Disorders of menstrual bleeding Flashcards
How common is abnormal uterine bleeding?
AUB is one of the most common reson for women of childbearing age to visit their GP.
Describe a classification system of abnormal uterine bleeding.
PALM-COEIN system:
Visually objective structural criteria, PALM:
- Polyps
- Adenomyosis (70% of pts with Adenomyosis have HMB)
- Leioma (Fibroid) (30% of HMB is due to fibroids)
- Malignancy (endometrial/cervical carcinoma)
Unrelated to structural abnormalities, COEIN:
- Coagulopathy (e.g. vWD)
- Ovulatory disorders
- Endometrial disorders
- Iatrogenic (.e.g warfarin, IUDs)
- Not Classified (e.g. thyroid disease, PID)
What are the different types of AUB?
- HMB: excessive menstrual loss
- IMB: bleeding between periods, often seen with endometrial/cervical polyps)
- PCB: Bleeding after sex. Often seen with cervical abnormalities
- PMB: bleeding more than 1 year after cessation of periods (endometrial pathology/vaginal atrophy)
- BEO: bleeding of endometrial origin. Diagnosis of exclusion.
What in the examination for HMB do you look for?
- Signs of anaemia
- Pelvic massess
- Cervix visualisation (polyps)
- Abnormal bruising
- Any other discharge (?PID)
What Investigations would you like to do in a woman presenting with HMB?
Blood tests:
- FBC (anaemia?)
- Coagulation screen (only if HMB since menarche or FHx of coag. defects)
- TFTs (if Hx suggestie of thyroid disorder)
Imaging:
- TVUSS (only if PCB, IMB, pain/pressure symptoms, mass palpable)
- ± Hysteroscopy
Sampling:
- High vaginal swabs (if PID suspected)
- Endometrial biopsy/outpatient hysteroscopy if
- risk factors, e.g. >45 yrs; TVUSS showed >4mm thick endometrium
- Tratment failure
- Hysteroscopy esp. if polyp or submucosla fibroid that can be resected.
How do you manage actue HMB?
Acute:
- ABC approach
- Stabilisation (incl. IV access to resuscitate/transfuse)
- Examination (exclude cervical abnormalities & pelvic masses)
- Bloods: FBC, coag screen
- Tranexamic acid (antifibrinolytic) PO or IV
- TVUSS
- High-dose progestogens to arrest bleeding
Medium-term:
- GnRH or ulipristal acetate (progesterone-receptor modulator)
Long-term:
- Identify and treat underlying cause
Describe the management of HMB (non-acute).
When discussing management options, always keep the patients fertility wishes in mind.
Conservative:
- In some cases, reassurence can be enough
Medical: (should be first line in the absence of sructural abnormality)
- Mirena (reduces blood loss by ~95% after 1 year)
- Tranexamic acid (antofibrinolytic, reduces blood loss by 50%)
- Mefenamic acid (an NSAID, inhibits prostaglandin syntehsis. Reduces blood loss by 30%)
- Norethisterone (a progesterone, taken cyclical)
- GnRH agonists (induce medical menopause)
Surgical: (restricted for women that failed medical management)
- Endometrial ablation (40% amenorrhoea, 40% reduced bleeding, 20% no difference)
- Uterine artery ebolisation (if associated with fibroids)
- Myomectomy/Transcervical resection of firboid (if large fibroids with pressure symptoms)
- Hyterectomy
What is dysmenorrhoea?
How common is it?
Dysmenorrhoea is painful on menstruation.
Around 45-90% of women of reproductive age experience dysmenorrhoea.
How can dysmenorrhoea be classified?
Primary (i.e. since menarche, rarely pathological) and secondary.
Alternatively, 1° can mean idiopathic, 2° in the presence of pelvic pathology. (Errr dude your definition is the alternative one *cough*).
What are causes of dysmenorrhoea?
Dysmenorrhoea is commonly caused by:
- Primary dysmenorrhoea (no identifiable cause)
- Pelvic inflammatory disease
- Endometriosis and adenomyosis
Uncommonly can also be caused by ovarian cysts and haemorrhage, ovarian torsion, obstructive Müllerian duct abnormalities, and cervical stenosis.
What are good questions to gage the severity of dysmenorrhoea?
- Do you have to take painkillers to help with the pain?
- Have you had to take time of work due to the severity of the pain?
What factor in the pain history of dysmenorrhoea would point towards endometriosis?
If the pain precedes the period this would point towards endometriosis.
What are Red-Flags in a patient with dysmenorrhoea?
- Abnormal cervix on examination
- Persistent PCB/IMB without associated features of PID
- Ascites and/or pelvic mass that is not obviously the uterus
- Ultrasound suggestive of cancer
What are investigations you want to carry out for dysmenorrhoea?
All women who present with abdominal pain should have a pregnancy test.
Pelvic examination is not usually necessary if history is indicative of primary dysmenorrhoea. Pelvic pathology such as endometriosis and PID can be picked up by examination.
If suspecting secondary dysmenorrhoea investigations include:
- High vaginal and endocervical swabs for STIs
- TV USS can be useful to detect endometriomas or appearances suggestive of adenomyosis
- Diagnostic laparoscopy can diagnose endometriosis, adhesions, and pelvic inflammatory disease.
- Bloods such as raised WCC and CRP may point to PID
- (hystersocopy if cercical stenosis likely, but this is rare)
How is primary dysmenorrhoea managed?
Conservative management: Give patient information leaflet and advice to try non-drug methods such as a hot water bottle which has strong evidence (as effective as NSAIDs). There is also some evidence that low fat, vegetarian diet may improve dysmenorrhoea. Transcutaneous nerve stimulation can also be recommended.
Medical management:
- Patient can also try NSAIDs if not contraindicated, or paracetamol if they are.
- If a woman does not wish to conceive, hormonal contraceptives such as COCP can be used to manage dysmenorrhoea as a first-line (limited evidence though recommended by experts). Oral and parenteral progesterone as well as the Mirena system can also be used.
- Analgesia and hormonal treatment can be combined if necessary.
RCOG recommends that women with cyclical pain should be referred to see a specialist for diagnostic laparoscopy within 3-6 months if symptoms do not resolve with hormonal treatment.
Describe the management of PMS.
The treatment of mild PMS involves lifestyle changes including:
- Healthy diet rich in fibre, complex carbohydrates, low in fat, and frequent small meals.
- Regular exercise
- Regular sleep
- Smoking/alcohol restriction
- Stress reduction techniques such as relaxation, yoga, mediation and breathing techniques.
Advise the patient that complementary therapies often help patients, including St John’s Wort (some evidence?) and Evening Primrose oil (no real evidence). Vitamin B6, calcium and magnesium may be helpful (though low quality evidence).
The treatment of moderate PMS (interferes with social, personal or professional life) involves all the above but also:
- New generation COCP such as Yasmin® (note: progesterone-only contraceptives make PMS worse!)
- Paracetamol or NSAID
- Referral for CBT if it is thought the woman would benefit from psychological intervention.
The management of severe PMS (interferes with daily living) involves all the above, but also:
- Active serotonin re-uptake inhibitor (SSRI) (off-label use) to be used continuously or just during luteal phase.
- Consider referral to specialist gynaecological clinic. They may perform a hysterectomy or bilateral salipingo-oopherctomy.
