Abnormal Vaginal Bleeding Flashcards
5 things required for normal menstruation to occur
- hypothalamic function
- pit. function
- ovarian function
- endometrial function
- patent cervix and vagina
What is mehorrhagia?
heavy menstrual bleeding in cyclical patterns which interferes with physical and social and emotional QoL
Best way of diagnosing menorrhagia
pictorial blood loss assessment charts are the best way but many doctors will diagnose based on subjective assessment
Systemic causes of HMB
thyroid disease
clotting disorders
Local causes of HMB
fibroids endometrial polyps/carcinoma endometriosis PID dysfunctional uterine bleeding
Iatrogenic causes of HMB
IUDs
Oral anticoagulants
Why do fibroids and polyps cause vaginal bleeding?
- they englarge the uterine cavity and so increase the SA of the endometrium
- they may secrete prostaglandins
Which local cause of HMB is diagnosed by exclusion?
Dysfunctional uterine bleeding
Which questions can help diagnose a proper HMB?
Flooding
Sanitary replacement
Clots
Nocturnal bleeding
What might be found on examination of a patient presenting with HMB?
Signs of anaemia Signs of thyroid disease Abdominal mass may be present Vaginal discharge Polyps/fibroids cervical motion tenderness enlarged uterus
Which blood tests are relevant for a pt presenting with HMB?
FBC
Thyroid
Clotting
Which imagining techniques will assist the Dx of HMB?
TVUSS / abdominal ultrasound
When should an endometrial biopsy be routinely taken?
Women aged over 45 with HMB and under 45 if there are risk factors for endometrial cancer
Apart from a gynaecology and obstetric history, which other history is key in a woman presenting with HMB?
Sexual history
Which antifibrinoltyic drug can be prescribed to help in HMB?
transexamic acid
Which other drug can be prescribed to help in HMB?
NSAIDs mefenamic acid, indomethacin or aspirin
What needs to be taken into account before providing a hormonal treatment for women?
fertility desires
Which IUS system is commonly prescribed in women who do not wish to conceive?
Mirena coil (levonorgestrel)
What is the risk of using GnRH agonists over a long period of time?
Bone density loss
What else should be prescribed with a GnRH agonist if it is planned to be used over a long period?
Add back hormone therapy
Which surgical procedures can be used to treat HMB?
Endometrial ablation
Hysterectomy
Which three systems can the causes of IMB and PCB be split into?
Cervical
Intrauterine
Hormonal
What are seam cervical causes of IMB/PCB?
Ectopy
Polyps
Malignancy
Cervicitis
What are some intra-uterine causes of IMB/PCB?
Polyps Submucosal fibroids Endometrial hyperplasia Endometrial malignancy Endometritis
Breakthrough bleeding is usually due to what cause?
Hormonal changes
Which investigations should be considered in a woman with unexplained symptoms of IMB/PCB?
HVS + ECS: rule out STI Cervical smear: exclude CIN or cervical cancer Pelvic USS: identify polyps or fibroids Hysteroscopy: for biopsy Laparoscopy: identify pelvic pathology
What are some possible treatment options for IMB/PCB?
Abx for any infections
Cautery to cervical surface
Removal of polyps/fibs
Why does PMB require prompt investigation?
Malignancy needs to be excluded
What percentage of women presenting with PMB will have a malignancy?
9%
Using anatomical regions of the female genital tract as a guide, what are some causes of PMB?
Ovaries: ovarian cancer, oes. sec. tumour
Uterus: Fibroid,polyp, hyperplasia, carcinoma
Cervix: atrophic changes, malignancy
Vagina: haematuria
Vulva: vulvitis, dystrophies, malignancies
What is the most common cause of PMB?
Atrophic changes to the lower genital tract due to oestrogen deficiency
Which physical change to the body can bring on PMB?
Gaining weight
Which other symptoms may accompany atrophic changes to the genital tract?
Vaginal dryness, soreness, superficial dyspareunia
What might you see O/E of a pt presenting with oestrogen deficiency as a cause of PMB?
Signs of anemia
Abdominal tenderness or masses
Vulval lesions
Which investigations should be performed on all women with PMB?
Pelvic USS
Hysteroscopic examination of the uterus
Endometrial biopsy
What is the most common medical treatment for PMB?
Oestrogen replacement either with progesterone as HRT or as a local cream/ring/pessary
