Menstrual Disorders Flashcards
Blood loss in normal menstrual cycle
<80ml over 7 days (16 tsp)
Range of menarche
10-16 years
Range of menopause
50-55 years
Average duration of menstruation
2-7 days
Average length of cycle
28 days (24-38 days)
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
Uterine & ovarian causes of HMB
Uterine fibroids Endometrial polyps Endometriosis Adenomyosis Pelvic inflammatory disease Pelvic infections Endometrial hyperplasia/carcinoma Polycystic ovary syndrome
Systemic disease and disorders causing HMB
Coagulation disorders
Hypothyroidism
Liver disease
Renal disease
Iatrogenic causes of HMB
Anticoagulation treatment
Herbal supplements (ginseng, ginko, soya)
Intrauterine contraceptive device
PALM COEIN (mnemonic to remember causes of HMB)
Polyp Adenomyosis Leiomyoma/fibroid Malignancy Coagulopathy Ovulation dysfunction Endometrium/hyperplasia Iatrogenic Not yet classified
What are fibroids
Non-cancerous growths made of muscle & fibrous tissue
Symptoms of fibroids
Asymptomatic HMB Pelvic pain Urinary symptoms (retention, frequency, difficulty initiating stream) Pressure symptoms Backache Infertility Miscarriage
Investigation of fibroids
US
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
What is endometriosis
Endometrial tissue present outside lining on uterus
Symptoms of endometriosis
HMB Pelvic pain Dysmenorrhoea Lower back pain Dyspareunia Diarrhoea Nausea Bloating Dysuria Painful bowel movements Infertility Fatigue Systemic symptoms
Endometriosis stage 1 (minimal)
Small patches/surface lesions/inflammation on/around organs in pelvic cavity
Endometriosis stage 2 (mild)
More widespread and starting to infiltrate pelvic organs
Endometriosis stage 3 (moderate)
Peritoneum or other structures effected. Sometimes scarring & adhesions.
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
