Menstrual Disorders Flashcards by Mai Alkari

Blood loss in normal menstrual cycle

<80ml over 7 days (16 tsp)

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Range of menarche

10-16 years

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Range of menopause

50-55 years

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Average duration of menstruation

2-7 days

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Average length of cycle

28 days (24-38 days)

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Classification of HMB

> 80ml/7 days.
And/or need to change mesntrual products every 1-2 hrs.
And/or passage of clots > 2.5cm.
And/or affecting quality of life

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Uterine & ovarian causes of HMB

Uterine fibroids
Endometrial polyps
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Pelvic infections
Endometrial hyperplasia/carcinoma
Polycystic ovary syndrome

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Systemic disease and disorders causing HMB

Coagulation disorders
Hypothyroidism
Liver disease
Renal disease

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Iatrogenic causes of HMB

Anticoagulation treatment
Herbal supplements (ginseng, ginko, soya)
Intrauterine contraceptive device

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PALM COEIN (mnemonic to remember causes of HMB)

Polyp
Adenomyosis
Leiomyoma/fibroid
Malignancy
Coagulopathy
Ovulation dysfunction
Endometrium/hyperplasia
Iatrogenic
Not yet classified

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What are fibroids

Non-cancerous growths made of muscle & fibrous tissue

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Symptoms of fibroids

Asymptomatic
HMB
Pelvic pain
Urinary symptoms (retention, frequency, difficulty initiating stream)
Pressure symptoms
Backache
Infertility
Miscarriage

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Investigation of fibroids

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Management of fibroids

HMB +/- small fibroids - COCP, POP, Mirena
Large fibroids & fertility preservation - fibroid embolisation, myomectomy.
Sumbucosal fibroids - hysteroscopic fibroid resection
Previous failure/decline & fertility preservation not required - hysterectomy

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What is endometriosis

Endometrial tissue present outside lining on uterus

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Symptoms of endometriosis

HMB
Pelvic pain
Dysmenorrhoea
Lower back pain
Dyspareunia
Diarrhoea
Nausea
Bloating
Dysuria
Painful bowel movements
Infertility
Fatigue
Systemic symptoms

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Endometriosis stage 1 (minimal)

Small patches/surface lesions/inflammation on/around organs in pelvic cavity

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Endometriosis stage 2 (mild)

More widespread and starting to infiltrate pelvic organs

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Endometriosis stage 3 (moderate)

Peritoneum or other structures effected. Sometimes scarring & adhesions.

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Endometriosis stage 4 (severe)

Infiltrative & affecting many pelvic organs & ovaries. Distortion of anatomy & adhesions.

Common sites of endometriosis

Fallopian tube
Ovary
Uterosacral ligaments
Pouch of Douglas

Investigations for endometriosis

Pelvic examination
US
Diagnostic laparoscopy - gold standard

Non-surgical management of endometriosis

COCP
POP
Mirena IUS
Depot provera
GnRH analogues

Surgical management of endometriosis

Ablation
Hysterectomy endometrioma excision
Pelvic clearance hysterectomy

What is adenomyosis

Endometrium embedded in myometrium

Symptoms of adenomyosis

HMB | Dysmenorrhoea

Management of adenomyosis

``` COCP POP Mirena IUS Depo Provera Hysterectomy ```

What are endometrial polyps

Pediculated structures extending into endometrium due to overgrowth of endometrial lining

Investigations of endometrial polyps

US | Hysteroscopy

Management of endometrial polyps

Polypectomy

Investigations for HMB

``` Pelvic examination Clotting profile Thyroid function US Laparoscopy (endometriosis suspicion) Endometrial biopsy (>44 & refractory to treatment) ```

Hormonal management of HMB

Mirena IUS COCP POP Depo provera

Non-hormonal management of HMB

``` Mefenamic acid Tranexemic acid GnRH analogues Endometrial ablation Fibroid embolisation Hysterectomy ```

First generation endometrial ablation

Diathermy with hysteroscopy

Second generation endometrial ablation

Thermal balloon | Radio frequency

Requirements for endometrial ablation

Uterine cavity length < 11cm Sub mucous fibroids <3cm Previous normal endometrial biopsy

Subtotal hysterectomy

Removal of uterus, cervix left

Total hysterectomy

Removal of uterus & cervix

Risks of hysterectomy

``` Infection DVT Bladder/bowel/vessel injury Altered bladder function Adhesions ```

Salpingo-oophorectomy

Removal of ovaries and fallopian tubes

Possible indications for saplingo-oophorectomy

Endometriosis | Ovarian pathology

Disadvantages of salpingo-oophorectomy

Immediate menopause - recommend HRT until 50

Advantages of salpingo-oophorectomy

Reduces risk of subsequent ovarian cancer

What is amenorrhoea

Infrequent, absent or abnormally light menstruation

Causes of amenorrhoea

``` Lifestyle - stress, malnourishment, obesity, intense exercise. Hormones - POP, Mirena, depot injection. Primary ovarian insufficiency Polycystic ovarian syndrome Hyperprolactinemia Prolactinomas Thyroid disorders Obstruction ```

Criteria of polycystic ovarian syndrome (2/3 for diagnosis)

US appearance Biochemical hyperandrogenism Clinical hyperandrogenism with oligomenorrhoea, hirsutism, acne, infertility & obesity. Oligomenorrhoea/amenorrhoea

Management of polycystic ovarian syndrome

Lifestyle changes | Symptoms based

What is dysfunctional uterine bleeding

Excessive uterine bleeding in premenopausal women not due to pregnancy or uterine/systemic diseases

Underlying pathophysiology of dysfunctional uterine bleeding

Ovarian hormonla dysfunction