Menorrhagia

Question 1

First line treatment of menorrhagia

Answer 1

Mirena coil

Question 2

Investigations AND examinations in menorrhagia

Answer 2

Bimanual and abdominal examination
FBC (for any anaemia), clotting and TFTs if indicated by Hx
Swabs (if STI history is relevant)

Hysteroscopy (if suspect endometrial Ca or submucosal fibroids)
Transvaginal USS - if possible large fibroids (palpable pelvic mass)

Question 3

Treatment of menorrhagia with no associated pain in patients wanting to have children/doesn’t want contraception

Answer 3

Tranexamic acid

Question 4

Treatment of menorrhagia with associated pain in patients wanting to have children/doesn’t want contraception

Answer 4

Mefenamic acid

Question 5

Treatment of menorrhagia when contraception is wanted

Answer 5

Mirena coil (first line)
COCP

Question 6

Options when medical management has failed,

Answer 6

Endometrial ablation
Hysterectomy
Myomectomy in fibroids

Question 7

Causes of menorrhagia

Answer 7

Dysfunctional uterine bleeding (most common cause - common at extremes of reproductive ages)
Fibroids
Endometriosis/adenomyosis
PID
Contraceptives esp Copper coil
Bleeding disorders, diabetes, hypothyroidism

Question 8

Fibroids investigations

Answer 8

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.

Pelvic ultrasound is the investigation of choice for larger fibroids.

Question 9

Endometriosis symptoms to ask about/talk about

Answer 9

Pelvic pain - dysmenorrhoea
Deep dyspareunia (deep pain on intercourse)
Infertility
Urinary and bowel sx - deposits of endometrial tissue can cause blood in urine, bowel

Question 10

Endometriosis on examination may reveal

Answer 10

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix

A fixed cervix on bimanual examination

Tenderness in the vagina, cervix and adnexa

Question 11

Diagnosing endometriosis

Answer 11

Pelvic ultrasound - may reveal large endometriomas and chocolate cysts but often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.

Laparoscopic surgery is the gold standard - biopsy gives definitive diagnosis

Question 12

Treatment of endometriosis

Answer 12

Analgesia

Hormonal treatment

Question 13

When to refer to gynaecology for fibroids

Answer 13

if greater than 3cm

Question 14

What treatment may be given before myomectomy

Answer 14

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Question 15

Surgical options for fibroids - when they are larger

Answer 15

Myomectomy
Uterine artery embolisation - by interventional radiologist
Endometrial ablation
Hysterectomy

Question 16

Surgical options for endometriosis

Answer 16

Laparoscopic adhesiolysis (may improve fertility)

Question 17

Non surgical treatment for endometriosis

Answer 17

Analgesia

Hormonal - COCP, mirena coil, POP, implant - stop ovulation and reduce endometrial thickening

GnRH agonists- They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.

Question 18

Investigations in adenomyosis

Answer 18

Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.

MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.