Identifying and managing menstrual symptoms Flashcards
What is an abnormal time for menstruation to occur for?
Over 8 days in length
Mennorrhagia
Heavy menstrual bleeding
Dysmenorrhoea
Painful menstrual bleeding
Oligomennorhoea
Infrequent periods>35 days - 6 months between bleeds
Primary amenorrhoea
Periods never start
Secondary amenorrhoea
Periods stop for over 6 months (not menopause)
Metrorrhagia/irregular bleeding
Periods out-with the range of 23-35 days with a variability of >7 days between shortest and longest cycles
Intermenstrual bleeding
Bleeding between periods
Post-menopausal bleeding
Bleeding 1 year after menopause
Premenstrual syndrome
Psychological and physical symptoms in luteal phase
Primary amenorrhoea
Lack of menses at age 15/16 with development of sexual characteristics
Lack of sexual characteristics or menses at 13
Constitutional - delay (temporary delay in skeletal muscle growth with no physical abnormalities causing it)
Female triad - disordered eating, ammenorhia, osteoporosis is athletic triad
Secondary amenorrhoea
Absence of periods for >6 months
causes are PCOS, increased prolactin, premature menopause
Amenorrhoea management
History
Exam - general, neuro, endocrine, pelvic
Bloods - oestrogeen, FSH, TSH, prolactin, preg test, androgens
Imaging - TVUSS, MRI head
Refer if unsure of pathology
Treat underlying cause
Osteoporosis risk - diet, bit D, Ca, COCP, HRT
PCOS
2/3 of following:
12 small follicles
Irregular periods
Hirsitism - clinical +/or biochemical (inc testosterone)
PC - amenorrhoea, oligomenorrhoea, weight gain, hirsutism
FSH increases in ovulation, normal in PCOS,
Testosterone, LH increase in PCOS
Complications and red flags of PCOS
Complications - T2DM, subfertiity, gestation diabetes, metabolic syndrome
Endometrial Ca- many years of amenorrhoea, unopposed oestrogen
Red flags - weight loss(reduce hyperinsulinism and hyperandrogenism, reduce risk of CVD and T2DM, restore periods and improve fertility
problems conceiving - refer if not trying to conceive then COCP
Menorrhagia definition and aetiology
> 80ml/cycle OR excessive blood loss that interferes with physical, emotional, social and material Q of L, +/- other symptoms
Most - no histological pathology, subtle abnormalities in haemostats/PG secretion
Hypothyroid and coagulopathy are rare
Common - idiopathic, fibroids, polyp (endometrial, cervical), dysfunctional uterine bleeding
Uncommon - hypothyroidism, coagulopathy, adenomyosis, cervical ectropion, endometriosis
Worrying - endometrial hyperplasia, cervical Ca, ovarian Ca, PID, pregnancy associated
Investigations in menorrhagia
Bleeding - clots, flooding, protection, other gynaecologist symptoms
Consequences - anaemia - SOB, fatigue, pallor
Systemic - thyroid, coagulopathy
Meds - anti-coagulants, hormonal contraceptives
Exam - speculum and bimanual, fibroids, adenomyosis, systemic disease and complications
Pregnancy test, bloods (Hb, TFTs, clotting), pelvis (TVUSS, endometrial biopsy, hysteroscopy)
menorrhagia tx
Intra-uterine system (Mirena coil - progesterone)
Combined pill
NSAIDs (mefenamic acid) and antifibrinolytics (tranexamic acid)
GnRH analogues - chemical menopause
Surgery (fibroids)
Fibroids/uterine leiomyomas
most common benign tumours in women
rare before menarche and shrink post-menopause
Asymptomatic but can cause menorrhagia, pelvic pain, dysmenorrhoea, pressure symptoms, subfertility
RFs - black/asian women, hereditary, reproductive years, early menarche, nulliparous
Red flags - acute pain, irregular bleeding, inc size postmenopausal
Dysmenorrhoea (primary)
Starts within 2 years of menarche, most severe on day 1 of bleeding/day before bleeding, cramping lower abdominal pain, radiates to lower back and legs, +/- GI nausea, vomiting, fatigue, headache
No pathology - inc PGs in menstrual fluid
NSAIDs to dec PGs, COCP/depot to dec ovulation, minera coil to dec bleeding and pain
Dysmenorrhoea (secondary)
Occurs many years after menarche
Cramping lower abdomen pain, radiates to lower back and legs, +/- GI nausea, fatigue, headache, deep dyspareunia, starts in luteal phase and continues throughout menstruation
Associated with pelvic pathology - endometriosis, chronic PID, fibroids, polyps, copper coil
Endometriosis aetiology
Retrograde menstruation Coelomic menstruation - peritoneal mesothelium - glandular epithelium Lymphatic/circulatory spread Immune dysfunction Genetic predisposition
Endometriosis presentation
Severe dysmenorrhoea Chronic pelvic pain Deep dysparenia Ovulation pain Chronic fatigue Dyschezia Infertility Irregular bleeding PMS Cyclical rectal bleeding/haematuria
Thickened nodular ligaments, fixed uterus, enlarged ovary, tenderness
Investigation - laparoscopy, TVUSS
Management - analgesia, COCP, POPs, GnRH analogues
Surgical - laparoscopy, hysterectomy
Fertility treatments
Intermenstrual and post-coital bleeding
Post-cotal - infection, cervical ectropion, cervical/endometrial polyps, cervical cancer, trauma/sexual abuse, vaginal atrophy
IMB - vaginal atrophy, cervical polyps, fibroids, ovarian Ca, post-smear, missed pill, breakthrough on hormonal contraception
Perimenopause
Months/years before menopause
Declining estradiol and progesterone
LH and FSH inc due to dec -ve feedback
Symptoms
Menopause
Last MP, supply of oocytes gone
Retrospective diagnosis 12 months after period cessation
Post-menopause changes
Reduced circling oestrogen - inc risk of osteoporosis, CVD, vaginal atrophy
