Menorrhagia Flashcards
What is the length of a normal menstrual cycle and length of menses? How is this usually written in medical shorthand?
Menstrual cycle - 21-35 days
Menses - 3-7 days
Write as menses/menstrual cycle (e.g. 5/28)
How much blood does a woman usually lose during menses?
35 mls/cycle
What is the definition of menorrhagia?
Prolonged (> 7 d) or excessive menstruation (> 80mls/cycle) occuring in regular cycles
What is the difference between abnormal menstrual bleeding and menorrhagia?
AMB can include other disorders than just menorrhagia (like irregular or more frequent cycles)
What are the two main classifications of causes of abnormal menstrual bleeding? Name the 9 specific causes (4 and 5 respectively)
Structural (PALM) - Polyps, Adenomyosis, Leiomyoma (Fibroid), Malignancy
Non-structural (COEIN) - Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified (lol)
Go through why each structural cause of AUB leads to bleeding
Polyp - highly vascular epithelial proliferations, prone to bleeding
Adenomyosis - not well understood, but during menstruation, blood may become trapped, leads to dilatation and stretching of uterus. Over time, the uterus can enlarge; more endometrium = more sloughing = more bleeding
Leiomyoma - Growth of tumour can increase surface area of endometrium = more sloughing = more bleeding
Malignancy (endometrial or cervical) - neovascularisation = easy bleeding
Go through how each non-structural cause of AUB leads to bleeding
Coagulopathy (often Von Willebrand’s Disease) - they bleed easily…
Ovulatory dysfunction - without regular ovulation, no corpus luteum forms. No corps luteum = no progesterone. No progesterone = unopposed oestrogen = endometrial hyperplasia. Endometrium will eventually shed when it outgrows blood supply = lots of bleeding
Endometrium - local factors in the endometrium can lead to increased bleeding (even with normal ovulation/hormones), like poor clotting, poor vasoconstriction, poor endometrial repair after sloughing. Diagnosis of exclusion
Iatrogenic:
OCP (especially without placebo - endometrial layer will continue to thin until blood vessels are exposed = break-through bleed), also Mirena IUD or any other hormonal contraceptive, dopamine-lowering drugs (tricyclic antidepressants - leads to more prolactin = less ovulation), anticoagulants (warfarin, heparin)
Not yet classified - includes chronic endometritis, AV malformations, myometrial hypertrophy….
Name 10 questions to ask on Hx for AUB
Menarche (perimenarchal can = anovulation)
Last normal menstrual period (exclude pregnancy)
Length of menses
Length and regularity of cycle (anovulation)
How many pads/tampons
How long does heavy bleeding go for
Intermenstrual or post-coital bleeding (suggests local cause)
Associated dysmenorrhoea or dyspareunia (suggests adenomyosis or endometritis)
Symptoms of anaemia - faint, light-headed, fatigued, palpitations
Any weight changes, hirsuitism, acne (PCOS, anovulation)
Any easy bruising, bleeding, FHx of bleeding disorder
Sexual Hx, condoms, discharge, pelvic pain (PID, endometritis)
Last Pap smear (Cervical Ca)
Medications (warfarin, OCP, IUCD, tricyclic antidepressants)
Impact on life
Name 4 examinations to do for someone with AUB
Vital signs Abdo exam (feel for mass) Speculum (look for any prolapsing polyps, fibroids, appearance of cervix, do Pap) Bimanual exam (feel for size, shape, axis of uterus, cervical excitation, adnexal masses)
Name 5 Ix that may be warrented for someone with AUB
FBE + iron studies
Coagulation proflie
Hormones (FSH, LH, estrodial, testosterone)
TVUS
Hysteroscopy + D&C
Name 3 medications that can be used for AUB (regardless of cause)
Prostaglandin inhibitor (mefenamic acid/Ponstan) Antifibrinolytic (tranexamic acid) Hormonal contraceptives (OCP, progestogens, IUCD)
Name 2 surgical treatments for AUB
Endometrial ablation
Hysterectomy
