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Gynae > Menstrual Disorders > Flashcards

Menstrual Disorders Flashcards

1
Q

Most common cause of heavy periods

A

Dysfunctional uterine bleeding (ovulatory or non-ovulatory)

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2
Q

3 main types of abnormal uterine bleeding bleeding

A

Heavy Menstrual bleeding, Intermenstrual bleeding, Postcoital and Postmentopausal bleeding

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3
Q

PALM–COEIN Classification of Abnormal Uterine Bleeding - what does it stand for?

A

Polyps
Adenomyosis
Leiomyoma
Malignancy and hyperplasia

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified

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4
Q

PALM–COEIN Classification of Abnormal Uterine Bleeding - what categories does it split it into?

A

Structural (PALM)
Non-structural (COEIN)

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5
Q

What abnormal bleeding patterns may be associated with cervical or endometrial malignancy

A

Intermenstrual bleeding
Postcoital bleeding

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6
Q

Intermenstrual and postcoital bleeding can be common in women using…

A

Hormonal contraceptives

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7
Q

How are intermenstrual and postcoital bleeding investigated in primary care?

A

Visualising the cervix, taking a smear if none recently and STI swabs to rule out infection

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8
Q

NICE guidelines recommend an endometrial sample in what cases in a women with intermenstrual bleeding

A

Intermenstrual bleeding persistent in a women >45yo

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9
Q

Specialist referral is needed in women with intermenstrual/postcoital bleeding if…

A

The cervix appears abnormal
Abnormal cytology or histology results
Continuation of postcoital / intermenstrual bleeding after normal smear or endometrial sample

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10
Q

Source of abnormal bleeding is usually from…

A

Uterus

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11
Q

Sources of abnormal bleeding other than the uterus

A

Bleeding from other parts of genital tract (e.g. vulva, vagina or cervix)
Bleeding from urinary or GI tracts should be excluded (can be mistaken for PV bleed)

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12
Q

Cause of abnormal bleeding from uterus

A

Anovulatory cycles
Pregnancy
Menopause
Structural abnormalities (fibroids, polyps, adenomyosis, uterine prolapse)
Bleeding disorders
Malignancy

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13
Q

Causes of abnormal bleeding from lower genital tract

A

Infection
Trauma
Urogenital atrophy
Malignancy

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14
Q

Types/categories of abnormal bleeding

A

Heavy menstrual bleeding
Intermenstrual or unscheduled
Post-coital
Post-menopausal bleeding

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15
Q

In most cases first exclude________ as the cause of abnormal PV bleeding (unless of menopausal age and last period >12m ago)

A

Pregnancy

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16
Q

Definition of Heavy Menstrual Bleeding

A

Bleeding volume that interferes with a woman’s quality of life

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17
Q

Quantifying heavy menstrual bleeding

A

Menstrual blood loss volume of ≥ 80 mL per cycle
Having to change sanitary products every 1-2 hours, needing to use two types of sanitary product together, bleeding through clothes or onto bedding, or the passage of blood clots

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18
Q

Common causes of heavy menstrual bleeding related to uterine structure

A

Fibroids
Polyps
Adenomyosis
Endometrial cancer or hyperplasia

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19
Q

Causes of heavy menstrual bleeding not related to uterine structure

A

Iatrogenic
Ovulatory dysfunction
Coagulation disorders
Endometrial disorders

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20
Q

Iatrogenic causes of heavy menstrual bleeding

A

Copper IUD
Tamoxifen
Depot medroxyprogesterone acetate
Menopausal hormone therapy
Anticoagulants
Aspirin
Some herbal supplements

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21
Q

Ovulatory function causes of heavy menstrual bleeding

A

Psychological stress
Weight gain or loss
Excessive exercise
PCOS
Thyroid disease

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22
Q

Endometrial disorders that can cause heavy menstrual bleeding

A

Deficiencies in vasoconstrictors and excessive production of plasminogen
Endometritis

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23
Q

Women with endometrial disorders causing heavy menstrual bleeding present with…

A

Predictable and cyclic menses, suggestive of normal ovulation, but they have heavy menstrual bleeding

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24
Q

Initial investigations for heavy menstrual bleeding

A

Urine pregnancy test
CBC, ferritin
TSH if sx suggestive of thyroid disease
Coags and LFTs if sx suggestive of haemostatic disease

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25
Q

Additional symptoms suggestive of haemostatic defect leading to heavy menstrual bleeding

A

Frequent nosebleeds
Easy bruising
HMB from menarche
Family hx of a coagulation disorder

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26
Q

Further investigations for heavy menstrual bleeding

A

Pipelle biopsy – to sample the endometrium to rule out hyperplasia or malignancy
Pelvic ultrasound (including endometrial thickness)

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27
Q

Structural causes of heavy menstrual bleeding become more common with ___________

A

Increasing age

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28
Q

Fibroids, polyps, adenomyosis and malignancy are rare causes of heavy menstrual bleeding in those aged ________

A

< 40 years

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29
Q

_______ are necessary to diagnose structural abnormalities or malignancy as causes of heavy menstrual bleeding

A

USS, pipelle biopsy or hysteroscopy

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30
Q

Can women with fibroids causing heavy menstrual bleeding be managed in primary care?

A

HMB associated with small fibroids (< 3 cm) can generally be managed in primary care with pharmacological treatments
Larger fibroids that cause significant uterine enlargement or cavity distortion, or endometrial polyps should be referred O&G

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31
Q

HMB from menarche can indicate an underlying ______ disorder

A

Coagulation

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32
Q

__________ in peri-menopause can cause HMB however, structural causes should be excluded using USS

A

Anovulatory cycles

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33
Q

Intermenstrual bleeding definition

A

Any cyclic or random bleeding between menstrual periods

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34
Q

Unscheduled bleeding (breakthrough bleeding) definition

A

Bleeding outside of the expected time of the withdrawal bleed in women using hormonal contraception or MHT

35
Q

Causes of intermenstrual/unscheduled bleeding

A

Ovulation
STIs
Endometrial or cervical polyps
Use of progestogen-only contraceptives
Endometrial hyperplasia or malignancy
Caesarean scar defect (isthmocele)

36
Q

Investigations for intermenstrual/unscheduled bleeding

A

Urine pregnancy test
STI testing
Smear – if last was >6–12 months ago
Pelvic USS (including endometrial thickness) – if intermenstrual bleeding is persistent or abnormal bimanual examination

37
Q

Some women may experience light intermenstrual spotting or bleeding around the time of ___________

A

Ovulation

If the hx and exam do not suggest risk of infection or cervical pathology, further investigation may not be immediately required

38
Q

Ideally, all sexually active women who have intermenstrual or unscheduled bleeding should have a speculum examination to check for __________

A

Any skin lesions, rashes, ulceration and vaginal or cervical discharge

39
Q

What should you ask women with unscheduled bleeding about if they are on an oral contraceptive or MHT?

A

Their adherence to their oral contraceptive or MHT regimen and if they are using any other medicines or over-the- counter products as these could affect the absorption of oral medicines

40
Q

From 1 November, 2019, the starting age for the National Cervical Screening Programme changed from __ years to __ years

A

20 to 25

41
Q

Rational for changing the starting age for smears

A

Cervical cancer in women aged < 25 years is rare and the evidence suggests that screening does not prevent cervical cancer in this age group.

42
Q

Post coital bleeding definition

A

Any bleed in 24hrs following vaginal intercourse

43
Q

Causes of post coital bleeding

A

STIs
Cervical ectropion or polyps
Atrophic vaginitis
Cervical cancer
Vaginal cancer
Trauma

44
Q

Investigations for post coital bleeding

A

Pregnancy test
STI testing
Smear – if the last was >6–12 months ago
Pelvic USS – if any abnormalities on bimanual

45
Q

Should you investigate a single episode of post coital bleeding

A

A single episode of post-coital bleeding in a woman with a normal cervical appearance and smear does not immediately warrant further investigation of cervical pathology

46
Q

Atrophic vaginitis is common in _________ women and can be managed using…

A

Post-menopausal
Vaginal moisturisers, lubricants or topical vaginal oestrogens

47
Q

Should cervical polyps be removed?

A

Yes
Cervical polyps < 1.5 cm can be removed in primary care and sent for histological examination;
If >1.5cm, refer to O&G

48
Q

If enlarged uterus or pelvic mass on bimanual exam what should you do?

A

Refer for pelvic USS

49
Q

In which situations would you refer for colposcopy in post coital bleeding

A

Persistent or recurrent post-coital bleeding
Abnormal cervical, vaginal or vulval appearance
Abnormal cervical smear result

50
Q

Definition of post menopausal bleeding

A

Any bleeding that occurs after 12 months or more of menopausal amenorrhoea

51
Q

Post-menopausal bleeding is a red flag for _____________ and this must be excluded as the cause of post-menopausal bleeding with high priority.

A

Endometrial cancer

52
Q

Investigations for post menopausal bleeding

A

Smear - if last was >6-12m ago
STI testing as indicated by risk
Pipelle biopsy
Pelvic USS
Hysteroscopy (if taking tamoxifen)

53
Q

Why do a pipette biopsy for post menopausal bleeding

A

To sample the endometrium to rule out hyperplasia or malignancy

54
Q

Cause of post-menopausal bleeding in order from most common to least

A

Endometrial or vaginal atrophy
MHT
Endometrial or cervical polyps
Endometrial hyperplasia Endometrial cancer Cervical cancer

55
Q

All women who present with post-menopausal bleeding who have not recently initiated MHT should be referred for ______. What about if she is taking tamoxifen?

A

Pelvic USS with high priority (i.e. within 2-4 weeks)
If the woman is taking tamoxifen, refer for hysteroscopy and pelvic USS

56
Q

Bleeding after _________ continuous MHT or _______ in women taking cyclical MHT should be investigated with pelvic USS

A

6 months of continuous
Unscheduled bleeding in women taking cyclic

57
Q

Infrequent menstrual cycles are defined as…

A

> 38 days between menstrual cycles

58
Q

Amenorrhoea definition

A

Absence of menstrual cycles

59
Q

Primary amenorrhoea is…

A

Failure to reach menarche

60
Q

Secondary amenorrhoea is…

A

Cessation of regular menses for >3 months or the cessation of irregular menses for >6 months

61
Q

The most common cause of primary amenorrhoea in a girl with no secondary sexual characteristics is…

A

A constitutional delay in growth and puberty

62
Q

If there is no obvious cause of primary amenorrhoea, e.g. anorexia, _______ may be the most appropriate course.

A

Watchful waiting

63
Q

The most common cause of secondary amenorrhoea is…

A

Pregnancy

64
Q

Causes of infrequent or absent menstrual cycles include (other than pregnancy)

A

Anovulatory cycles
PCOS or functional anovulation, e.g. excessive exercise, eating disorder, stress, some medicines.
Thyroid disease and hyperprolactinaemia are less common causes.

65
Q

Infrequent menstruation following menarche is usually due to…
This often settles into a normal pattern within…

A

Anovulatory cycles and hypothalamic- pituitary-ovarian axis immaturity

2-3 years

66
Q

2 stages of life when infrequent menstruation may occur and is not of concern

A

Following menarche
Peri-menopause

67
Q

Risk factors for endometrial cancer or hyperplasia

A

Age >45 or age >35 with one or more of the following:
– BMI ≥ 30
– Diabetes
– Hypertension
– Exposure to unopposed oestrogen e.g. MHT
– Nulliparity, infertility, PCOS
– Māori or Pacific ethnicity
– Family hx of endometrial, colorectal, small intestine, ureter or renal cancer

Taking tamoxifen

68
Q

First choice treatment for HMB for women also requiring long term contraception

A

Mirena

69
Q

Hormonal treatments for HMB

A

Mirena
COC
Depot / POP
Cyclical progesterone

70
Q

Do cyclical progesterones for HMB provide contraception?

A

No

71
Q

Non hormonal treatment options for HMB

A

Tranexamic acid
NSAIDs

Both started at the onset of menses

72
Q

Diagnosis of PCOS

A

Rotterdam criteria
Must exhibit 2 of:
Biochemical/clinical signs of hyperandrogenism
Oligomennorhoea (<9 periods/year)
Polycystic ovaries

And the exclusion of other causes

73
Q

Features of PCOS not in diagnostic criteria

A

Obesity
Insulin resistance
Impaired glucose tolerance and T2DM
Dyslipidaemia
Cardiovascular disease
OSA
Infertility

74
Q

An approach to a patient with a possible PCOS should be 2-fold, directed towards ________ as well as _________

A

Making a diagnosis
Screening for associated endocrine abnormalities

75
Q

PCOS treatment - any intervention directed at reducing central obesity (e.g. lifestyle modification) will not only improve quality of life, but also ______

A

Correct hyperinsulinism and improve fertility and lipid and androgen profiles

Can have a lifelong impact on reducing possible long-term complica- tions of the syndrome

76
Q

In patients with PCOS even a _______ reduction in body mass restores ovulation and fertility

A

5%

77
Q

The cause of infertility in patients with PCOS is generally…

A

Lack of ovulation because of a failure of the follicles to develop beyond 10mm

78
Q

Pharmacological treatment for infertility in PCOS

A

Clomiphene citrate
Metformin (controversial)

79
Q

How does clomiphene citrate work?

A

An oral estrogen antagonist that raises circulating levels of FSHand induces follicular growth in most women with PCOS and anovulation

80
Q

Risks with using clomiphene citrate?

A

Multiple pregnancies
Ovarian hyper-stimulation syndrome

81
Q

How is metformin beneficial in PCOS?

A

Increases menstrual cyclicity
Reducing fasting insulin levels, BP and LDL cholesterol
Improves androgen levels and hirsutism

82
Q

Menstrual dysfunction, including irregular periods, in women with PCOS can be managed by what medications?

A

Progestins (e.g. medroxyprogesterone or norethisterone) or the oral contraceptive pill
Metformin

83
Q

Treatment of hirsutism in PCOS

A

Cyproterone + ethinylestradiol (Ginet)
Spironolactone

84
Q
A

Gynae (4 decks)

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