Menstrual disorders

Question 1

Quantification of menorrhagia

Answer 1

> 80ml

Objective quantification:

• Going through pads quickly
• Soiling bed/ clothes
• Clots
• Dizziness

Question 2

Common disorders that affect menstrual bleeding

Answer 2

Dysfunctional uterine bleeding 
Fibroids 
Adenomyosis 
Endometriosis 
IUD
PID
Polyps 
Clotting disorders 
Hypothyroidism 
Liver disease

Question 3

Dysfunctional uterine bleeding

Answer 3

Primary menorrhagia

- no identified pathology

Question 4

Clotting disorders that cause heavy menstrual bleeding

Answer 4

Von Willebrands disease

Thrombocytopenia

Question 5

Low risk pt with heavy menstrual bleeding

Answer 5

Less than 45 yo
No IMB
No RF for endometrial cancer

Question 6

High risk pt with heavy menstrual bleeding

Answer 6

45+ yo
IMB
Endometrial cancer risk factors
Suspected pathology

Question 7

Assessment of a low risk pt with heavy menstrual bleeding

Answer 7

History
Examination
Bloods - FBC

Question 8

Investigations for a high-risk pt with heavy menstrual bleeding

Answer 8

Pelvic examination - speculum and bimanual

USS

Hysteroscopy + biopsy

Bloods - FBC, ferritin - iron deficiency anaemia

Question 9

Treatment of HMB

Answer 9

1st line: tranexamic acid and mefenamic acid or ibuprofen
2nd line: IUS
3rd line: POP, implant or injection
4th: COCP

Question 10

Treatment for symptomatic fibroids

Answer 10

GnRH analogues to shrink fibroids
Ulipristal acetate - esyma

Surgically remove - myomectomy
Uterine artery embolisation

Question 11

Treatment for symptomatic endometrial polyp

Answer 11

Myosure - hysteroscopic removal of polyp

If family is complete: endometrial ablation - novasure

Question 12

Short term emergency control of HMB

Answer 12

Norethisterone - progestin

GnRH analogues - monthly injection

Question 13

How does tranexamic acid work

Answer 13

NSAID which inhibits tissue plasminogen activation and therefore inhibit fibrinolysis

Question 14

Side effects of tranexamic acid

Answer 14

Nausea
Dizziness
Tinnitus 
Rash 
Abdominal cramps

Question 15

History for menorrhagia

Answer 15

• Age at menarche
• Cycle length, days menstruating and variation
• Intermenstrual bleeding and post coital bleeding
• Contraceptive history
• Sexual history
• Possibility of pregnancy
• Plans for future pregnancies
• Cervical screening history
• Migraines with or without aura (for the pill)

Question 16

When to perform a hysteroscopy

Answer 16

• Suspected submucosal fibroids
• Suspected endometrial pathology, such as endometrial hyperplasia or cancer
• Persistent intermenstrual bleeding

Question 17

When to perform a transvaginal USS

Answer 17

Possible large fibroids (palpable pelvic mass)

Possible adenomyosis (associated pelvic pain or tenderness on examination)

Examination is difficult to interpret (e.g. obesity)

Hysteroscopy is declined

Question 18

Additional tests to consider in women with additional symptoms

Answer 18

Swabs - evidence of infection (e.g. abnormal discharge or suggestive sexual history)

Coagulation screen - FHx of clotting disorders or periods have been heavy since menarche

Ferritin - clinically anaemic

TFTs - features of hypothyroidism

Question 19

When to give tranexamic acid or mefenamic acid

Answer 19

Tranexamic acid - no associated pain

Mefenamic acid - pain

Question 20

Management of menorrhagia when contraception wanted or accepted

Answer 20

1st - Mirena coil
2nd - COCP
3rd - Cyclical oral progestogens, such as norethisterone

Question 21

When to refer to secondary care

Answer 21

Severe symptoms

Fibroids > 3cm

Unsuccessful treatment