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Menstrual Disorders Flashcards

1
Q

What is normal in terms of mesnstruation?

A
  • Menarche> menopause aged 13-51 on average
  • Cycle: 4-5/21-35
  • Mean blood loss 30-40ml
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2
Q

What triggers menstruation?

A

Fall in progesterone 2 weeks after ovulation if not pregnant

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3
Q

Menorrhagie

A

Heavy periods (>80ml loss per cycle)

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4
Q

Dysmenorrhoea

A

Painful periods

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5
Q

Inter-menstrual bleeing

A

Bleeding between periods

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6
Q

Postcoital period

A

Bleeding after intercourse

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7
Q

Oligomenorrhoea

A

Infrequent periods

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8
Q

What is important to obtain in a menstrual history?

A

Remember it is subjective, patient’s perspective

  • Clots/flooding/number of tampons and pads
  • Pain (with heavy flow or premenstrual)
  • Ask about effect of symptoms on lifestyle and quality of life
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9
Q

What examination should be carried out for menstrual problems?

A
  • General
  • Abdominal
  • Speculum
  • Bimanual
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10
Q

What does choice of investigation dependon?

A

Varies from patient to patient depending on symptoms

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11
Q

What investigations may be carried out for heavy bleeding?

A
  • Full blood count
  • Thyroid function and Coagulation only if history suggestive
  • Endometrial biopsy (over 45 /persistent IMB/ obesity)
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12
Q

What should you test for with a history of IMB and PCB?

A

Chlamydia

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13
Q

What investigations may be carried out fro menstrual problems?

A
  • FBC
  • Biopsy
  • Other blood tests as required
  • Pregnancy test
  • STI testing
  • Transvaginal ultrasound
  • Hysteroscopy
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14
Q

When should a hysteroscopy be performed?

A

For persistent IMB, suspected endometrial pathology on US

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15
Q

What are the likely causes of menstrual problems in the early teens?

A
  • Anovulatory cycles

- Coagulation problems

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16
Q

What are the likely causes of menstrual problems from late teens to 40?

A
  • Chlamydia
  • Contraception related
  • Endometriosis/ adenomyosis
  • Fibroids
  • Endometrial or cervical polyps
  • Dysfunctional bleeding
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17
Q

What are the likely causes of menstrual problems from 40 to the menopause?

A
  • Perimenopausal anovulation
  • Endometrial cancer
  • Warfarin use
  • Thyroid dysfunction
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18
Q

What is the FIGO classification of abnormal bleeding?

A
  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy/hyperplasia
  • Coagulation
  • Ovarian
  • Endocrine
  • Iatrogenic
  • Not yet classifief
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19
Q

What is dysfunctional uterine bleeding?

A

Abnormal bleeding but no structural / endocrine /neoplastic / infectious cause found for (yet)

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20
Q

What accounts for 50% of hysterectomies for menorrhagia?

A

DUB

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21
Q

What is endometriosis?

A
  • Endometrial type tissue outside the uterine cavity

- Oestrogen dependent chronic condition

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22
Q

Where does endometriosis commonly affect?

A
  • Ovary
  • Pouch of Douglas
  • Pelvic peritoneum
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23
Q

What are the theories of endometriosis pathogenesis?

A
  • Retrograde menstruation
  • Coelomic metaplasia
  • Haematogenous spread
  • Direct transplantation
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24
Q

What are the symptoms of endometriosis?

A
  • May be asymptomatic
  • Premenstrual pelvic pain
  • Dysmenorrhoea
  • Deep dyspareunia
  • Subfertility
25
What are the signs of endometriosis?
- May be none - Tender nodules in rectovaginal septum - Limited uterine mobility - Adnexal mass
26
How is endometriosis diagnosed?
- Gold standard is laparoscopy (clear, red, bluish, black or white lesions) - MRI for deep endometriosis - Ultrasound can diagnose endometrioma (chocolate cyst)
27
How is endometriosis treated medically?
Hormonal treatment and analgesics - Progestogen oral/injection/ Levonorgesterel Intrauterine system (LNG-IUS) - Combined oral contraceptive pill - GnRH analogues (eg leuprorelin)
28
How is endometriosis treated surgically?
- Excision of deposits from peritoneum/ovary - Diathermy / laser ablation of deposits - Removal of ovaries with or without hysterectomy
29
Adenomyosis
The presence of endometrial tissue in the myometrium
30
What are the signs and symptoms of adenomyosis?
- Heavy painful periods - Bulky tender uterus - Usually in parous women - May co-exist with endometriosis
31
How is adenomyosis diagnosed?
- MRI may suggest diagnosis but limited availability | - Histology of uterine muscle – generally post hysterectomy
32
How is adenomyosis treated?
Treat symptoms of heavy and painful periods with hormonal contraception - LNG IUS (Mirena) - Progestogens - Combined oral contraceptive pill
33
What are fibroids?
Smooth muscle growths also known as leiomyoma
34
What is the epidemiology of fibroids?
- Common and usually asymptomatic - Up to 60% of 40 year olds have fibroids of varying size - Higher incidence in Afro-Caribbean women
35
How are fibroids diagnosed?
- Clinical exam: irregularly enlarged uterus - Ultrasound - Hysteroscopy (if inside uterine cavity)
36
What are the types of fibroids?
Sub mucous -Protrude into uterine cavity Intramural -Within uterine wall Sub serous -Project out of uterus into peritoneal cavity
37
What are the symptoms of fibroids?
- Pressure symptoms (dependent on location) - Menorrhage: enlarge the uterine cavity SA - Submucous or firboud polyps may can IMB - Asymptomatic - Can rapidly increase in size in pregnancy causing pain, malpresentation or obstruction in labour (cervical fibroid)
38
How are fibroids treated?
- Standard menorrhagia treatment if cavity not too distorted - GnRH analogues or Ulipristal acetate may be used temporarily to shrink the fibroids – usually preoperatively - Submucous fibroids: Transcervical resection hysteroscopically - Myomectomy - Uterine artery embolisation - Hysterectomy
39
When are fibroids treated?
Only if symptomatic
40
What treatment is there fore dysfunctional uterine bleeding?
Reassurance there is no sinister pathology Medical treatment - Non hormonal: Tranexamic acid or Mefanamic acid - Hormonal: Progestogen only tablets, injections (Depo Provera), Levonorgesterel Intrauterine System, Combined pill Surgical treatment (if family complete) - Endometrial ablation - Hysterectomy
41
Why are tranexamic and mefenamic acid used in DUB?
=Tranexamic acid (antifibrinolytic) reduces blood loss 60% - Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain - Both of them are taken at the time of periods - Suitable for those trying to conceive - Do not regulate cycles
42
Why is hormonal therapy used for DUB?
Contraception -Makes periods lighter, regular and less painful LNG IUS and Dep-provera -Reduces bleeding, may still be irregular, may be amenorrhoeic Oral progesterones - Day 5-25 cycle reduce bleeding +regulate - Day 15-25 may regulate cycle but does not reduce amount of bleeding
43
What are the pre-requisites for endometrial ablation for DUB?
- Uterine cavity length <11 cm - Submucous fibroids < 3cm - Previous normal endometrial biopsy
44
What are the possible outcomes of endometrial ablation?
- 60% no periods - 85% satisfied - 15% will have subsequent hysterectomy
45
What doe endometrial for DUB involve?
- Permanent destruction of endometrium using different energy sources - First generation ablation: under hysteroscopic vision – uses diathermy - Second generation ablation: thermal balloon, radiofrequency
46
How can surgical removal of the uterus be performed?
- Abdominal - Vaginal - Laparscopic
47
What types of laparascopic hysterectomy are there?
- Laporoscopically assisted vaginal hysterectomy (LAVH) - Laparoscopic hysterectomy - Total laparoscopic hysterectomy TLH - Laparoscopically assisted subtotal hysterectomy
48
What is a total hysterectomy?
Cervix and uterus removed
49
What is a subtotal hysterectomy?
Uterus removed but cervix left
50
What are the risks of hysterectomy?
- Infection - DVT - Bladder injury - Bowel injury - Vessel injury - Altered bladder function - Adhesions
51
What does hysterectomy guarantee?
Amenorrhoea
52
How long is recovery from a hysterectomy?
- 3-5 days in hospital (open / vaginal) - 1-2 days laparoscopic approach - 2-3 months full recovery
53
What is a total hysterectomy with salpingo-oophrectomy?
Removal of uterus, cervix, fallopian tubes and ovaries
54
When may a woman's ovaries be removed?
May be removed in a woman with endometriosis or presence of ovarian pathology
55
What are the disadvantages of an oophorectomy?
Immediate menopause so HRT recommended until age 50
56
What are the advantages of an oophorectomy?
Reduces risk of subsequent ovarian cancer
57
Why is there high risk of menopause following hysterectomy with sparing of ovaries?
High risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply
58
What does management on menstrual problems depend on?
- Impact on quality of life - Underlying pathology - Desire for further fertility - Women’s preferences

reproductive system 2 (35 decks)

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