Gynae: Menorrhagia Flashcards
1
Q
What should you ask in the history of presenting complaint for menorrhagia?
A
Could you tell me more about that?
- How much are you bleeding?
- What sanitary protection are you using?
- How often are you changing it?
- Have you ever passed any clots of blood?
- Has it ever “flooded”?
How long has this been going on for?
How have things changed over time?
What is your cycle like?
- How long is it?
- How long does your period last for?
- Is it regular?
2
Q
What other symptoms should you ask about?
A
Gynae symptoms
- Dysmenorrhoea
- Pelvic pain
- Dyspareunia
- Intermenstrual bleeding
- Post-coital bleeding
- Discharge
- Problems with bowels/urine
Systemic symptoms: tiredness, fainting, SoB, weight loss/gain, appetite
3
Q
What questions should you include in ICE?
A
- How has this affected your life? (Work/Family life)
- Is there anything you’re particularly concerned about?
- Is there anything you think might be causing your problems?
- What would you like to happen today?
4
Q
Hx: other questions about periods
A
- How old are you?
- How old were you when you started your periods?
5
Q
Hx: questions about children
A
- How many children?
- How many pregnancies?
- Did you ever have any complications?
- Are you hoping to have children in the future?
6
Q
Hx: questions about gynae history
A
- Are your smears up to date?
- Have you ever had an abnormal smear?
- Have you ever had any infections?
7
Q
Hx: questions about other medical problems
A
- Have you ever had breast or ovarian cancer?
- Did you take tamoxifen?
- Have you ever had problems with your thyroid, liver, kidneys?
- Have you ever had any blood clots?
- Has anyone in your family had any blood clot?
8
Q
Rest of Hx: family Hx and drugs
A
- Has anyone in your family suffered from a gynaecological disease?
- Has anyone in your family ever had endometrial or colon cancer?
- Are you on any medications?
- What are you using for contraception?
9
Q
How would you define menorrhagia?
A
- Objectively, menorrhagia can be defined as a menstrual blood loss of >80ml/month
- The average is 40ml/month -Approximately 10% of the female population will bleed this much
- The significance of this is that women are likely to develop iron deficiency anaemia at this level of blood loss
- However, only half of women who complain of heavy periods will actually meet this objective criteria – menorrhagia could also be considered as menstrual bleeding which is sufficient to cause distress or disruption to the woman’s life
10
Q
How do you assess blood loss in menorrhagia?
A
- Various studies have shown that actually number of towels/tampons used, passage of clots and duration of bleeding actually bear little relation to the amount of blood lost
- Flooding and the use of double protection are indicative of pathological levels of blood loss, as is iron deficiency anaemia
- Most important indication may be the effect it is having
11
Q
Name the causes of menorrhagia
A
Uterine disease
- Benign: fibroids, adenomyosis, pelvic infection, endometrial polyp
- Malignant: endometrial cancer, cervical cancer
Systemic disorders (v rare)
- Hypo/Hyperthyroidism
- Hepatic disease
- Renal disease
- Clotting abnormalities
12
Q
What examinations would you like to perform?
A
- General inspection: examine woman looking for features of underlying causes and also for features of iron deficiency anaemia
- Abdominal examination
- Bimanual examination
- Speculum examination
13
Q
What Ix would you like to perform?
A
- Bloods: FBC (iron deficient anaemia), TFT and clotting screen (If indicated by Hx)
- Transvaginal US: identification of abnormal structural uterine pathology, abnormality and ovarian assessment
- Endometrial assessment: biopsy (pipelle) or hysteroscopy (esp in younger women with persistent menorrhagia, irregular bleeding or endometrial Ca risk factors)
- Cervical smear: if due or appears suspicious on speculum
- Triple swabs: rule out infective cause/PID
14
Q
Treatment: non hormonal options
A
NSAIDs Mefenamic acid
- Inhibit prostaglandin synthesis and reduce endometrial blood loss by ~25%
- May also treat dysmenorrhoea •Not if e.g. past history of a GI bleed, may cause N/V/D Antifibrinolytics
Tranexamic acid
- Inhibit plasminogen activator, increasing clot formation in the spiral arterioles
- Can reduce blood loss by ~50% •Side effects: GI, nausea, tinnitus
- Not suitable if predisposed to thromboembolism
15
Q
Treatment: Hormonal options
A
Mirena (1st line Treatment )
- Delivers progestogen directly to uterus - highly effective contraceptive
- After 12 months, blood loss reduced by 95% but there is initially a high incidence of irregular bleeding
- Does not protect against STIs, may cause unscheduled bleeding, may cause pain
Combined OCP
- Reduces blood loss by ~50% 3rd line Treatment
Systemic progestogens
- E.g. norethisterone 5mg TDS PO
- Reduces blood loss by 80% by directly inhibiting ovulation and directly suppressing endometrium
Depot injectable progestogen
- Side effects: nausea, bloating, headache, breast tenderness, weight gain, acne
GnRH analogues
- Cause amenorrhoea
- Usually for short-term use only (max 6/12)
- Hot flushes, vaginal dryness, loss of bone mineral density with time
16
Q
Treatment: surgical options
A
Endometrial ablation
- E.g. resection, laser ablation, electocautery
- Relieves majority of symptoms in 80%
- Complications are rare but include uterine perforation, haemorrhage, infection and hyponatraemia (due to excess absorption of irrigation fluid)
- Pregnancy contraindicated following ablation
Hysterectomy
- Only treatment option which will guarantee amenorrhoea
- Complications: haemorrhage, bowel trauma, damage to urinary tract, infection, thromboembolism, risk of vaginal prolapse in later years
- Usually a total hysterectomy (i.e. cervix too) as benefits of leaving it are uncertain and woman must continue to have smears
- In someone >50, bilateral salpingo-oophorectomy may also be performed
17
Q
What is a fibroid? Where can they be located?
A
- Benign tumours of the myometrium, occur in > 25% of women, more common near menopause
- Growth is oestrogen and prob progesterone dependent. In pregnancy, they’re equally likely to grow or shrink. Regress in menopause
- Each fibroid is monoclonal in origin
18
Q
Describe some clinical features of fibroids
A
- 50% are aymptomatic,
- 30% have menorrhagia (heavy bleed), timing unchanged. Some can have intermenstrual loss if fibroid submucosal.
- Dysmenorrhoea, seldom cause pain
- If press on bladder, can get frequency/ urgency/ hydronephrosis
- O/E- Solid mass on pelvic/ abdo examination
19
Q
Describe the progression of fibroids
A
- Enlargement very slow. Stop growing and calcify post-menopause.
- Degenerations due to inadequate blood supply- ‘red degeneration’ characterised by pain and uterine tenderness, in hyaline or cystic degeneration, fibroid is soft and partly liquefied.
*Investigations and examinations are the same as mentioned in early cards for menorrhagia
20
Q
Describe the treatment for fibroids
A
Assymptomatic + small/ slow growing fibroid:
- no treatment needed.
Medical treatment:
- Tranexamic acid, NSAIDS or progestogens (1st line - often ineffective). Size of fibroid will determine whether IUS can be fitted or not
- GnRH agonists induce temporary menopause state but can only use for 6 months (used near menopause or before surgery to make it easier)
Surgical-
- Hysteroscopic surgery- fibroid polyp/small submucosal fibroid (<3cm) resected at hysteroscopy. (transcervical resection of fibroid) Pretreat with GnRH for 1-2 months to shrink, lower vascularity and thin endometrium.
- Myomectomy- Open or laproscopic. Blood loss can be heavy (rx of transfusion, hysterectomy to save life) and small fibroids can be missed so can get recurrence.
- Radical hysterectomy- Laproscopic/ vaginally/ abominally. GnRH pretreatment for 2-3 months.
Others
- Embolisation- Uterine artery embolization by radiologist, 80% success rate, alternative to myomectomy or hysterectomy. Reduces fibroid volume 50%, shorter hospital stay+faster recovery. Pain may get worse, readmission rates higher, may still need hysterectomy. Effect on fertility unclear so not offered if woman desires further pregnancy.
21
Q
What is adenomyosis? Give a brief overview of symptoms and management
A
- Definition: presence of endometrium & its underlying stroma within myometrium, most common ~40 years old
- Associated with endometriosis + fibroids
- Symptoms: painful regular heavy menstruation (symptoms subside post-menopause and can be absent)
- Signs: Uterus mildly enlarged and tender
- Investigations: not easily diagnosed on US but seen on MRI
- Management: Oestrogen dependent but unknown why it occur - progesterone IUS or OCP +/- NSAIDs can control sxs, but hysterectomy often needed.
22
Q
What is an intrauterine polyp? How do you diagnose and manage them?
A
- Small benign tumours in uterine cavity. Often cause menorrhagia and rarely prolapse through cervix.
- Diagnosed on US or post-hysterectomy. Resect with diathermy or avulsion to cure.
