Menstrual cycle disorders

Question 1

What is the acronym for remembering the causes of abnormal uterine bleeding?

Answer 1

PALM- polyps, adenomyossis, leiomyomas, malignancy

COIN- coagulation, ovulatory disturbance, idiopathic

Question 2

Definition of objective menorrhagia?

In women with dysfunctional uterine menorrhagia what is the cause (clue combination)

Answer 2

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

Question 3

What are the causes of Menorrhagia (structural and non-structural)

Answer 3

Structural: Fibroids, polyps, Adenomysosis, Chronic PID

Non-structural: Obesity, hypothyroidism, bleeding disorders eg VWF, coagulation eg Warfarin,

Question 4

What are findings on examination for menorrhagia?

Answer 4

Anaemia- SOB fatigue

Pelvic exam- tenderness (adenomyosis, mass then fibroid or polyp)

Question 5

Investigations for menorrhagia?

Answer 5

1. Bloods- FBC, coagulation screen, TFT’s
2. Transvaginal ultrasound +/- Saline scan (polyps, do postmenstrual)
3. Endometrial biopsy- pipelle or with hysteroscopy if polyp

Question 6

Management of menorrhagia (pharmacological)

Answer 6

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)

Question 7

Surgical management of menorrhagia?

Answer 7

1. Hysteroscopic polyp removal
2. Hysteroscopic endometrial ablation (via thermal balloons, cryotherapy or radiotherapy)
3. Radical myomectomy open or laproscopic (only laproscopic if <4 fibroids)
4. Hysterectomy last resort

Question 8

What are the complications of endometrial ablation, and contraindications

Answer 8

Complication- uterine perforation 
Contraindications: 
future pregnancy 
Acute PID 
Malignancy

Question 9

What is primary and secondary dysemnorrhoea?

Answer 9

Primary- no cause found
Secondary- underlying pathology, occurs prior to menstruation relieved by menstruation. Associated with menorrhagia, dyspaurenia

Question 10

What are the causes and IX of secondary dysmenorrhoea?

Answer 10

• Adenomyosis
• Endometriosis
• Fibroids
• PID
• Ovarian tumours

IX- pelvic ultrasound and laproscopy

Question 11

Management of primary dysmenorrhoea, and when is secondary suspected?

Answer 11

1. Mefanamic acid/ Ibuprofeon
2. COCP- ovulation suppression

Suspect if not responding to treatments

Question 12

What is irregular or intermenstrual bleeding associated with and what is epidemiology?

Answer 12

• associated with menorrhagia

Epidemiology: common at extremes of reproductive ages, and certain contraceptives get breakthrough bleeds

Question 13

What are causes of intermenstrual bleeding?

Answer 13

1. Pregnancy- ectopic/ gestational trophoblastic disease
2. Physiological- get spotting near ovulation, anovulatory cycles ( eg menarche, perimenopause)
3. Pelvic pathology- fibroids, polyps, cervical ectropion, , cervical-endometrial-ovarian carcninom, chronic pelvic infection
4. Iatrogenic- tamoxifen, smear test, drugs altering clotting parameters eg SSRI’s, anticoagulants, corticosteroids

Question 14

What is the most important differential to exclude in intermenstrual bleeding?

Answer 14

Malignancy

Question 15

What are the investigations for intermenstrual bleeding?

Answer 15

1. Pregnancy test
2. Bloods- FBC, clotting, FSH and LH (find out if menopause)
3. Infection screen- NAAT endocervical swab
4. Cervical smear ]
5. Transvaginal ultrasound
6. Endometrial biopsy

Question 16

In the case of intermenstrual bleeding or menorrhagia what are the red flag features for which an endometrial biopsy should be performed?

Answer 16

• 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

Question 17

What is the management of intermenstrual bleeding?

Answer 17

Pharmacological: Mirenua IUS or COCP, or HRT if perimenopausal
Surgical: enodmetrial ablation- same as menorrhagia

Question 18

What is the most important to differential to exclude in post-coital bleeding?

What are other causes?

Answer 18

• Cervical carcinoma
• Cervical ectropion
• Cervical polyp
• Vaginal cancer
• Cervicitis/vaginitis

Question 19

What are the investigations for post-coital bleeding?

Answer 19

1. Speculum
2. Cervical smear (if negaitve then cryotherapy for ectropion if positive then colposcopy)
3. Polyp- avulsed and send for histology

Question 20

What is the definition of dysfunctional uterine bleeding?

Answer 20

Irregular uterine bleeding in the abscence of histopathological findings
typically associated with anovulatory cycles

Question 21

What is the epidemiology of dysfunctional uterine bleeding?

Answer 21

• Most common in adolescenets (after menarche) and perimenopausal women

Question 22

What are the causes of dysfunctional uterine bleeding, and what is most important to exclude?

Answer 22

Exclude pregnancy- ectopic, threatned or incomplete miscarriage

1. Anovulatory cycles
   - perimenopausal women: light irregular bleeding due to oestrogeon breakthrough bleed
   - Adolescents: prolonged heavy bleeding (endometrium is hella proliferative)
2. Oral contraceptives- progesterone only pills if ratio of P: O too high then cause breakthrough bleed

Question 23

What conditions may present with anovulatory cycles?

Investigations for dysfunctional uterine bleeding

Answer 23

POCS
Thyroid disease
Hyperprolactinaemia

Same as menorrhagia, diagnosis of exclusion and add FSH/LH if perimenopausal to diagnose menopause