Disorders of menstruation Flashcards
Differential diagnoses for dysmenorrhoea
Primary dysmenorrhoea
Pelvic inflammatory disease
Endometriosis/Adenomyosis
Fibroids
Uterine abnormalities (e.g. non-communicating accessory uterine cavity)
Cervical stenosis and haematometra (imperforate hymen)
Risk factors for primary dysmenorrhoea
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
Cause of pain in primary dysmenorrhoea
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
Typical presentation of primary dysmenorrhoea
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
Natural history of primary dysmenorrhoea
tends to improve with age and often after childbirth
Non-pharmacologic management of primary dysmenorrhoea
heat to lower abdomen, ?exercise ?sexual activity
Pharmacologic management options for primary dysmenorrhoea
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
History suggestive of SECONDARY dysmenorrhoea
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
Investigations in secondary dysmenorrhoea
Chlamydia screening for PID
Pelvic USS
Laparoscopy
Pregnancy test?
Symptoms of endometriosis
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
Potential examination findings of endometriosis
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
Diagnosis of endometriosis
Pelvic USS may detect some findings (e.g. endmetrioma)
Laparoscopy - also therapeutic (resection/ablation)
Therapeutic options of endometriosis
NSAIDs COCPs If fail: FnRH agonists (IM or nasal), progestins (e.g. mirena), Danazol Surgical ablation or resection May require assisted reproduction
Complications of endometriosis
Adhesions
“chocolate” ovarian cysts (endometriomas)
Infertility
Types of uterine leiomyomas/fibroids
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
Definition of uterine fibroid/leiomyomas
Benign monoclonal tumours arising from smooth muscle cells of the myometrium responsive to oestrogen and progesterone
Symptoms of uterine fibroids
- 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)
Examination findings in women with uterine fibroids
Enlarged, mobile uterus with irregular contour on pelvic examination
Natural history of uterine fibroids
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
Medical therapy for uterine fibroids
HRT
Antifibrinolytic agents
NSAIDs
Danazol and gestrinone
Surgical therapy for uterine fibroids and indications
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
