GYN: General Gynaecology -- Menorrhagia

Question 1

Investigations for menorrhagia

Answer 1

• CBC, iron profile, clotting profile, TFT
• USG
• Endometrial sampling [if >40Y]

Question 2

Treatment options for dysfunctional uterine bleeding + S/E

Answer 2

• Non-hormonal:
  
  • Transamin
  • Mefanemic acid (GI upset)
  • Fe supplement
• Hormonal:
  
  • COCP (nausea, headache, breast tenderness)
  • PO Norethisterone (initial irregular PV bleeding)
  • Depo-Provera (initial irregular PV bleeding, osteoporosis)
  • Mirena (initial irregular PV bleeding, inc. risk of PID, ectopic pregnancy)
  • GnRH analogue (osteoporosis)
• Surgery:
  
  • Endometrial ablation (haemorrhage, infection, perforation, infertility)

Question 3

Advantages & Disadvantages of performing prophylatic bilateral salpingo-oophorectomy in the same operation

Answer 3

• Advantage: avoid ovarian tumour / pathology in the future
• Disadvantage:
  
  • same operation: prolong surgical time & GA, surgical risk
  • surgical menopause: inc. risk of osteoporosis, vasomotor symptoms, mood disturbance

Question 4

Indications of Mirena

Answer 4

• Contraception
• Dysfunctional uterine bleeding
• Endometrial hyperplasia without atypia
• Dysmenorrhoea

Question 5

Side effects of Mirena

Answer 5

• irregular bleeding in first 6~12 months
• increase risk of PID
• increase risk of ectopic pregnancy
  …

Question 6

What to tell patients about Mirena?

Answer 6

Explain S/E:
* normal to see spotting in first few weeks
* seek help if signs of PID, ectopic pregnancy
- PID: (first 21 days) fever, PV bleed, lower abdominal pain, foul smelling discharge…
- EP: +ve pregnancy test, PV bleed, lower abdominal pain
* cannot protect STD –> keep practice safe sex
FU:
* after 1st & 4th menses if no complications
* change every 5 years (avoid pulling on the string)

Question 7

DDx for menorrhagia

Answer 7

• Dysfunctional uterine bleeding
• Structural causes:
  
  • Polyps
  • Adenomyosis
  • Leiomyoma (fibroid)
  • Malignancy
• Medical causes:
  
  • HypoT
  • Clotting disorder
  • Anticoagulant
• Pregnancy-related causes:
  
  • miscarriage
  • IUCD

Question 8

Contraindications

Answer 8

• Pregnancy
• Distorted uterine cavity
• Infection
• Malignancy (breast CA…)

Question 9

DDx for menorrhagia despite using Mirena

Answer 9

• Expulsion of Mirena
• Endometrial CA

Question 10

Indications for hysteroscopy

Answer 10

• Diagnostic:
  
  • persistent PMB / menorrhagia
  • TVS shows endometrial thickness >5mm in postmenopausal women
  • failed endometrial sampling
• Therapeutic:
  
  • Hysteroscopic polypectomy
  • Hysteroscopic myomectomy
  • Removal of IUCD when the string is broken
  • Adhesiolysis in Asherman syndrome

Question 11

Risks associated with hysteroscopy

Answer 11

• Bleeding
• Infection
• Intrauterine adhesion
• HypoNa (glycine complication)
• Uterine perforation (0.1%)

Question 12

Which groups of women have a higher risk in hysteroscopy?

Answer 12

• with previous myomectomy
• with previous CS

Question 13

Precautions in hysteroscopy

Answer 13

• Aseptic technique
• Beware signs of uterine perforation