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Obstetrics & Gynaecology - Things I forget > Disorders of menstrual bleeding > Flashcards

Disorders of menstrual bleeding Flashcards

1
Q

What are the causes of HMB?

A 
Dysfunctional uterine bleeding
Fibroids
Endometrial polyps
Endometrial hyperplasia
Adenomyosis
Endometrial cancer
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2
Q

What is the definition of HMB?

A

> 80mL of blood loss PV
or
Excessive bleeding that interferes with a women’s physical, emotional or social QoL

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3
Q

What investigations are conducted for HMB?

A

Coagulation and TFTs (Hypo/Hyperthyroidism both can cause menorrhagia) may be conducted to eliminate systemic causes if suspected

Transvaginal ultrasound to:
• Assess endometrial thickness
• Exclude fibroids/ovarian mass
• Detect polyps

Endometrial biopsy if indicated

FBC for anaemia

Diagnostic hysteroscopy is last line but is gold standard for evaluating uterine cavity

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4
Q

What are the indications for endometrial biopsy?

A

HMB/IMB in patient:
>45 years old
Persistent intermenstrual bleeding
Treatment failure
Risk factors for endometrial cancers (Obesity, diabetes, FHx of HNPCC, PCOS, nulliparity)
Ultrasound suggests endometrial thickening

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5
Q

What is the management of HMB?

A

Mirena (LNG-IUS) - Releases progesterone, preventing proliferation of the endometrium, also thickens cervical mucus

Tranexamic acid - Oral anti-fibrinolytic (useful if trying to conceive)

NSAIDs - Reduce prostaglandin production

COCP - Prevents ovulation, hence no endometrial thickening

GnRH analogues - Results in amenorrhoea, needs HRT too

If all else fails, hysterectomy

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6
Q

What are the causes of intermenstrual bleeding?

A 
Fibroids
Adenomyosis
Cervical polyps
Ovarian cysts
PID
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7
Q

What are the investigations for intermenstrual bleeding?

A

Speculum examination for polyps

FBC for anaemia

Ultrasound examination if:
• >35 years
• <35 years but medical management failed

Endometrial biopsy if indicated

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8
Q

What is the management of IMB?

A

First line: LNG-IUS, COCP

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9
Q

What are the causes of post-coital bleeding?

A

Cervical ectropion
Cervical carcinoma
Cervical polyp
Cervicitis/Vaginitis

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10
Q

What are the causes of dysmenorrhoea?

A

Primary dysmenorrhoea = Onset of menstrual pains from menarche, no pathology, treat with NSAIDs or COCP

Secondary dysmenorrhoea = Pelvic pathology
Investigated via pelvic ultrasound and laparopscopy
Endometriosis
Adenomyosis
PID
Ovarian tumours

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11
Q

What are the clinical features of fibroids?

A

Three types:
• Submucosal
• Intramural
• Subserosal

Fibroid growth is oestrogen and progesterone dependent, hence grow during pregnancy and shrink during menopause

Most are asymptomatic
HMB most common presenting symptom
Submucosal fibroids are likely to bleed, leading to IMB
Large fibroids pressing on bladder can cause frequency and urinary incontinence
Subfertility if submucosal or if fibroid compresses tubal ostia

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12
Q

What are the investigations for fibroids?

A

Ultrasound to determine size and number
MRI can help differentiate from adenomyosis
Hysteroscopy can be used to assess uterine distortion if fertility an issue

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13
Q

What is the management of fibroids?

A

First line: Mirena (LNG-IUS)

Tranexamic acid if fertility is important and main worry is bleeding

Surgery:
• Hysteroscopic resection (must use GnRH agonist to shrink fibroid first
• Myomectomy
• Uterine artery embolisation

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14
Q

What are the clinical features of adenomyosis?

A

Growth of endometrial tissue in myometrium
Associated with fibroids and endometriosis
Subsides after menopause

Mostly asymptomatic, but may have dysmenorrhoea with HMB

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15
Q

What are the investigations for adenomyosis?

A

May be suspected on ultrasound

Confirmed with MRI scan

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16
Q

What is the management of adenomyosis?

A

LNG-IUS
COCP
Hysterectomy if ineffective, but may try GnRH agonist trial to determine if symptoms would improve

17
Q

What are the clinical features of endometrial polyps?

A

Typically occur in 40-50 y/o women, or women on tamoxifen

Often asymptomatic
Can cause HMB or IMB

Diagnosed via ultrasound or hysteroscopy

18
Q

What is the management of endometrial polyps?

A

Resection of the polyp via cutting diathermy or avulsion

19
Q

What are the symptoms and risk factors for endometrial hyperplasia?

A 
Risk factors:
	• Tamoxifen
	• Obesity
	• >35 years old
	• Oestrogen without progesterone
	• Early menarche/Late adrenarche
	• Nulliparity

Symptoms: HMB & PMB

20
Q

What are the investigations for endometrial hyperplasia?

A

Ultrasound may show endometrial thickening

Confirmed by biopsy which may show typical or atypical cells

21
Q

What is the management of endometrial hyperplasia?

A

Progesterone-only pill
LNG-IUS

If atypical cells, hysterectomy

22
Q

What are the symptoms of cervical polyps?

A

Post-coital bleeding
Intermenstrual bleeding

Endocervix polyps commonly seen in premenopausal women
Ectocervix polyps commonly seen in menopausal women

23
Q

What is the management of cervical polyps?

A

Normally they fall off themselves. If symptomatic, doctor may pull or cut them off, no anaesthesia necessary

24
Q

What are the clinical features of cervical ectropion?

A

Larger area of columnar epithelium on ectocervix (normally squamous epithelium)
Associated with increased oestrogen
Risk factors = COCP, pregnancy, puberty

Symptoms: Dyspareunia, post-coital bleeding, discharge

25
Q

What is the management of cervical ectropion?

A

If troublesome, treat with ablative treatment - cold coagulation

26
Q

What are the clinical features of endometriosis?

A

Growth of ectopic endometrial tissue outside of the uterus

Endometriosis triad:
Dysmenorrhoea
Subfertility
Dyspareunia

Symptoms are related to location:
• Female Reproductive Tract
	□ Dysmenorrhoea 
	□ Lower abdominal and pelvic pain 
	□ Dyspareunia 
	□ Rupture/torsion of endometrioma 
	□ Low back pain 
	□ Subfertility
• Urinary Tract
	□ Cyclical haematuria/dysuria
	□ Loin/flank pain (ureteric obstruction)
• GI Tract
	□ Dyschezia (pain on defecation)
	□ Cyclical rectal bleeding 
	□ Obstruction 
• Surgical Scars/Umbilicus
	□ Cyclical pain, swelling and bleeding
27
Q

How is endometriosis investigated?

A

Laparoscopy is the gold-standard investigation

Ultrasound not very helpful, may be useful for endometriomas

28
Q

How is endometriosis treated?

A

NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief

Hormonal treatments such as the COCP or progestogens (Mirena) tried if symptoms are not relieved

If subfertility is the issue, then surgery is recommended - Laparoscopic excision and laser treatment of endometrial tissue

Hysterectomy with removal of the ovaries and all visible endometriosis lesions should be considered in women who have completed their family and failed to respond to conservative treatments

29
Q

What is the presentation of endometrial tissue in the ovary?

A

Forms an endometrioma

The endometrial tissue may contain old blood which gives it a chocolate cyst appearance

Obstetrics & Gynaecology - Things I forget (16 decks)

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