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
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
