Heavy menstrual bleeding Flashcards
Definition of uterine fibroid
- Benign tumor of uterine smooth muscle (leiomyoma)
- Estrogen dependent
- Reproductive age
Classification of uterine fibroid
- Submucous
- Intramural
- Subserous
- Pedunculated
- Cervical
Risk factor for uterine fibroid
- Reproductive age
- Nulliparity
- Obesity
- Family history
Symptoms of uterine fibroid
- Asymptomatic (majority)
- Menorrhagia
- Anemic symptoms
- Pressure symptoms
Bladder: frequency, retention
Rectum: constipation
Pelvic vein: leg edema, hemorrhoid, varicose vein - Pain: in acute degeneration
- Subfertility
PE finding of uterine fibroid
- General: signs of anemia
- Abdominal: mass (firm, smooth, non-tender)
- Bimanual: differentiate uterine fibroid from ovarian mass
- Speculum: r/o local lesion (cervical polyp), any bleeding from os, vaginal discharge
Difference between ovarian and uterine mass
> Uterine
- Firm
- Suprapubic
- Can’t get below
- Cervix moved from vaginal finger @ bimanual
> Ovary
- Cystic
- Iliac fossa
- Can get below
- Do not move from vaginal finger
Investigation for uterine fibroid
> Blood
- FBC: anemia due to menorrhagia
- BUSE/ Cr: may compress ureter, causing hydronephrosis
- UPT: exclude pregnancy
- TFT: exclude hypothyroidism
- Coagulation profile: exclude bleeding disorder
> Imaging
- Ultrasonography: details of mass, endometrial thickness, exclude hydronephrosis
- Diagnostic hysteroscopy: look for fibroid, polyp, allow biopsy
Management of uterine fibroid
> Medical
- Hormonal: GnRH agonist, COCP
- Non-hormonal: tranexamic acid, mefenamic acid
> Surgery
- Conservative: myomectomy, hysteroscopic removal, uterine artery embolization
- Definitive: hysterectomy
Indication of surgical management in fibroid
- Causing symptoms
- Distort uterine cavity and likely to complicate future pregnancy
- Grow rapidly
- Infertility
Indication of hysterectomy in fibroid
- Women over 40 y/o
- Fertility not desired
- Severe bleeding during myomectomy
Complication of fibroid in pregnancy
- Miscarriage
- Premature labor
- Malpresentation
- Obstructed labor
- Postpartum hemorrhage
Clinical features of adenomyosis
- Increasing severe menorrhagia
- Dysmenorrhea
- Dyspareunia
- Urinary frequency
Management for adenomyosis
> Definitive
- Hysterectomy
> Uterus-sparring
- Hormonal medication for menorrhagia (eg: levonorgestrel IUD)
- Uterine artery embolization
- Uterus-sparring resection
Risk factor of endometriosis
- Low birth weight
- Early menarche
- Late menopause
- Genetics
- Red meat
- Obesity
Clinical feature of endometriosis
- Menorrhagia
- Severe dysmenorrhea
- Deep dyspareunia
- Infertility
Definition of dysfunctional uterine bleeding
Any variation from normal uterine bleeding:
- Frequency
- Regularity
- Duration
- Volume
Cause of dysfunctional uterine bleeding
“PALM-COEIN”
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
- Coagulopathy
- Ovulatory dysfunction
- Endometrial dysfunction
- Iatrogenic
- Not otherwise classified
Causes of heavy menstrual bleeding
- Coagulopathy
- Endocrine disorders (eg: hypothyroidism, hyperthyroidism)
- Structural lesions (eg: polyps, fibroids)
- Medication (eg: anticoagulant, platelet inhibitors, NSAIDs)
Management of endometrial hyperplasia
> Premenopausal
- Progesterone (eg: IUCD, COCP): reverse EH by stromal decidualization and subsequent thinning of the endometrium
> Postmenopausal
- Progesterone
- Hysterectomy
Indication for hysterectomy in endometrial hyperplasia
- Progestin therapy is declined or contraindicated
- Those with bothersome bleeding
- At highest risk of developing endometrial carcinoma
- Those who desire definitive therapy
Disadvantage of GnRH agonist
- Expensive
- When stopped ,regrow within few months
- Alter surgical plane and make surgery more difficult
- Smaller fibroid become indistinct missed during surgery -> increase recurrence rate
Why do Hysterectomy and not TAHBSO in fibroid patient
- Bilateral oophorectomy in premenopausal increase risk of fracture, multiple morbidity, cardiovascular disease and neurologic dysfunction
- However. got risk of ovarian ca if ovaries are preserved
Complication of UAE
- Fever
- Infection
- Fibroid expulsion
- Potential ovarian failure
Specific sign for endometriosis
- Focal tenderness on vaginal examination
- Nodules in the posterior fornix
- Adnexal masses
- Immobility or lateral placement of the cervix or uterus
