Gynaecology - Menstrual disorders: AUB, Amenorrhea and Menopause, Dysmenorrhoea Flashcards
FIGO definition of normal menstruation
FIGO classification of AUB
AUB
Ddx
AUB
Approach and history taking questions
Heavy menstrual bleeding
Ddx
HMB
Approach and history taking questions
HMB
Physical exam
HMB
First line Ix
Blood test:
- CBC: Hb, platelets
- Pregnancy test: to exclude pregnancy → must be done (or document no unprotected sex) before EA
- ± clotting profile: if HMB since menarche, or FHx +ve
- ± Fe profile: for Fe def anemia
- ± TFT: only when clinically symptomatic (uncommon)
Further investigations:
- Endometrial aspirate/sampling (EA) (子宮內膜吸取術)
- Hysteroscopy (宮腔鏡檢查術) ± endometrial biopsy
- Pelvic US when suspect structural pathology
- Saline infusion sonography (sonohysterography, SIS)
Hysteroscopy and endometrial biopsy
Indications
Process
Compare TAUS and TVUS
Saline Infusion sonography
Indication and use
HMB
Medical management options
Hormonal treatment:
- Combined OC pills (COCP): 1st line unless C/I
- Levonorgestrel IUD (Mirena): also 1st line unless C/I
- High-dose oral progestin: if prefer to avoid or C/I to estrogen
- Danazol: a/w significant S/E, NOT used nowadays
- Gonadotrophin-releasing hormone agonist (GnRHa): a/w significant S/E, NOT used nowadays
Non-hormonal treatment:
- NSAIDs: e.g. mefenamic acid (Ponstan)
- Tranexamic acid (TXA, Transamin): antifibrinolytic agent (flow control only)
- Fe supplement: FeSO4 300mg BD ×12w
HMB
Surgical management options
Endometrial ablation (子宮內膜去除術)
Hysterectomy (子宮切除術)
- Abdominal hysterectomy (AH)
- Vaginal hysterectomy (VH): approach through vaginal introitus
- Laparoscopic hysterectomy (LH)
- ± concurrent oophorectomy: preferred when near menopause: ovaries no use after menopause
HMB
COCP
- Forms
- MoA
- Effect
- Advantage
- S/E
- C/I
HMB
Mirena
- MoA
- Effect
- Advantage
- S/E
- C/I
HMB
High-dose oral progestin
- Forms
- MoA
- Advantage
- S/E
HMB
Mefenamic acid
- MoA
- Effect
- Use
HMB
Transamin
- MoA
- Max dose
- C/I
HMB
Endometrial ablation
- Indications
- C/I
- Preoperative preparation
- Procedure
- Complications
HMB
Hysterectomy
- Indication
- Choice of route of hysterectomy
Intermenstrual and Irregular Bleeding
Ddx
IMB
History taking questions
IMB
PE
IMB
First line investigations
IMB
Management options
Post coital bleed
Ddx
Post coital bleed
Management flowchart
Post menopausal bleed
Definition
Ddx
Post menopausal bleed
History taking questions
PE
PMB
First-line investigations
Treatment options
Primary and secondary amenorrhea
Definitions
Primary amenorrhea
Ddx
Secondary amenorrhea
Ddx
Physiological causes of amenorrhea
Functional hypothalamic amenorrhea
Hormonal profile
Common causes
Primary ovarian insufficiency
- Definition
- Hormonal profile
- Causes
PCOS
Diagnostic criteria
Cryptomenorrhea
Classical symptom
Causes
Cryptomenorrhea (outflow tract obstruction)
- present with cyclical abdominal pain due to accumulation of blood in vagina (hematocolpos) or uterus (hematometra)
Genetic causes of amenorrhea
Primary amenorrhea
Common clinical presentation and features
Secondary amenorrhea
Common clinical presentation and features
Primary amenorrhea
Key history taking questions
Secondary amenorrhea
Key history taking questions
Primary amenorrhea
P/E features
Secondary amenorrhea
P/E features
Primary amenorrhea
Workup investigations
Secondary amenorrhea
Workup investigations
Primary and secondary amenorrhea
Routine hormonal investigations
Primary and secondary amenorrhea
Second-line investigations
Hypogonadotropic hypogonadism (Class 1)
Cause
Ix results
Hypogonadotropic hypogonadism (Class 1)
Management of underlying cause
Hormonal and fertility management
Normogonadotropic anovulation (Class 2)
- Cause
- Ix results
Normogonadotropic anovulation (Class 2)
Management of underlying cause
Hormonal and fertility management
Hypergonadotropic hypogonadism (Class 3)
Cause
Ix findings
Hypergonadotropic hypogonadism (Class 3)
Management of underlying cause
Hormonal and fertility management
Hyperprolactinemia (Class 4)
Ix findings
Management
Outflow tract abnormalities
Ix findings
Management
Concealed male karyotype
Ix findings
Management
Outline flowchart for amenorrhea assessment
Define Climacteric, Menopause and Perimenopause
Types of menopause
Menopause
Stages and endocrine stages
Climacteric symptoms
- Vasomotor symptoms
Climacteric symptoms
- Neuropsychiatric symptoms
Climacteric symptoms
- Sexual and urogenital changes
Postmenopausal osteoporosis
- Cause
- Risk factors
- Risk assessment
Menopause
Diagnosis
Menopause
Hormone replacement therapy
- duration
- options/ regimens
HRT
Benefits and risks
The combined regimen has a higher risk of CA breast and CAD compared to Estrogen only regimen despite conventional belief that estrogen only regimen induces CA breast
HRT
Contraindications
Fibrocystic disease is not a relative C/I
HRT
Indications
Initiating HRT:
Indication:
- premature menopause: <40y for bone and cardiac protection (no extra lifetime risk)
- symptomatic menopausal pt: only for vasomotor symptoms ± mild mood disorder (not for cardio- and bone protection alone)
- (menopausal women with established osteoporosis)
- (hypopituitarism and other endocrine disease)
Timing: need not await amenorrhea before starting HRT
HRT
When to stop therapy
Standard duration about 2-3 years
Taper from standard to low dose after 1st year
Stop regimen during winter
Investigations for metabolic and cardiovascular profile every 2 years
Rapid symptom control within a month usually
Taper off and remain low dose regimen if possible after few months of symptom relief
HRT
Algorithm of HRT administration
Menopause
Management of menopausal symptoms
Postmenopausal osteoporosis
Primary ovarian insufficiency
- Definition
- Causes
Primary ovarian insufficiency
Workup
Management
Endometrial aspirate
Indications
Process
