MENORRHAGIA Flashcards
What is the definition of menorrhagia?
Excessive menstrual blood loss which interfered with a woman’s physicial, social, emotional or maternal quality of life which can occur alone or in combination with other sym,proms
It is defined in clinical settings as blood loss of >80ml and/or a duration of menstruation >7 days. This is not really used anymore as it’s highly subjective so we now focus more on the impact on QOL
Whats the normal volume of blood loss during menstruation?
25-80ml
Prevalence of menorrhagia in adolescent population?
37%
Causes of menorrhagia
• Uterine and ovarian pathologies
◦ Uterine fibroids
◦ Endometrial polyps
◦ Cancer of ovary, uterus, cervix of endometrium
◦ Endometriosis and adenomyosis
◦ Polycystic ovary syndrome
◦ Pelvic inflammatory disease
◦ Dysfunctional uterine bleeding (no identifiable cause - often occurs in young girls)
◦ Anovulatory cycles
• Systemic conditions
◦ Coagulation disorders e.g. VWD
◦ Hypothyroidism
◦ Diabetes mellitus
◦ Hyperprolactinaemia
◦ Liver or renal disease
• Meds
◦ Anticoagulants, antiplatelets, NSAIDs, COCP
◦ Intrauterine contraceptive device - particuarly copper coil
INvestigtaions for menorrhagia?
FBC- for IDA
Pregnancy test if reproductive age
Vaginal or cervical swab is ?infection
TFT is features of hypothyroidism
Test for coagulation disorders if had menstrual bleeding since menarche and have a personal or FHx
If history and exam suggests high risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis then investigate further:
Hysteroscopy for suspected fibroids, polyps, endometrial pathology
Pelvi USS for suspected large fibroids (palpable uterus through abdomen, pelvic mass)
Transvaginal USS for suspected adenomyosis (significant dysmenorrhea or bulky tender uterus on exam)
If history and exam suggest low risk then consider starting Tx without further investigations
How should you manage women with menorrhagia who does not require contraception and there is no underlying pathology?
Mefanamic acid 500mg tds (particuarly if dysmenorrhea as well) or tranexamic acid 1g tds - start on the first day of the period
(If no improvement try other drug whilst awaiting referral)
How should you manage women with menorrhagia who requires contraception and there is no underlying pathology?
First line: Intrauterine levonorgestrel system (Mirena coil)
Second line: COCP
Third line: long -acting progestogens
What is second generation endometrial ablation?
It involves passing a specifically designed balloon into the endometrial cavity and filling it with high-temperature fluid to burn the endometrial lining
It replaced first generation which involves a hysteroscopy and direct destruction of the endometrium. Second generation is safer and faster
used for menorrhagia Tx
How does the levonorgestrel intrauterine system work?
The Mirena coil releases a progestin hormone called levonorgestrel which helps to thin the endometrium and reduce the amount of menstrual bleeding
Moa tranexamic acid?
Blocks lysine binding sites on plasminogen to prevent plasmin formation
Plasmin cannot then bind fibrin and induce fibrinolysis which stabilises the clot and prevents haemorrhage
Side effects of tranexamic acid?
Diarrhoea
Nausea
Vomiting
What drug called is mefanamic acid?
NSAID
How do NSAIDs help in menorrhagia?
They inhibit cox1 and cox2 enzymes which decreases prostaglandin production = decreases intensity of uterine contractions and reduces bleeding
How can contraceptive pills help in menorrhagia/
They can regulate the menstrual cycle so that it is more predictable and often lightens the menstrual flow
They can thin the lining of the endometrium, stabilise hormone levels and reduce production of prostaglandins
What is uterine artery embolisation?
A minimally invasive procedure where a radiologist inserts a catheter into the femoral artery and, using real-time imaging, will guide it to the uterine arteries that supple blood o the fibroids. They then place tiny particles such as polyvinyl alcohol into these arteries which blocks the blood flow to the fibroids and causes them to shrink
What is a myomectomy?
Surgical removal of uterine fibroids
What is a hysterectomy?
Surgical removal of the uterus
What is the medical term for a fibroid?
A leiomyoma
What are fibroids?
Benign smooth muscle tumours of the uterus
A mixture of smooth muscle cells and fibroblasts
What are the different types of fibroids?
Subserosal - outer serosal surface of uterus and extend into peritoneal cavity so commonly asymptomatic
Intramural - develop within myometrium, as they grow they can distort the uterus shape so can cause menorrhagia or dysmenorrhoea by interfering with the constriction of blood vessels
Submucosal - inner mucosa surface of uterus and extend into uterine cavity. Even when relatively small they can cause significant menorrhagia, dysmenorrhoea or reduced fertility
Pedunculated - on a stalk
How common are fibroids?
Occur in 20% of white women and 50% of black women in later reproductive years
Risk factors for fibroids?
Increasing age - rare before puberty as fibroids are usually oestrogen-dependant. Peak at perimenopausal years and decline after
Early menarche - due to prolonged exposure to oestrogen
Nulliparity
Older age at first pregnancy - as they tend to enlarge during first trimester of pregnancy and then shrink post partum
Black and Asian women
FHx
Symptoms of fibroids?
May be asymptomatic
Menorrhagia which may result in IDA
Bulk-related symptoms e.g. lower abdominal cramps during menstruation, bloating, urinary symptms with large ones
Subfertility or infertility
What would you feel on abdominal and pelvic examination in a pt with uterine fibroids?
Firm enlarged irreguarly shaped non-tender uterus on pelvic exam (note the uterus can be up to 10 times its normal size)
Central irregular abdominal mass on abdo palpation
How do we diagnose uterine fibroids?
Transvaginal USS - well-defined, solid, concentric, hypoechoic masses that cause a variable amount of acoustic shadowing
How do we manage asymptomatic fibroids?
No treatmen but periodic review to monitor size and growth
How d we manage menorrhagia secondary to fibroids?
Levonorgestrel intrauterine system (note cannot be used if there is distortion of the uterus)
NSAIDs e.g. mefanamic acid
Tranexamic acid
COCP
Oral progestogen
Injectable progestogen
How do we treat fibroids to remove them indefinitely?
Medical - GnRH agonists such as goserelin may reduce the size of the fibroids but typically short term (<6 months) treatment due to SE
Surgical - myomectomy, hysteroscopic endometrial ablation, hysterectomy
Uterine artery embolisation
Side efefcts of GnRH agonists
Menopausal symptoms s - hot flushes, vaginal dryness
Loss of bone mineral density
Prognosis of fibroids?
Generally regress after menopause due to drop in oestrogen
Complications of fibroids?
Subfertility or infertility as they can distort the uterine cavity and interfere with implantation
IDA
Complications during pregnancy - miscarriage, red degeneration, foetal malpresentation, preterm
Compression of adjacent organs - recurrent UTIs, urinary retention, hydronephrosis - rare
Torsion of a pedunculated fibroid - rare
Haemoperitoneum - rare
What is red degeneration of a fibroid?
Also called fibroid vascular infarction
Ischaemic, infarction and necrosis of the fibroid due to disrupted blood supply
More likely in larger fibroids i.e. >5cm during the 2nd and 3rd trimester or pregnancy as the fibroid rapidly enlarges and outgrows its blood supply
How does red degeneration of a fibroid present?
Severe abdominal pain, low grade fever, tachycardia and often vomiting
What is endometriosis?
A common condition characterised by growth of endometrium-like tissue outside the uterus
Where is endometriosis most typically found?
In the pelvis: ovaries, uterosacral ligaments, pouch of Douglas, rectum, sigmoid colon, bladder and distal ureter
Extrapelvic deposits are rare
Cause of endometriosis
Exact cause not known. Several theories:
Retrograde menstruation - endometrial cells throw backwards from uterine cavity through fallopian tubes and implant on pelvic organs where they seed and grow during menstruation
Lymphatic or circulatory dissemination
Generic predisposition
Metaplasia
Immune dysfunction
Certain environmental toxins
How common is endometriosis?
10% of women of reproductive age have a degree of it
Prevalence of endometriosis in women with infertility?
30-50%
Risk factors endometriosis?
Early menarche
Short monthly cycles or heavy menstrual periods lasting >7 days
Late menopause
Delayed childbearing
Nulliparity
FHx
Vaginal outflow obstruction
White ethnicity
Low BMI
Autoimmune disease
Late first sexual encounter
Smoking
How can endometriosis present?
May be asymptomatic or…
- chronic pelvic pain dull heavy or burning
- Dysmenorrhoea
- Deep dyparaneuria
- may have menorrhagia
- Period-related or cyclic GI or urinary symptoms - blood in stool, dysuria or haematuria
- infertility
Why can endometriosis cause period-related GI or urinary symptms?
As there can be deposit of endometriosis in the bowel or urinary tract
Why does endometriosis cause severe dysmenorrhoea?
As the endometrial tissue responds to the hormones as the uterus does. During menstruation the uterus sheds and bleeds causing inflammation of the tissues around the sites of endometriosis
Why can endometriosis cause infertility?
Due to adhesions around ovaries and fallopian tubes which can obstruct the route to the uterus
Pelvic examination findings in endometriosis?
Reduced organ motility - due to adhesions
Tender nodularity in posterior vaginal fornix - common site for endometriotic lesions to occur
Visible vaginal endometriotic lesiosn
How do we investigate endometriosis?
Gold standard is laparoscopy
Transvaginal USS may be considered to asssist the diagnosis as it is much less invasive
How do we manage endometriosis-related pain?
NSAIDs
Hormonal treatment - COCP or progestogen
Review woman after 3-6 months and if ineffective then refer to gynae
How do we manage endometriosis in secondary care?
GnRH analogues to induce a pseudomenopause by lowering oestrogen - this is used in pt awaiting surgery to help with pain in the interim
Surgical - laparoscopic excision of elation of endometriosis + adhesiolysis to improve conception chances. Ovarian cystectomy is recommended. Sometimes this can be followed by hormonal treatment and this is known as combination treatment.
Relapses will almost certainly occur so the ultimate management is a hysterectomy and bilateral salpingo-opherectomy with subsequent replacement of hormones.
Why do GnRH agonists work for the cyclical pain in endometriosis?
As after menopause endometriosis pain tends to improve as oestrogen is reduced
Using GnRH induces a pseudomenopause which will also do this
Explain how a hysterectomy and bilateral saplingo-opherectomy helps in endometriosis?
This is removal of the uterus and ovaries
This may not resolve all the symptoms but…
By removing the ovaries you induce a menopause which can stop ectopic endometrial tissue responding to the menstrual cycle
What management for endometriosis can improve fertility in some women?
Surgical removal of adhesions as this returns the anatomy to normal
What is adenomyositis?
The presence of endometrial tissue within the myometrium
(Note this is a distinct diagnosis to endometriosis)
What causes adenomyositis?
When the endometrial stroma is allowed to communicate with the underlying myometrium after uterine damage e.g. pregnant, childbirth, uterine surgery
This invasions can be focal or diffuse and is most commonl found in the posterior wall of the uterus
Risk factors for adenomyosis?
High parity women at the end of their reproductive years (80% of cases in women 40-50s)
Previous uterine surgery e.g. c-section, fibroid removal, dilatation and curettage
Why does adenomyosis symptoms subside post menopause?
As the ectopic endometrial tissue is hormone responsive
Symptoms of adenomyosis?
Dysmenorrhoea - cramping or sharp knife-like
Chronic pelvic pain
Menorrhagia
Dispareunia
Bimanual palpation findings in adenomyosis?
Enlarged boggy tender uterus
Investigtaions adenomyosis?
Transvaginal USS is first line
MRI is an alternative
Definitive diagnosis is histological after a hysterectomy but this is rarely done
Management of adenomyosis?
Symptomatic - tranexamic acid or mefanamic acid
Hormonal - Mirena coil, COCP, cyclical oral progestogens
GnRH agonists
Uterine artery embolisation - short/medium term Tx for women who wish to avoid hysterectomy or want to preserve fertility
Hysterectomy is definitive treatment
Complications of adenomyosis?
Infertility
Miscarriage
Preterm
SGA
PPROM
Malpresentation
C-sections
Postpartum haemorrhage
Anaemia from menorrhagia
How common is PCOS?
1 in 10 of women of reproductive age
Prevalence is about 2.5% but up to 70% are undiagnosed
What is PCOS
A heterogeneous endocrine disorder that appears to emerge at puberty.
Characterized by hyperandrogenism, ovulation disorder, and polycystic ovarian morphology on USS.
What causes PCOS?
Cause is unknown and its likely to be multi factorial
Insulin resistance and compensatory hyperinsulinaemia are key factors in many women
Insulin resistance is present in around 65–80% of women with PCOS, independent of obesity, and is further exacerbated by excess weight
Reduced production of sex hormone-binding globulin (SHBG) in the liver — as testosterone is bound to SHBG, more testosterone is available in the blood in the biologically active unbound form, even though the total testosterone level may be normal or only modestly elevated.
Increased androgen production— this stops follicular development and therefore causes anovulation and menstrual disturbance.
Hormonal imbalance is common in women with PCOS.
Serum LH levels are elevated in approximately 40% of women with PCOS due to increased production from the anterior pituitary
The theca cells of the ovary produce excess androgens due to hyperinsulinaemia or increased serum levels of LH.
When the concentration of LH increases relative to that of FSH, the ovaries preferentially synthesize androgens from androgen precursors rather than oestrogens
The theca cells in women with PCOS seem to be more efficient at converting androgen precursors to testosterone than normal theca cells
Women with PCOS may have increased serum oestrogen levels.
Follicular development is arrested at some stage short of full maturation of an ovulatory follicle. Therefore, although there is no ovulation, oestrogen production continues and there is no oestrogen deficiency. However, as a result of continued exposure to oestrogen unopposed by progestogen, the endometrium may become hyperplastic. In addition, testosterone is converted to oestrogen in peripheral fat
PCOS also appears to have a genetic link.
Risk factors PCOS
Diabetes
Family history
Obesity
Symptms of PCOS?
Subfertility and infertility
Menstrual disturbance - oligomenorrhoea and amenorrhoea
Hirsutism and acne
Obesity
Acanthosis nigricans
What causes hirsutism and acne in PCOS?
Hyperandrogenism
What cause acanthosis nigricans in PCOS?
Insulin resistance
What is Acanthosis nigricans?
Thickened rough dark skin on axial and elbows that has a velvety texture
Investigations for PCOS
Bloods: total testosterone, SHBG, free androgen index
Measure the following to rule out other causes of menstrual disturbances: LH:FSH, prolactin, TFT
Check for impaired glucose tolerance
Pelvic USS - multiple cysts on ovaries
In PCOS what would you expect to see from the following investigations:
- total testosterone
- Sex hormone binding globulin
- Free androgen index
- LH:FSH
- prolactin
- TFT
Total testosterone - normal-mod elevated (if very raised consider other causes)
SHBG - normal-low
Free androgen index - normal or elevated
LH:FSH raised (not that useful)
Prolactin normal-mild elevated
TFT - normal
What is the free andorgen index and how do we calculate it?
(100 x total testosterone) / SHBG value
It assess the amount of physiologically active testosterone present
What is the definition of finding polycystic ovaries on USS?
The presence of 12 or more follicles in at least 1 ovary or increased ovarian volume
What is the name of the diagnostic criteria for PCOS?
Rotterdam critera
What is the Rotterdam criteria?
- infrequent or no ovulation (usually manifested as infrequent or no menstruation)
- clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
- polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
Management of PCOS (general, hirsutism/acne, infertility)
General:
Weight reduction
Contraception if needed - COCP (may also help hirsutism and acne)
Hirsutism and acne:
- topical retinoids
- hair removal
- COCP third generation e.g. Dianette (co-cyprindiol) which has anti-androgen effect
- topical eflornithine (slows enzyme in hair follicles reducing hair growth)
- spironolactone, flutamide, finasteride may be used under specialist supervision (all anti-androgen effect)
Infertility:
- weight reduction
- anti-oestrogen therapies e.g. clomifene (encourages ovulation by stimulating gonadotrophin release)
- Metformin, particuarly if pt is obese (increases peripheral insulin sensitivity)
- gonadotrophins
Manage CVD risk factors
Prognosis of PCOS?
After menopause the hyperandrogenic manifestations may improve as ovarian function declines
This may allow withdrawal of the hyperandrogenic treatments
Complications PCOS
• infertility - single most common cause of infertility
• CVD
• Metabolic disorders
• Obstructive sleep apnoea syndrome
• Psychological disorders
• Pregnancy complications
• Endometrial cancer increased risk (due to prolonged oligomenorrhoea or amenorrhoea, insulin resistance, obesity and diabetes)
• NAFLD
Describe why PCOS can increase the risk of endometrial cancer
Women with PCOS dont ovulate or not frequently at least so they dont produce sufficient progesterone but do continue to produce oestrogen.
This means the endometrial lining continues to proliferate under the influence of oestrogen without regular shedding during menstruation
This results in endometrial hyperplasia and this increases cancer risk
How do we monitor endometrial cancer in women with PCOS?
Any women with more than 3 months between periods or abnormal bleeding must be investigated with pelvic USS to asses endometrial thickness
Cyclical progestogens should be used to induce a period prior to the scan
If the endometrial thickness is >10mm they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer
How can we protect women with PCOS against endometrial cancer?
Mirena coil
Or induce a withdrawal bleed with cyclical progestogens or COCP
How can pelvic inflammatory disease cause menorrhagia?
The inflammation and scarring can disrupt normal menstrual flow or cause direct changes to endometrial tissue
What is dysfunctional uterine bleeding?
Irregular bleeding between monthly periods in the absence of underlying pathology
What are Anovulatory cycles?
A menstrual cycle in which the release of an egg from the ovaries does not occur
They may still experience bleeding however
What can anovulation that persists for more than a year cause?
Infertility
What can cause Anovulatory cycles?
Hormonal birth controls
Being underweight, overweight, excessive exercise, low calories
Significant stress
PCOS
How may Anovulatory cycles present?
Irregular periods
Lack of periods
Lighter menstrual bleeding
How can the copper coil affect menstrual cycle? Why?
20-50% of women will have heavier periods for 12 months after insertion
Placing the IUD causes some tissue damage which can prompt the release of prostaglandins. It may also cause local inflammation which can cause thinning of the endometrium. Some women may also just have a natural reaction to copper
Why is laparoscopy not the first line investigation for endometriosis if it is gold standard?
Due to the risk of complications e.g. bowel perforation
If you have amenorrhoea with low-levels of gonadotrophins, what does this indicate?
A hypothalamic cause - not releasing enough GnRH
Causes: excess exercise, weight loss, starvation, emotional stress
When in the menstrual cycle is endometriosis typically worst?
During the luteal phase due to the ectopic endometrial tissue proliferating in response to rising oestrogen levels - end of menstrual cycle before period
Why is COCP contraindicated in pt with migraine with aura?
Due to increased risk of ischaemic stroke
What is a ruptured endometrioma?
When endometrial tissue forms on the ovaries it can produce a cyst called an endometrioma
This cyst can fill with blood and grow large
This can rupture cause Haemoperitoneum
It can present with acute abdo pain, fever, nausea, vomiting, peritonitis
You will see free fluid in the pelvis during USS
What is an endometrioma?
Cystic lesions that stem from the disease process of endometriosis.
They are most commonly found in the ovaries. They are filled with dark brown endometrial fluid and are sometimes referred to as “chocolate cysts.”
Their presence indicates a more severe stage of endometriosis
What is the only effective treatment for large fibroids causing problems with fertility if the woman wishes to conceive in the future?
Myomectomy
Explain a laparoscopy to a pt for confirming/treating endometriosis?
A keyhole surgery where small cuts are made in your tummy. A small tube with a light source and camera will be inserted which sends images of the inside of your tummy/pelvic to the television monitor.
Fine instruments will be used to cut away or apply heat/laser to patches of endometriosis to destroy the tissue or remove them
This is carried out under general anaesthetic
Endometrial thickness throughout the menstrual cycle
- During menstruation: 2-4mm
- Early proliferative phase (day 6-14): 5-7mm
- Late proliferative: up to 11 mm
- Secretory phase: 7-16 mm
