Disorders of menstruation

Question 1

Differential diagnoses for dysmenorrhoea

Answer 1

Primary dysmenorrhoea
Pelvic inflammatory disease
Endometriosis/Adenomyosis
Fibroids
Uterine abnormalities (e.g. non-communicating accessory uterine cavity)
Cervical stenosis and haematometra (imperforate hymen)

Question 2

Risk factors for primary dysmenorrhoea

Answer 2

Age under 30
BMI under 20
Smoking
Menarche before 12y
Longer menstrual cycles/duration of bleed
Irregular or heavy menstrual flow
History of sexual assault
Family predisposition

Question 3

Cause of pain in primary dysmenorrhoea

Answer 3

Prostaglandins released from endometrial sloughing at beginning of mensses - incoordinate contractions at high frequency - high intrauterine pressure - exceeds arterial pressure - uterine ischaemia - anaerobic metabolism and build up of metabolites - stimulation of C-fibres - pain

Question 4

Typical presentation of primary dysmenorrhoea

Answer 4

Begins during adolescence after ovulatory cycles first established (approx 2y post menarche)
Pain begins 1-2 days before or with onset of bleeding, diminishes over 12-72 hours
Recurrent - almost all cycles
Crampy, intermittently intense pain usually
Usually lower abdo/suprapubic MIDLINE pain
+/- nausea, diarrhoea, fatigue, headache, malaise
normal examination

Question 5

Natural history of primary dysmenorrhoea

Answer 5

tends to improve with age and often after childbirth

Question 6

Non-pharmacologic management of primary dysmenorrhoea

Answer 6

heat to lower abdomen, ?exercise ?sexual activity

Question 7

Pharmacologic management options for primary dysmenorrhoea

Answer 7

NSAIDS - relieve in 70-90%, start at onset of menses (1-2 days before if severe) and use for 1-2 days
COCP - prevent ovulation thus red PG levels, first line in sexually active females
IUD (mirena)
If NSAID/OCP ineffective after 2-3 cycles, try another modality
Tocolytics (GTN, NO, nifedipine) rarely used
TENS
Re-evaluate if refractory to treatment for 6 months ?diagnosis

Question 8

History suggestive of SECONDARY dysmenorrhoea

Answer 8

Onset after 25y
Abnormal uterine bleeding (heavy, irregular, intermenstrual)
Non-midline pelvic pain
Absence of systemic symptoms (n+v, diarrhoea, back pain, dizziness, headache)
Dyspareunia or dyschezia
Progression in symptom severity

Question 9

Investigations in secondary dysmenorrhoea

Answer 9

Chlamydia screening for PID
Pelvic USS
Laparoscopy
Pregnancy test?

Question 10

Symptoms of endometriosis

Answer 10

Dysmenorrhoea and pelvic pain
- onset 1-2 days before menses, persisting throughout
- most likely to have onset several years after menarche
- Pelvic pain chronic sharp or dull at focal site (typically)
Deep dyspareunia
Infertility
Constipation, Dyschezia
Dysuria
Ovarian Mass
May be asymptomatic

Question 11

Potential examination findings of endometriosis

Answer 11

Tenderness of vaginal fornix
Lateral displacement of cervix
Localised tenderness in pouch of Douglas or uterosacral ligaments
Palpable tender nodules in those areas
Thickening and induration of uterosacral ligaments
Pain with movement of uterus
Adnexal mass +/-tenderness
Fixation of adnexa/uterus in retroverted position

Question 12

Diagnosis of endometriosis

Answer 12

Pelvic USS may detect some findings (e.g. endmetrioma)

Laparoscopy - also therapeutic (resection/ablation)

Question 13

Therapeutic options of endometriosis

Answer 13

NSAIDs
COCPs
If fail: FnRH agonists (IM or nasal), progestins (e.g. mirena), Danazol
Surgical ablation or resection
May require assisted reproduction

Question 14

Complications of endometriosis

Answer 14

Adhesions
“chocolate” ovarian cysts (endometriomas)
Infertility

Question 15

Types of uterine leiomyomas/fibroids

Answer 15

Intramural: develop within the uterine wall
Submucosal: derive from cells just below the endometrium and protrude into the uterine cavity - can be broad based or pedunculated
Subserosal myomas: derive from myometrium at serosal surface of uterus, protruding externally from uterus, can be broad based or pedunculated

Question 16

Definition of uterine fibroid/leiomyomas

Answer 16

Benign monoclonal tumours arising from smooth muscle cells of the myometrium responsive to oestrogen and progesterone

Question 17

Symptoms of uterine fibroids

Answer 17

• Heavy or prolonged menstrual bleeding (NOT intermenstrual or postcoital)
• Pelvic pressure and pain
• Bulk-related symptoms (urinary frequency, difficulty emptying bladder, urinary obstruction, back pain, constipation)
• dysmenorrhoea
• Deep dyspareunia
  Reproductive dysfunction (conception, miscarriage, adverse pregnancy outcomes)

Question 18

Examination findings in women with uterine fibroids

Answer 18

Enlarged, mobile uterus with irregular contour on pelvic examination

Question 19

Natural history of uterine fibroids

Answer 19

up to 40% regress over 6 months to 3 years in premenopausal women
Menopause generally causes relief of menstrual bleeding symptoms unless on HRT
Most women will have shrinkage or leiomyomas at menopause

Question 20

Medical therapy for uterine fibroids

Answer 20

HRT
Antifibrinolytic agents
NSAIDs
Danazol and gestrinone

Question 21

Surgical therapy for uterine fibroids and indications

Answer 21

Indications: abnormal bleeding or bulk-related symptoms, infertility or recurrent pregnancy loss
Options:
Hysterectomy (if have completed childbearing, failed prior minimally invasive therapy, significant symptoms/multiple fibroids)
Myomectomy (if wish to retain uterus, risk of more fibroids developing)
Endometrial ablation (if completed childbearing, +/- hysteroscopic myomectomy, improves bleeding symptoms but not bulk-related)
Uterine artery occlusion or embolisation
MRI guidance focused US