Disorders of menstrual bleeding Flashcards
What are the causes of HMB?
Dysfunctional uterine bleeding Fibroids Endometrial polyps Endometrial hyperplasia Adenomyosis Endometrial cancer
What is the definition of HMB?
> 80mL of blood loss PV
or
Excessive bleeding that interferes with a women’s physical, emotional or social QoL
What investigations are conducted for HMB?
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
What are the indications for endometrial biopsy?
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
What is the management of HMB?
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
What are the causes of intermenstrual bleeding?
Fibroids Adenomyosis Cervical polyps Ovarian cysts PID
What are the investigations for intermenstrual bleeding?
Speculum examination for polyps
FBC for anaemia
Ultrasound examination if:
• >35 years
• <35 years but medical management failed
Endometrial biopsy if indicated
What is the management of IMB?
First line: LNG-IUS, COCP
What are the causes of post-coital bleeding?
Cervical ectropion
Cervical carcinoma
Cervical polyp
Cervicitis/Vaginitis
What are the causes of dysmenorrhoea?
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
What are the clinical features of fibroids?
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
What are the investigations for fibroids?
Ultrasound to determine size and number
MRI can help differentiate from adenomyosis
Hysteroscopy can be used to assess uterine distortion if fertility an issue
What is the management of fibroids?
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
What are the clinical features of adenomyosis?
Growth of endometrial tissue in myometrium
Associated with fibroids and endometriosis
Subsides after menopause
Mostly asymptomatic, but may have dysmenorrhoea with HMB
What are the investigations for adenomyosis?
May be suspected on ultrasound
Confirmed with MRI scan
What is the management of adenomyosis?
LNG-IUS
COCP
Hysterectomy if ineffective, but may try GnRH agonist trial to determine if symptoms would improve
What are the clinical features of endometrial polyps?
Typically occur in 40-50 y/o women, or women on tamoxifen
Often asymptomatic
Can cause HMB or IMB
Diagnosed via ultrasound or hysteroscopy
What is the management of endometrial polyps?
Resection of the polyp via cutting diathermy or avulsion
What are the symptoms and risk factors for endometrial hyperplasia?
Risk factors: • Tamoxifen • Obesity • >35 years old • Oestrogen without progesterone • Early menarche/Late adrenarche • Nulliparity
Symptoms: HMB & PMB
What are the investigations for endometrial hyperplasia?
Ultrasound may show endometrial thickening
Confirmed by biopsy which may show typical or atypical cells
What is the management of endometrial hyperplasia?
Progesterone-only pill
LNG-IUS
If atypical cells, hysterectomy
What are the symptoms of cervical polyps?
Post-coital bleeding
Intermenstrual bleeding
Endocervix polyps commonly seen in premenopausal women
Ectocervix polyps commonly seen in menopausal women
What is the management of cervical polyps?
Normally they fall off themselves. If symptomatic, doctor may pull or cut them off, no anaesthesia necessary
What are the clinical features of cervical ectropion?
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
What is the management of cervical ectropion?
If troublesome, treat with ablative treatment - cold coagulation
What are the clinical features of endometriosis?
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
How is endometriosis investigated?
Laparoscopy is the gold-standard investigation
Ultrasound not very helpful, may be useful for endometriomas
How is endometriosis treated?
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
What is the presentation of endometrial tissue in the ovary?
Forms an endometrioma
The endometrial tissue may contain old blood which gives it a chocolate cyst appearance
