Heavy Menstrual Bleeding and Irregular Bleeding

Question 1

What is the Palm Coien classification system?

Answer 1

Structural

• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy

Non-structural

• Coagulopathy
• Ovulatory
• Iatrogenic
• Endometrial dysfunction/Endocrine
• Never forget pregnancy

Question 2

What are the RFs for endometrial cancer?

Answer 2

• Chronic anovulatory cycles
• Unopposed oestrogen (always give with progesterone)
• Iatrogenic = therapy
• Not ovulating regularly
  
  • Obesity
  • Infertility
  • PCOS
• Nulliparous
• Endometrial hyperplasia
  
  • Simple 1% cystic dilated gland
  • Complex 3% crowding gland
  • Atypical 30% nuclear atypia within cells
• FHx NMPCC / related cancers - hereditary.
• Tamoxifen = 2-3x ↑risk

Question 3

What is the current screening for Cervical cancer?

Answer 3

• often asymptomatic but if you have postcoital bleeding or intermenstrual bleeding - need to do colposcopy.
• Screening:
  
  • Old - Pap-smear (every 2 years from 20 or after intercourse)- cytology atypia
  • New - HPV serology in women >25 every 5 years
    
    • PCR - for RNA have to have liquid,
  • colposcopy +/- biopsy

Question 4

What is endometrial dysfunction?

Answer 4

• diagnosis of exclusion

Question 5

A women presents aged 36 with amenorrhoea. What is a major diagnosis you need to exclude? What are potential causes?

Answer 5

Is she pregnant?

Other DDx:

• not primary so all secondary
• Brain:
  
  • stress
  • excessive exercise
  • anorexia/bulimia
  • thyroid
• Uterus:
  
  • Ashermann’s syndrome
  • contraception (specific)
  • chemotherapy/surgery
• Ovaries:
  
  • PCOS
  • surgery/chemo

Question 6

What are some causes of amenorrhoea? What is the pathophysiology of these?

Answer 6

Divide it into Primary and Secondary

Brain/Thyroid

Primary:

• Kallman’s syndrome (failure of migration of some nerves producing GnRH and also have smell - anosmia)

Secondary: (low FSH/LH)

• stress
• excessive exercise
• anorexia/bulimia
• chronic disease
• pituitary adenoma
• thyroid (hypo/hyper) - usually late sign
• intracranial lesion

Uterus

Primary:

• no uterus/very small uterus/non-functioning uterus
• Mullerian duct problems (MRRH)

Secondary:

• pregnancy
• contraceptive
• chemotherapy
• Ashermann’s syndrome (endometrium disapears from retained products)
• hysterectomy/endometrial ablation

Ovaries

​Primary:

• Androgen insensitivity syndrome
• primary ovarian failure (Turners syndrome)

Secondary

• PCOS
• chemo/radiotherapy
• surgery

Vagina

Primary

• don’t have a vagina (absence)
• septums/imperforate hymen (blue domed hymen)

Secondary:

• none (surgery)

Question 7

What examinations should you do in a women presenting with 2 weeks of HMB?

Answer 7

• BP/Pulse
• Abdominal exam
  
  • bimanual examination (big uterus?)
• PAP smear

Question 8

What investigations would you order in someone with 2 weeks of HMB?

Answer 8

1. Pregnant? β-HCG
2. Anaemic? FBE/Iron studies
3. Thyroid function
4. PCOS? criteria for diagnosis (NIH vs Rotterdam)
   
   • Hormones:
     
     • FSH/LH
     • oestrogen (androgen levels)
     • Progesterone (only tells you about ovulation recently)
   • US Dx:
     
     • more than 12 follicles (<10mm, most <5mm) and how big the ovaries.
     • moves to redefine and make it aged based (studies from the 80s).
     • thickened endometrium (depends on cycle, postmenopausal <4mm)
5. PAP smear?

Question 9

What is the initial management of a women with HMB aged 36? Suspected PCOS?

Answer 9

• Transexamic acid (fast, not expensive, anyone unless you have active clot) 2 tabs 4x a day only when bleeding
  
  • antifibrinolytic - slows down fibrinolysis
• POP (not COCP - don’t know if they have cancer, 36 years old, smoker)
  
  • doesn’t make the cancer worse
  • norethisterone (primelut) 5mg tabs,
  • provera (more flexibility with dosing)
  • 5 days worth and stop get withdrawal bleed, 3 week course.
• Iron replacement

Question 10

What are the results you’d get back for PCOS?

Answer 10

• Hormone investigations (ideally do day 2 of cycle)
  
  • FSH is higher
  • LH is 3x the FSH
  • high free testosterone
• OGTT (impaired fasting glucose)
• overweight
• endometrial hyperplasia (don’t ovulate often, stuck in first half of the cycle).
  
  • oestrogen thickens, progesterone stabalises the endometrium
  • chronically unopposed oestrogen without modulation.

Question 11

What is the management of PCOS?

Answer 11

• hystroscopy
  
  • sample of the endometrium
• lifestyle changes (diet/exercise)
• impaired glucose tolerance - metformin

Question 12

What are the considerations of a women with PCOS getting pregnant?

Answer 12

• getting pregnant (fertility specialist)
  
  • irregular cycles
  • older age
• gestational diabetes risk

Question 13

What is the comprehensive management of a women with HMB? First with investigations, then with conservative and medical management.

Answer 13

Investigations:

• FBE/iron
• β-HCG
• TVUS
• +/- Coags, FSH/LH/Androgren (PCOS), TFTs,

Conservative:

• iron replacement/infusions

Non-Hormonal:

• ponstan (with food for ulcers)
• TXA (2 big tabs, 4x daily, anyone without active clots)

Hormonal:

• OCP continous
• POP (mood symptoms)
• GnRH analogues
• Mirena

Surgical:

• endometrial ablation
• MRgFUS (UAE)
• hysterectomy