Menstrual cycle disorders Flashcards
What is the acronym for remembering the causes of abnormal uterine bleeding?
PALM- polyps, adenomyossis, leiomyomas, malignancy
COIN- coagulation, ovulatory disturbance, idiopathic
Definition of objective menorrhagia?
In women with dysfunctional uterine menorrhagia what is the cause (clue combination)
Blood loss greater than 80ml without causing iron deficiency anaemia
If dysfunctional then women will not have histopathology but combo of endometrial dysfunction, abnormal ovulatory function and coagulation
What are the causes of Menorrhagia (structural and non-structural)
Structural: Fibroids, polyps, Adenomysosis, Chronic PID
Non-structural: Obesity, hypothyroidism, bleeding disorders eg VWF, coagulation eg Warfarin,
What are findings on examination for menorrhagia?
Anaemia- SOB fatigue
Pelvic exam- tenderness (adenomyosis, mass then fibroid or polyp)
Investigations for menorrhagia?
- Bloods- FBC, coagulation screen, TFT’s
- Transvaginal ultrasound +/- Saline scan (polyps, do postmenstrual)
- Endometrial biopsy- pipelle or with hysteroscopy if polyp
Management of menorrhagia (pharmacological)
1st line- Mirena IUS
2nd line: Antifibronyltics Tranxanamic aid or NSAIDs Mefanemic acid or COCP
3rd line: Progestogens or GnRH analougues (produced amenorrhoea unless HRT added)
Surgical management of menorrhagia?
- Hysteroscopic polyp removal
- Hysteroscopic endometrial ablation (via thermal balloons, cryotherapy or radiotherapy)
- Radical myomectomy open or laproscopic (only laproscopic if <4 fibroids)
- Hysterectomy last resort
What are the complications of endometrial ablation, and contraindications
Complication- uterine perforation Contraindications: future pregnancy Acute PID Malignancy
What is primary and secondary dysemnorrhoea?
Primary- no cause found
Secondary- underlying pathology, occurs prior to menstruation relieved by menstruation. Associated with menorrhagia, dyspaurenia
What are the causes and IX of secondary dysmenorrhoea?
- Adenomyosis
- Endometriosis
- Fibroids
- PID
- Ovarian tumours
IX- pelvic ultrasound and laproscopy
Management of primary dysmenorrhoea, and when is secondary suspected?
- Mefanamic acid/ Ibuprofeon
- COCP- ovulation suppression
Suspect if not responding to treatments
What is irregular or intermenstrual bleeding associated with and what is epidemiology?
- associated with menorrhagia
Epidemiology: common at extremes of reproductive ages, and certain contraceptives get breakthrough bleeds
What are causes of intermenstrual bleeding?
- Pregnancy- ectopic/ gestational trophoblastic disease
- Physiological- get spotting near ovulation, anovulatory cycles ( eg menarche, perimenopause)
- Pelvic pathology- fibroids, polyps, cervical ectropion, , cervical-endometrial-ovarian carcninom, chronic pelvic infection
- Iatrogenic- tamoxifen, smear test, drugs altering clotting parameters eg SSRI’s, anticoagulants, corticosteroids
What is the most important differential to exclude in intermenstrual bleeding?
Malignancy
What are the investigations for intermenstrual bleeding?
- Pregnancy test
- Bloods- FBC, clotting, FSH and LH (find out if menopause)
- Infection screen- NAAT endocervical swab
- Cervical smear ]
- Transvaginal ultrasound
- Endometrial biopsy
In the case of intermenstrual bleeding or menorrhagia what are the red flag features for which an endometrial biopsy should be performed?
- IMB/menorrhagia >40 years
- Endometrial thickness (>4mm or 10mm)
- Risk factors for endo cancer: obesity, diabetes, PCOS< nulliparity
- If endometrial ablation going to be used
- If IUS going to be fitted
What is the management of intermenstrual bleeding?
Pharmacological: Mirenua IUS or COCP, or HRT if perimenopausal
Surgical: enodmetrial ablation- same as menorrhagia
What is the most important to differential to exclude in post-coital bleeding?
What are other causes?
- Cervical carcinoma
- Cervical ectropion
- Cervical polyp
- Vaginal cancer
- Cervicitis/vaginitis
What are the investigations for post-coital bleeding?
- Speculum
- Cervical smear (if negaitve then cryotherapy for ectropion if positive then colposcopy)
- Polyp- avulsed and send for histology
What is the definition of dysfunctional uterine bleeding?
Irregular uterine bleeding in the abscence of histopathological findings
typically associated with anovulatory cycles
What is the epidemiology of dysfunctional uterine bleeding?
- Most common in adolescenets (after menarche) and perimenopausal women
What are the causes of dysfunctional uterine bleeding, and what is most important to exclude?
Exclude pregnancy- ectopic, threatned or incomplete miscarriage
- Anovulatory cycles
- perimenopausal women: light irregular bleeding due to oestrogeon breakthrough bleed
- Adolescents: prolonged heavy bleeding (endometrium is hella proliferative) - Oral contraceptives- progesterone only pills if ratio of P: O too high then cause breakthrough bleed
What conditions may present with anovulatory cycles?
Investigations for dysfunctional uterine bleeding
POCS
Thyroid disease
Hyperprolactinaemia
Same as menorrhagia, diagnosis of exclusion and add FSH/LH if perimenopausal to diagnose menopause
