Disorders of menstrual cycle Flashcards
What is the objective definition of heavy menstrual bleeding?
blood loss >80ml per period
Causes of menorrhagia?
- fibroids: 30% of women, 20% at reproductive age
- Endometrial polyps: 10% (abnormal growth from mucous membrane)
- adenomyosis (endometrial tissue grows into wall of uterus)
- pelvic infection (PID)
- coagulation disorders
- IUDs
- obesity (increased oestrogen)
- endometrial/ cervical/ ovarian carcinoma
- thyroid disease
how would you illicit a heavy flow from history?
- flooding: spilling onto clothes, pants or bedding
- length of cycle and IMB
- affecting daily life
- what sanitary pads used
What associated symptoms might they have? (apart from menhorragia)
What might discharge associated with menhorragia indicate?
What endocrine disorder may cause it?
- anaemia: tiredness, dyspnoea, cv symptoms
- dyspareunia
- irregular, IMB, post-coital: endometrial or cervical polyp
- cervical ectropion
- PID
- hyperthyroidism and menhorragia
what may you find on abode exam in menhorragia?
- bulky uterus: suggests fibroids
- tenderness: endometriosis, PID or adenomyosis
what investigations should be done in menhorragia to illicit cause?
- bloods: clotting screen, FBC, TFTs
- TV pelvic USS: fibroids or polyps
- High vaginal and endocervical swab: unusual vaginal discharge and RF for PID
- endometrial biopsy: those aged 45+ or suspicion of cancer ( PCB, IMB)
- hysteroscopy
- colposcopy
what are the red flag symptoms for gynae?
- PCB: STI, cervical ectropion, cervical polyps
what contraceptives can cause IMB?
- depot
- missed COCP
- POP
- IUCDs
What is the first and 2nd line treatment for menhorragia?
what are the SE’s of TXM and what is the benefits?
- Mirena: localised levonogesterol- progestogen
- mefenamic acid: NSAID (benefit in dysmenorrhoea, CI in asthmatics)
- TXM Acid: antifibrinolytic, only take during menstruation
- COCP: doubles up as contraceptive, regulates cycle so good if IMB
- S/E: GI symptoms and tinnitus
- NSAIDs and TXM good for those wanting to conceive!
when should you not give the combined OCP?
- DVT risk factor groups
- overweight
What is 3rd line treatment for HMB?
- GnRH agonists: complete amenorrhoea, causes menopause e.g. goserelin
- Norethisterone: (progestogens)
what is the downside of GnRH agonist use?
- can only be used for 6 months, no long term solution
What is the surgical options for heavy menstrual bleeding?
- hysteroscopy: endometrial ablation, polyp removal, resection of fibroid
- hysterectomy
- myomectomy
- UAE
what is the aetiology behind post-coital bleeding?
what is the differential diagnoses?
- lack of healthy squamous epithelium on cervix
- PID
- cervical malignancy
- cervical ectropion
- cervical/ pedunculate polyp
- pedunculate fibroid
- atrophic vaginitis
what investigations should you do for post-coital bleeding?
- smear test
- ultrasound
- hysteroscopy
- pipelle (endometrial biopsy)
what happens in cervical ectropion?
- endocervical columnar epithelium protrudes through external os onto vaginal portion
- undergoes squamous metaplasia, transforms to stratified squamous epithelium
- transforms due to acidity of vagina
how would cervical ectropion be distinguished from cancer?
what are the associated symptoms?
- pap smear or biopsy
- excessive, non-purulent vaginal discharge (> surface area of columnar epithelium containing mucus-secreting glands)
- possible post-coital bleeding
what is the treatment for ectropion?
what may make ectropion malignant change?
- none if asymptomatic
- discontinue oestrogen hormone: causes os to open
- ablation of metaplasia
- HPV infection
How does ectropion look on the cervix?
- red, velvet like area
- raw-looking granular appearance
- associated with hormonal changes
what is dysmenorrhoea?
where can it radiate to?
- cramping abdominal pains during periods
- lower back, legs and may be associated with GI symptoms or malaise
what is dysmenorrhoea caused by?
what non-gynae symptoms are associated?
- increased prostaglandins in endometrium
- uterine contraction and ischaemia
- vomiting, migraine, bloating, emotional symptoms
when does primary dysmenorrhoea occur?
what is involved in aetiology?
- begins with onset of ovulatory cycles, most common in adolescents
- pain is most severe on day of menstruation
- PGE2 and PGF2a in menstrual fluid, increased contractility and pain
how do you treat primary dysmenorrhoea pain?
what contraceptives?
- NSAID reduces production of PGF2a and thus dysmenorrhoea
- Mefanamic acid and ibuprofen effective
- offer paracetamol if NSAIDs contraindicated
- COCP: suppression of ovulation reduces severity of dysmenorrhoea
- Depot progestogens: injectable progestogen only contraceptive supresses ovulation
- Mirena: reduces blood loss and effective with pain
what conditions are secondary dysmenorrhoea associated with?
when does the pain present typically?
- pelvic pathology
- onset many years after menarche
- commonly associated with:
endometriosis, adenomyosis, PID, fibroids and cervical stenosis - normal copper coil can also aggravate
- pain precedes and relieved by onset of menstruation
what are typical associated symptoms of secondary dysmenorrhoea? (think causes)
- deep dyspareunia
- irregular menstruation
- menorrhagia
how may you treat secondary dysmenorrhoea?
- genital tract swabs to exclude pelvic infection (PID)
- USS if fibroids suspected
- laparoscopy if PID or endometriosis suspected
