Menstrual Cycle & it's abnormalities

Question 1

What is menstrual cycle ?

Question 2

What is Normal Menstruation?

Question 3

Menarche?

Question 6

What is Abnormal Menstruation ?

Answer 6

• Menorrhagia
• Intermenstrual bleeding
• irregular periods
• postcoital bleeding - bleed during or after sex
• Primary amenrrhoea - never had a period until 15 years of age
• Secondary amenrrhoea - had periods in the past but it stopped
• Oligomenorrhoea
• Postmenopausal bleeding
• Premenstrual syndrome

Question 7

What is Menorrhagia ?

Answer 7

Heavy Menstrual Bleeding

when there is excessive menstrual blood loss which interferes with a women’s physical, social, emotional/material quality of life and which can occur alone or in combination with other symptoms.

Question 8

What are the symptoms of Menorrghaia?

Answer 8

If the periods ( blood loss) of > 80ml or duration of > 7 days

Question 9

What is the common cause of Menorrhagia ?

Answer 9

50 % of cases is Dysfunctional Uterine Bleeding (DUB)
No assoc pathology
* Polycystic ovaries
* Fibroids
* Endometrial ca
* Ovarian ca
* Endometriosis
* Clotting disorders - systemic problems
* PID - Pelvic inflammatory disease
* Miscarriage
* Iotrogenic causes - medications

Question 10

What are the iotrogenic causes of Menorrhagia ?

Answer 10

Anticoagulant
Antiplatalet

Question 11

How would you take history of pts with Menorrhagia include gynae?

Answer 11

• How many epidsodes ?
• Onset - age/sudden or gradual

**Assess the amount, timing of the bleeding **
* No. of sanitary towel / tampone used ?
* Presence of blood clots/flooding
* Menstrual cycle ( menstrual calender is helpful)
* & how often it is happening?
* Age of the pt now & the age when she first started her periods?
* Pain
* Any other symptoms ?
* Family & sexual history

Question 12

Associated symptoms of menorrhagia?

Answer 12

• IMB
• PCB
• Pelvic pain
• dyspreunia
• symptoms of anaemia

Question 13

what is the PMH of Menorrhagia ?

Answer 13

Gynae history
Smear history
Obstetric history
Thyroid history

Question 14

What do you look in the examination of Menorrhagia ?

Answer 14

Anaemia
Features of underlying systemic disease - hypothyroidsim, coagulation disorder, PCOS
aBDO EXAM

Question 15

What is the investigation of Menorrhagia ?

Answer 15

• Full Blood count (TSH, Clotting studies if indicated)
• Pregnancy test
• Swabs if indicated

Pelvic Ultrasound - Transabdominal +/- transvaginal

• If history or examination suggests significant dysmenorrhoea, a bulky tender uterus or a pelvic mass*

Question 16

What are the further investigation would you do in Menorrhagia ?

Answer 16

Hysteroscopy +/- endometrial biopsy
Women aged over 45 years with heavy menstrual bleeding
* History suggesting submucosal fibroids, polyps or endometrial pathology
* Persistent intermenstrual or irregular bleeding despite normal cervical smear

Question 17

What are the RF of Endometrial pathology ?

Answer 17

• Obesity, PCOS, tamoxifen
• Symptoms that have not improved with medical management
• If an abnormality is suspected after physical examination or pelvic ultrasound (apart from fibroids <3cm D

*Outpatient vs inpatient under general or regional anaesthesia

Question 18

What are the surgical treatment for Menorrhagia ?

Answer 18

Hysteroscopic such as
* polyp removal
* Endometrial ablation
* Transcervical resection of fibroid

• Uterine artery embolization
• Myomectomy
• Hysterectomy

Question 19

How would you refer someone to Menorrhagia ?

Answer 19

• Suspected cancer pathway ( 2 week refferal )
• Urgent ( Ascites +/- or pelvic or abdominal mass ( not obviously fibroids)

** Others include **
Iron deficiency anaemia failing to respond to treatment
Menorrhagia not improving despite initial treatments
Fibroids ≥3cm
Compressive symptoms from large fibroids

Question 20

What is Dysmenrrhoea ?

Answer 20

Painful menstruation
- due to excess endometrial prostaglandins
- increase in uterine contractions and prostaglandins

Common reason for absence in school or at work

Question 21

What are the RF of Dysmenorrhoea ?

Answer 21

Early menarche
Heavy menstrual flow
Nulliparity
Family history
Stress
? Diet, smoking, alcohol

Question 22

What is Primary Dysmenorrhoea ?

Answer 22

• No associated pelvic pathology
• Common with onset of ovulatory cycles 6m–1y after menarche
• Pain from start of period lasting 24-72 hours
• Associated symptoms?
• Examination?
• Usually responds to NSAIDs or ovulation suppression (COCP)
• Reassurance important
• Pelvic pathology more likely if medical treatment fails

Question 23

What is Secondary Dysmenorrhoea ?

Answer 23

• Underlying pelvic pathology
• More likely years after menarche
• Pain can precede period by several days & last throughout
• Assoc gynaecological symptoms
• dyspareunia, menorrhagia, irregular menstruation
  Examination?
  Investigation?

Question 24

What are the causes of Secondary Dysmennorhea ?

Question 25

What is the management of dysmenorrhea ?

Answer 25

• Underlying cause
• NSAID (+/or paracetamol)
• Hormonal contraceptive
• COCP
• Progesterone-only contraception
• Non-drug methods
• Local application of heat
• TENS
• Refer if no response