Menstrual abnormalities Flashcards
Describe the ‘normal menstrual cycle’
Usually lasts somewhere between 23-39 days
- LUTEAL PHASE IS ALWAYS THE SAME (12-16 DAYS)
Women bleed for 2-8 days
They usually do not bleed excessively through pads and tampons
They do not experience excessive pain (some cramping)
Should not experience other symptoms to excess (skin changes, mood changes, breast tenderness)
Should not experience bleeding at any other time of the cycle (PCB, IMB)
What is abnormal bleeding?
- Abnormal in volume
- heavy (interferes with Q of L)
- excessive duration (2-8 days) - Irregularity, timing (delayed or frequent)
>39 days oligomenorrhoea
<23 days polymenorrhoea - Non menstrual bleeding (PCB, IBD,PMB)
What things might cause an affect on the tone of the uterus and thus cause menorrhagia?
When the endometrium is slighted off the uterus contracts down in order to expel it as well as begin to occlude some of the uterine blood vessels to stem bleeding
- Sometimes structural abnormalities in the womb stop this from happening such as…
FIBROIDS
ADENOMYOSIS
What are the main causes of abnormal bleeding and how can they be remembered?
PALM COEIN
P - polyps
A - Adenomyosis
L - Leiomyoma (FIBROID)
M - Malignancy or pre-malignancy
C - Coagulopathy
O - Ovulatory functional disorder (PCOS)
E - Endometritis (inflammation in uterus)
I - Iatrogenic e.g. exogenous sex steroids (COCP),IUCD,warfarin
N - Not yet classified
What Hx factors are important when a woman presents with menorrhagia?
- How many pads/tampons does she bleed through?
- Is she passing any clots
- WHAT EFFECT IS IT HAVING ON HER QOL
- Is it associated with any pain (dysmenorrhoea or dyspareunia-sex, deep or superficial)
- Is she bleeding at other times (PCB or IMB)
- Ask about symptoms of anaemia
- Ask about contraceptive history
- Ask about gynaecological history
- Ask about her smears
- Ask about obstetric hx
How should menorrhagia be investigated?
GYNAECOLOGICAL
BEDSIDE
-General exam-look for signs of anemia
Abdo exam-pelvic mass/tenderness
Pelvic exam
- VE, Speculum and bimanual
(size, position, mobility and texture of uterus)
BLOODS:
- FBC (anaemia, low platelets)
- Clotting and TFTs if indicated by history
IMAGING:
- USS is first line (can be done in 1ry care)
- done if irregular on bimanual exam
- will reveal masses
SPECIAL TESTS
-Consider a hysteroscopy with a endometrial biopsy (if over 45, endometrial thickness is >4mm on TVUSS
or treatment failure)
How can menorrhagia be managed medically?
- Rule out serious causes (exam, bloods, imaging, special test)
- 1st line: offered in GP is often MEFENAMIC ACID (an NSAID) + TRANEXAMIC ACID
-2nd line:
If this doesn’t work should recommend the MIRENA IUS (if cavity is normal and not disrupted by submucosal fibroids
3rd line -COCP
4th line- Long acting progesterones
What options are there if medical management of menorrhagia fails?
SURGICAL MANAGEMENT
ENDOMETRIAL ABLATION - using microwaves to kill the endometrial layer
MYOMECTOMY - removing the myometrium stops endometrial proliferation
HYSTERECTOMY - final surgical option - obviously discuss impact on fertility
If the woman is having IMB or PCB where are the problems likely to lie?
They’re not likely to be due to her endometrium as this bleeding would be cyclical.
Problems likely to be lower down - VAGINA OR CERVIX
What would be some key questions to ask about PCB?
When does it occur (during sex or just after)
Is it associated with pain and is this pain deep or superficial?
How much blood is there and what is it like (fresh, brown)
Is it after every sex?
Any IMB
Describe the pain
What kind of impact is it having on woman’s sex life/life in general?
Pain at any other time?
Bleeding at any other time?
Prev gynae hx, obs hx, smear gx, contraceptive hx
What would be some key questions to ask about IMB?
Find out when it is (constant, intermittent, cyclical)
How much blood is there and what is it like?
Does it happen between every period?
What are the periods themselves like?
Any pain?
Any PCB or dyspareunia?
Gynae, obs, smear and contraceptive hx?
What are some causes of PCB and IMB?
Leading causes are CERVICAL CAUSES: - Ectropion - VERY COMMON - Cervicitis - Polyps - Cancer The problem could be ENDOMETRIAL - Polyps or fibroids Or the problem could be VAGINAL - Atrophy or irritation within vagina
How should someone with PCB or IMB be investigated?
FBC and Coag screen
ALWAYS VISUALISE CERVIX with speculum - if you manage then perform HVS and smear
If nothing found on cervix and you’re considering endometrial pathology consider hysteroscopy or USS
How should women with PCB or IMB be managed?
Depends on cause
- Resection of fibroids
- AgNO3 ablation of ectropion
- Reassurance
- Mirena IUS
How should smear results be managed?
NORMAL - reassure woman
- BORDERLINE or MILD DYSKARYOSIS - test sample for HPV. If positive go to colposcopy, if negative back on normal recall
- MODERATE DYSKARYOSIS - Could be CIN II, refer for urgent 2 week wait
- SEVERE DYSKARYOSIS - Could be CIN III - refer for urgent 2 week wait
- SUSPECTED INVASIVE CANCER - urgent 2 week wait
- INADEQUATE - Repeat smear, if 3 samples are inadequate then refer for colposcopy
