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Women's Health - Year 4 > Abnormal Vaginal Bleeding > Flashcards

Abnormal Vaginal Bleeding Flashcards

1
Q

what is menarche?

A

first menstrual cycle, between age of 11 and 15. Cycle duration usually 21-35 days

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2
Q

what does FSH do?

A

binds to granulosa cells to stmulate follicle growth, permit conversion of androgens from theca cells to oestrogens and stimulate inhibin secretion

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3
Q

what does LH do?

A

acts on theca cells to stimulate production and secretion of androgens

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4
Q

describe the hypothalamic pituitary gonadal axis?

A
  • GnRH from hypothalamus
  • Stimulates LH and FSH release from anterior pituitary, these act mainly on the ovaries
  • Controlled by feedback systems
  • Moderate oestrogen level – negative feedback on HPG axis
  • High oestrogen level (in absence of progesterone) – positive feedback on HPG axis
  • Oestrogen in presence of progesterone – negative feedback on HPG axis
  • Inhibin selectively inhibits FSH at anterior pituitary
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5
Q

follicular phase of ovarian cycle

A
  • Beginning of new cycle as follicles mature and release oocyte
  • Start of new cycle there is little ovarian hormone production and follicle begins to develop independently of gonadotropins or ovarian steroids.
  • Due to low steroid and inhibin levels – little negative feedback at HPG axis resulting in increase FSH and LH
  • This stimulates follicle growth and oestrogen production
  • As oestrogen levels rise, negative feedback reduces FSH levels and only one follicle can survive
  • Follicular oestrogen eventually becomes high enough to initiate positive feedback, increasing levels of GnRH and gonadotropins and LH surge due to increased follicular inhibin, selectively inhibitning FSH production at anterior pituitary
  • Granulosa cells become lutenised and express receptors for LH
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6
Q

describe ovulation

A
  • LH surge follicle rupture and mature oocyte travels to fallopian tube where it is viable for ovulation for around 24 hours
  • After ovulation the follicle remains luteinised, secreting oestrogen and progesterone negative feedback. This along with inhibin (inhibits FSH) stalls cycle for fertilisation
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7
Q

describe the luteal phase of the ovarian cycle

A
  • Corpus luteum is tissue in ovary that forms at site of ruptured following ovulation.
  • Produces oestrogens, progesterione and inhibin to maintain conditions for fertilisation and implantation
  • In absence of fertilisation the corpus luteum regresses after 14 days
  • Significant fall in hormones, relieving negative feedback and resetting HPG axis
  • If fertilisation – embryo syncytiotrophoblast produces HcG, exerting luteininsing effect and maintaining corus luteum
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8
Q

proliferative phase of uterine cycle?

A
  • Following meses, this runs alongside follicular phae t prepare reproductive tract for fertilisaiton and implantation
  • Oestrogen initiates fallopian tube formation, thickening of endometrium, increased growth and motility of myometrium and production of thin alkaline cervical mucus
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9
Q

secretory phase of uterine cycle

A
  • Runs alongside luteal phase
  • Progesterone stimulates further thickening of endometrium into glandular secretory form, thickening of myometrium, reduction of motility of myometrium, thick acidic cervical mucus production, changes in mammary tissue and other metabolic changes
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10
Q

menses

A
  • Marks beginning of new menstrual cycle
  • Occurs in absence of fertilisation once corpus luteum has broken down and internal lining of uterus is shed
  • 2-7 days with 10-80ml blood loss
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11
Q

how can causes of heavy vaginal bleeding be classified?

A

Causes can be classified into structural causes and non structural causes

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12
Q

HEAVY VAGINAL BLEEDING

structural causes

A 
PALM
•	Polyp
•	Adenomyosis
•	Leiomyoma (fibroid)
•	Malignancy and hyperplasia
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13
Q

HEAVY VAGINAL BLEEDING

nonstructural causes

A 
COEIN
•	Coagulopathy
•	Ovulatory dysfunction
•	Endometrial
•	Iatrogenic 
•	Not yet classified
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14
Q

HEAVY VAGINAL BLEEDING

risk factors

A
  • Age – most likely at menarche and approaching menopause
  • Obesity
  • Previous caesarean section – risk factor for adenomyosis
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15
Q

HEAVY VAGINAL BLEEDING

clinical features

A
  • Bleeding during menstruation deemed excessive to the individual
  • Fatigue
  • Shortness of breath
  • During history enquire about menstural cycle, smear history, contraception, medical history, medications
  • Examination
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16
Q

HEAVY VAGINAL BLEEDING

what should be examined

A

should include; general observation, abdominal palpation, speculum and bimanual examination.
• Pallor
• Palpable uterus or pelvic mass – smooth or irregular uterus -> fibroids / tender uterus or cervical exciation point toward ademomyosis/endometriosis
• Inflamed cervix/cervical polyp/ cervical tumour
• Vaginal tumour

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17
Q

HEAVY VAGINAL BLEEDING

differential: pregnancy

A

Urine pregnancy test

May indicate miscarriage or ectopic pregnancy

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18
Q

HEAVY VAGINAL BLEEDING

differential: endometrial/cervical polyps

A

Can cause intermenstrual or post coital bleeding

Generally not associated with dysmenorrhoea

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19
Q

HEAVY VAGINAL BLEEDING

differential: adeomyosis

A

Associated with dysmenorrhea

Bulky uterus on examination

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20
Q

HEAVY VAGINAL BLEEDING

differential: fibroids

A

History of pressure symptoms eg urinary frequency

Bulky uterus on examination

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21
Q

HEAVY VAGINAL BLEEDING

differential: malignancy or endometrial hyperplasia

A

Bleeding from vaginal or cervical malignancies or that provoked by ovarian tumours

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22
Q

HEAVY VAGINAL BLEEDING

differentials: coagulopathy

A

Von willebrands disease most common coagulopathy to cause heavy menstrual bleeding
HMB since menarche, history of post partum haemorrhage, surgical related bleeding or dental related bleeding, easy bruising/epistaxis, bleeding gums, family history of bleeding disorder
Consider anticoagulant eg warfarin

23
Q

HEAVY VAGINAL BLEEDING

differentials: ovarian dysfunction

A

Polycystic ovary syndrome and hypothyroidism

24
Q

HEAVY VAGINAL BLEEDING

differentials: iatrogenic

A

Contraceptive hormones

Cooper IUD

25
Q

HEAVY VAGINAL BLEEDING

differentials: endometriosis

A

<5% all heavy menstrual bleeding cases

26
Q

HEAVY VAGINAL BLEEDING

what investigations can be considered

A 
FBC
TFT
hormone testing
coag screen (and von willebrands)
US pelvis
cervical smear
high vaginal and endocervical swabs
pipelle endometrial biopsy
hysteroscopy and endometrial biopsy
27
Q

HEAVY VAGINAL BLEEDING

what might FBC show

A

Anaemia if blood loss 120ml

28
Q

HEAVY VAGINAL BLEEDING

why do TFT

A

if there are other signs and symptoms of underactive thyroid

29
Q

HEAVT VAGINAL BLEEDING

why do other hormone testing

A

If other clinical features eg polycystic ovary syndrome

30
Q

HEAVY VAGINAL BLEEDING

when is coagulation screen indicated

A

If suspicion of clotting disorder on history taking

31
Q

HEAVY VAGINAL BLEEDING

when should US pelvis be considered

A

Transvaginal US most useful for assessing endometrium and ovaries
Should be considered if uterus or pelvic mass is palpable on examination, or if pharmacological treatment failed

32
Q

HEAVY VAGINAL BLEEDING

when should pipelle endometrial biopsy by considered

A

Persistent intermenstrual bleeding
>45 years old
Failure of pharmacological treatment

33
Q

HEAVY VAGINAL BLEEDING

when should hysteroscopy and endometrial biopsy be untertaken

A

When ultrasound identifies pathology or inconclusive

34
Q

HEAVY VAGINAL BLEEDING

describe pharmacological management

A

when no suspicion of pathology there is 3 tiered approach

  • Levonorgestrel-releasing intrauterine system (also acts as a contraceptive, licensed for 5 years, thins endometrium and shrink fibroids)
  • Tranexamic acid, mefenamic acid or combined oral contraceptive pill – dependent on fertility wishes – tranexamic acid only taken during menses to reduce bleeding, no effect on fertility / mefenamic acid is NSAID so helps analgesia for dysmehorrhoea, only during menses, no effect on fertility
  • Progesterone only – oral norethisterone (taken day 5-26 cycle), depo or implant – oral norethisterone not contraceptive when taken like this / depo and implant progesterone long acting reversible contraceptives
35
Q

HEAVY VAGINAL BLEEDING

name methods surgical managment

A

endometrial ablation

hysterectomy

36
Q

HEAVY VAGINAL BLEEDING

endometrial ablation

A

suitable for women who don’t want to conveive anymore (still need contraception), reduce HMB by 80%, outpatient with LA

37
Q

HEAVY VAGINAL BLEEDING

hysterectomy

A

only definitive treatment. Amenorhoea and end to fertility. It can be subtotal to remove uterus but not cervix or total which is removal of uterus with cervix.
Ovaries are not removed, can be performed through abdominal incision or via vagina

38
Q

IRREGULAR VAGINAL BLEEDING

  1. what is it
  2. prevelance
  3. who gets it
A
  1. Menstrual cycles that do not follow a rhythmic pattern or with a pattern differing significantly from expected as normal.
  2. 10-15% gynaecoogic visits
  3. adolescents / those experiencing climacteric changes
39
Q

IRREGULAR VAGINAL BLEEDING

causes

A

anovulation or oligo-ovulation
climacteric or menopause, hypogonadism (exercise induced
associated with low body weigth and anovulaition)
excess oestrogen (obesity, polycystic ovary disease
exogenous oestrogen)
elevated prolactin
psychosocial conditions (anorexia, bulimia, stress)
chronic illness
renal or hepatic failure
thyroid disease

40
Q

IRREGULAR VAGINAL BLEEDING

  1. associated issues
  2. evaluation
A
  1. anovulation, infertility and obesity

2. menstrual calender, endometrial biopsy, curettage, hysteroscopy

41
Q

IRREGULAR VAGINAL BLEEDING

management

A

focused on underlying cause
• If anovulation and fertility not desired peridic progestin therapy may stabilise cycles
• Medroxyprogesterone acetate 5-10mg for 1-14 days each month

42
Q

VAGINAL BLEEDING
cervical cancer
1. clinical features
2. investigations

A 
1. History abnormal pap smear
Bleeding related to intercourse
Pelvic pain
Multiple sexual partners
Early onset sexual activity
  1. Pap smear – malignant cells
    Colposcopy
    Cervical biopsy
43
Q

VAGINAL BLEEDING
thyroid dysfunction
1. clinical features
2. investigations

A
  1. Hypo - Weight gain, cold sensitivity, weakness, lethargy, constipation

Hyper – weight loss, heat intolerance, palpitations, nervousness

  1. TSH assay
    T3/T4
44
Q

VAGINAL BLEEDING
miscarriage
1. clinical features
2. investigations

A 
1. Previous missed period
Reproductive age
Suprapubic pelvic pain
Bleeding
Postcoital bleeding
History of known gynae abnormality
Speculum exam
  1. Serum Hcg -positive
    Ultrasound – abdo and vaginal
    Rhesus blood goup
45
Q

VAGINAL BLEEDING
pelvic inflammatory disease
1. clinical features

  1. investigations
A 
1. Lower abdo pain
Vaginal discharge
Bleeding between cycles
Histry of STD
Early onset sexual activity
Multipl sexual partners
Uterine tenderness
Cervical motion tenderness
Adnexal tenderness
Fever
  1. Polymorphonuclear leukocytes on wet mount of vaginal secretions

FBC- raised WBC

46
Q

VAGINAL BLEEDING
endometritis
1. clinical features

  1. investigations
A 
1. Lower abdo pain
Fever
Abnormal discharge
Bleeding between cycles
History of STD
Tenderness on examination
  1. Polymorphonuclear leukocytes on wet mount of vaginal secretions

FBC- raised WBC

47
Q

VAGINAL BLEEDING
uterine fibroid
1. clinical features

  1. investigations
A 
1. Perimenopause
Bowel/bladder change
Pelvic pain/pressure
High consumption alcohol and red eat
Nulliparity
Family history leiomyomas
Pelvic mass palpable on bimanual examination

2. Transvaginal ultrasound – myomas
Sonohysterography
Hysteroscopy
MRI
Hysterosalpingography
48
Q

VAGINAL BLEEDING
endometrial polyp
1. clinical features

  1. investigations
A

1.History of irregular spotting and bleeding between periods
Usually unremarkable

  1. Transvaginal US
    Sonohysterography
49
Q

VAGINAL BLEEDING
cervical polyp
1. clinical features

  1. investigations
A
  1. Postcoital bleeding
    May be seen on cervical polyp
  2. Hysteroscopy
    Transvaginal US
50
Q

VAGINAL BLEEDING
ectropion
1. clinical features

  1. investigations
A
  1. History of postcoital bleeding
    Speculum examination – cervix reveals red rather than pink cervix
  2. Transvaginal US
    Sonohysterography
51
Q

VAGINAL BLEEDING
menorrhagia
1. clinical features

  1. investigations
A
  1. Excessive menstrual bleeding
    Underlying aetiology- anovulation in women with pcos, hirsutism, acne, obesity
  2. Transvaginal US or sonohystegraphy
    Endometrial biopsy
52
Q

VAGINAL BLEEDING
polycystic ovary syndrome
1. clinical features

  1. investigations
A
  1. Perimenopause, perimenarche, irregular cycle lengh, interspersedamenorrhoea, systemic illness, medcations
    Hirsutism, acne, obesity
  2. Serum LH elevated
    Serum progesterone – decreased
    Serum testosterone increased
53
Q

VAGINAL BLEEDING
dysfunctional uterine bleeding
1. clinical features

  1. investigations
A
  1. Irregular menstrual period
    Painless bleeding not associated with other significant complaints
    Peripubertal/perimenopausal
  2. Transvaginal ultrasound
    FBC – normal to low Hb, Hct low with long standing, excessive bleeding

Women's Health - Year 4 (15 decks)

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