haematuria and low Hb/thrombocytosis/high blood glucose level

26
Q

How is endometrial cancer treated?

A

Depends on the staging of cancer.

Early stage disease:
- total abdominal hysterectomy
- bilateral salpingo-oophorectomy

27
Q

What is cervical cancer? Common types of cervical cancer?

A

Refers to cancer of the cervix.

Common types of cancer are:
1. Squamous cell carcinoma.
2. Adenocarcinoma

Highest incidence rate age 30-34

28
Q

Presentation of cervical cancer

A

Post-coital bleeding
Intermenstrual bleeding
Vaginal discharge
Dyspareunia
Pelvic pain

29
Q

What is the criteria for 2ww urgent referral for suspected cervical cancer?

A

Appearance of cervix consistent with cervical cancer

AND

one of the following:
- post-coital/intermenstrual/post-menopausal bleeding
- abnormal persistent vaginal discharge (infection excluded)

30
Q

Risk factors for cervical cancer?

A

Genital HPV infection
Early age of first sexual intercourse
Multiple sexual partners
Lower socioeconomic status
Smoking
COCP use

31
Q

What is the cervical cancer screening programme?

A

Smear test (for anyone with a cervix):
- every 3 yrs for age 25-49
- every 5 yrs for age 50-64

  1. Test for HPV
  2. If HPV +ve →cytology
  3. If cytology abnormal →refer for colposcopy
  4. If cytology normal →repeat smear in 12 months

If HPV is -ve →routine recall

32
Q

What is HPV vaccine?

A

Gardisil 9 is the HPV vaccine that protects against 9 of the types of HPV that can cause cancer/genital warts.

It prevents up to 90% of cervical cancer.

HPV vaccine offered in to boys and girls in Year 8 and to anyone in a high risk population (e.g. HIV +ve, men who have sex with men).

HPV is a risk factor for cervical, oral, and anal cancer.

33
Q

What is amenorrhoea?

A

Refers to absence of menstruation.

34
Q

How is amenorrhoea classified?

A

Primary
- lack of menstruation by the age of 15
- or lack of menstruation by the age of 13 AND no secondary sexual characteristics

Secondary
- no menstruation in women who previously had ‘normal’ menstrual cycle

35
Q

Causes for primary amenorrhoea?

A

Hormonal
Anatomical
Genetic

36
Q

Causes for secondary amenorrhoea?

A

Hypothalamic-pituitary causes
- common lifestyle

Endocrine
- PCOS
- hyperprolactinaemia
- thyroid problems

Premature ovarian insufficiency, menopause

Anatomical

Pregnancy

Iatrogenic
- medication
- surgery

37
Q

What is hypothalamic-pituitary amenorrhoea?

A

Common cause of secondary amenorrhoea

No anatomical abnormalities

Various triggers affect GnRH pulsatile (regular) secretion from hypothalamus, which can lead to anovulation (no egg being released), hence causing amenorrhoea.

38
Q

Investigations in relation to hypothalamic-pituitary amenorrhoea

A

BMI check
Progesterone challenge (medroxyprogesterone acetate 10mg for 7-10d)
- give the women a progesterone for 7-10 days to see if she gets a bleed.
- bleed will occur if there is enough oestrogen.
- if no bleed, they have very low oestrogen.

39
Q

What triggers affect GnRH in hypothalamic-pituitary amenorrhoea?

A

Weight loss
Excessive exercise
Vitamin deficiency secondary to anorexia nervosa or reduced nutritional intake (e.g. due to Coeliac disease, thyroid problem)

40
Q

How is hypothalamic-pituitary amenorrhoea managed?

A

Depends on cause.

Menses unlikely to resume unless pt removes/improves the trigger.

E.g.
- reduce exercise intensity
- increasing nutritional intake
- working towards healthy BMI
- managing stress

41
Q

What is PCOS (polycystic ovarian syndrome)?

A

Is the most common endocrine disorder in women of reproductive age.

Causes metabolic and reproductive problems in women.

42
Q

How does PCOS present?

A

Oligomenorrhoea
Subfertility
Acne
Hirsuitism
Obesity
Mood changes including depression and anxiety
Male pattern baldness
Acanthosis nigricans (secondary to insulin resistance)

43
Q

Causes of PCOS?

A

Hormonal imbalances
Hyperandrogenism
Insulin resistance
Elevated levels of luteinising hormone (LH)
Raised oestrogen level

44
Q

How is PCOS diagnosed?

A

Rotterdam criteria
At least two of the following criteria are met:
- Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
- Oligo-/anovulation
- Clinical (acne, hirsutism, alopecia) or biochemical (raised free androgen index) features of hyperandrogenism

45
Q

How is PCOS managed?

A

Pt education
- Long term risks: CVD, endometrial cancer
- healthy wt (medication, bariatric surgery)
- manage CV RFs (obesity, diabetes -HbA1C screening, smoking, alcohol, diet, exercise)
- emotional wellbeing
- discuss subfertility/pregnancy concerns

46
Q

Investigations for amenorrhoea?

A

BMI
Urine test

Blood tests
- FSH
- LH
- Prolactin
- Testosterone/free androgen index (FAI)
- Oestradiol
- TFTs (hypo/hyperthyroidism)

Trans-vaginal US

47
Q

How to manage heavy menstrual bleeding?

A

1st line: Mirena coil

2nd line:
Hormonal:
- CHC
- cyclic PO progestogen
- POP (progesterone only pill)
- PO implant
- PO injectable

Non-hormonal
- tranexamic acid +/- NSAID (e.g. mefenamic acid)

If fibroids >3cm →consider specialist referral, but offer a trial of tx until appt.

Sexual Health + Obs & Gynae (5 decks)

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