Menstrual Disorders

Question 1

First of all define Menorrhagia, Dysmenorrhoea, oligomenorrhoea, IMB & PCB?

Answer 1

Menorrhagia = Heavy periods, technically >80ml but its subjective
Dysmenorrhoea = painful periods
Oligomenorrhoea = Irregular periods
IMB = Intermenstrual bleeding
PCB = Post-coital bleeding

Question 2

What questions might you ask when a patient complains of heavy or painful periods?

Answer 2

Are they clots & how large?
Do you use tampons or pads or both?
What type do you use and how often do you change them?
Do you ever flood (aka bleed through clothes)?#
QOL questions like does it affect your work, hobbies or ability to go out in public?

Question 3

Age is a good way of narrowing down the likely cause of abnormal bleeding, What problems might you expect in an early teenager?

Answer 3

Probably anovulatory cycles, which is quite normal as they go through puberty
Or a coagulation disorder (unlikely to develop later)

Question 4

What problems might you expect in someone from puberty up to their 40s? (fertile age)

Answer 4

Chlamydia
Contraception issuesEndometriosis or adenomyosis
Fibroids
Endometrial or cervical polyps
Dysfunctional Bleeding

Question 5

What problems might you expect in someone >40s?

Answer 5

Perimenopausal anovulation
Endometrial cancer
Iatrogenic warfarin
Thyroid disfunction

Question 6

So if a woman comes to you with a bleeding problem what kind of blood tests would you like to do?

Answer 6

FBC
Thyroid function (if history indicates)
Coagulation screen (if younger)
Endometrial biopsy (if >45, persistent IMB or obese)
Pregnancy test (important to ALWAYS consider pregnancy)

Question 7

Who would you test for chlamydia?

Answer 7

Any patient with IMB and/or PCB, especially if they’re younger

Question 8

What non-blood tests are worth considering in a menstrual disorder?

Answer 8

Transvaginal US
Hysteroscopy for endometrial pathology e.g. polyps, fibroids or cancer

Question 9

When would a hysteroscopy be indicated?

Answer 9

Persistant IMB
Or if the US showed up a suspected endometrial pathology

Question 10

What acronym do we use to remember the causes of abnormal uterine bleeding?

Answer 10

PALM-COEIN (FIGO classification):
- Polyps
- Adenomyosis & Endometriosis
- Leiomyoma (fibroid)
- Malignancy
- Coagulation disorder
- Ovarian (e.g. PCOS)
- Endocrine (e.g. Thyroid)
- Iatrogenic (e.g. Warfarin)
- Not Classified

Question 11

What is Endometriosis?

Answer 11

When endometrial tissue is found outside the uterine cavity e.g. in pouch of douglas, pelvic peritoneum or ovary
Its a chronic oestrogen-dependant condition

Question 12

How might endometriosis present

Answer 12

Pre-menstrual pelvic pain and dysmennorhoea
Deep Dyspareunia
Subfertility

On exam you may find tender nodules in rectovaginal septum, adnexal masses or limited uterine mobility.

They may also be asymptomatic

Question 13

So a 25yr old woman comes in complaining that her periods are painful and hurts before, she also experiences pain during intercourse, how would you test her for endometriosis?

Answer 13

Start with an exam to get some more evidence.
Then:
- Laparoscopy is gold standard
- US for endometriomas (chocolate cysts)
- MRI can be helpful in deep endometriosis

Question 14

You give a diagnosis of endometriosis, what medical treatments will you suggest?

Answer 14

Hormonal contraceptives to control the symptoms:
- cOCP
- Oral/injectable progestogens
- GnRH analogues
- LNG-IUS (progestogen)

Question 15

What surgical treatments could you offer for endometriosis?

Answer 15

Can excise the endometrial deposits
Can do diathermy or laser ablation

Can go as far as oophorectomy +/- hysterectomy

Question 16

Define Adenomyosis?

Answer 16

Endometrial tissue appearing in the myometrium

Question 17

How might adenomyosis present?

Answer 17

Menorrhagia & Dysmenorrhoea
The uterus may feel bulky and tender
Generally the woman will be parous and you may find it co-exists with endometriosis

Question 18

How can we diagnose adenomyosis?

Answer 18

Harder than endometriosis, generally its done by histology after a hysterectomy is done.
An MRI can suggest it but can’t differentiate from fibroids

Question 19

So if we suspect adenomyosis how can we treat them?

Answer 19

Start with symptom control using hormonal contraceptives:
- cOCP
- Oral/injectable Progestogens
- LNG-IUS

Try Endometrial Ablation

Most cases these will fail and you’ll end up doing a hysterectomy

Question 20

Define a Fibroids or Leiomyoma?

Answer 20

A smooth muscle growth in the uterine wall, its very common and generally asymptomatic

Question 21

Who’s more at risk of fibroids?

Answer 21

Afro-carribean women

Question 22

Types of fibroid?

Answer 22

Sub-mucosal project into uterine cavity
Intramural
Sub-serous project into peritoneal cavity

Question 23

What presentations could suggest fibroids?

Answer 23

• Pressure symptoms
• Menorrhagia (increased uterine surface area)
• IMB
• Pain, malpresentation or obstructed labour in pregnancy

Question 24

How do we test for a fibroid?

Answer 24

You may find the uterus to be irregularly enlarged on exam

US & Hysteroscopy

Question 25

So If a woman has a fibroid and is symptomatic but the uterine cavity isn’t distorted how would you treat her?

Answer 25

Medically with hormonal contraceptives

Question 26

What if a woman with a fibroid has a disorted uterine cavity?

Answer 26

Treat surgically:
- Transcervical resection for submucosal fibroids
- Myomectomy
- Uterine Artery Embolisation
- Hysterectomy

Can use GnRH analogues neo-adjuvantly to shrink them for surgery