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Menstrual Disorders Flashcards

1
Q

What is adenomyosis?

A

Disorder in which endometrial tissue is found deep within the myometrium.

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2
Q

Presentation of adenomyosis

A

Painful periods
May be associated with heavy menstrual bleeding
Deep dyspareunia

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3
Q

Investigations of adenomyosis

A

Bedside
Bimanual Examination (boggy and bulky uterus)

Imaging & Other
Ultrasound Scan
MRI

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4
Q

What is seen on bimanual examination in adenomyosis?

A

boggy and bulky uterus

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5
Q

boggy and bulky uterus

A

adenomyosis

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6
Q

Management of adenomyosis

A

1st Line: Levonorgestrel Intrauterine System
2nd Line: Tranexamic Acid, NSAIDs, COCP, Cyclical Progestogens
3rd Line: Endometrial Ablation or Hysterectomy

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7
Q

1st line management of adenomyosis

A

1st Line: Levonorgestrel Intrauterine System

Followed by:
2nd Line: Tranexamic Acid, NSAIDs, COCP, Cyclical Progestogens
3rd Line: Endometrial Ablation or Hysterectomy

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8
Q

dysmenorrhoea

A

painful periods

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9
Q

How can dysmenorrhoea be defined?

A

primary (no underlying pathology) and secondary (occurring in the context of an underlying gynaecological condition)

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10
Q

Causes of secondary dysmenorrhoea

A

Endometriosis
Adenomyosis
Fibroids
Pelvic Inflammatory Disease

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11
Q

Presentation of dysmenorrhoea

A

Severe lower abdominal pain associated with their period
May be associated with heavy menstrual bleeding
May be associated with dyspareunia (in pelvic inflammatory disease)

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12
Q

Investigation for dysmenorrhoea

A

Bedside
Bimanual Examination
Speculum Examination
High Vaginal and Endocervical Swabs
Urine Dipstick and MSU (to rule out UTI)

Imaging & Other
Ultrasound Scan (useful for visualising fibroids)
MRI Scan (useful for visualising adenomyosis and endometriosis)
Diagnostic Laparoscopy
Gold standard for investigation of endometriosis

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13
Q

Why do a urine dip and MSU in dysmenorrhoea?

A

rule out UTI

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14
Q

Why do a USS in dysmenorrhoea?

A

visualise fibroids

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15
Q

Why do a MRI scan in dysmenorrhoea?

A

Visualise adenomhyosis and endometriosis

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16
Q

Why do a diagnostic laparoscopy in dysmenorrhoea?

A

Gold standard for investigation of endometriosis

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17
Q

Gold standard for investigation of endometriosis

A

Diagnostic Laparoscopy

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18
Q

Management of dysmenorrheoa

A

1st Line: NSAIDs (e.g. mefenamic acid)
2nd Line: COCP

Alternatives
Levonorgestrel Intrauterine System (Mirena)
Often used first-line in dysmenorrhoea associated with heavy menstrual bleeding
Applying Heat
GnRH Analogues
Surgical Management (e.g. myomectomy for fibroids, polypectomy, endometrial ablation, hysterectomy)

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19
Q

1st line management of dysmenorrhoea

A

1st Line: NSAIDs (e.g. mefenamic acid)

Followed by:
2nd Line: COCP

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20
Q

What is first line management in dysmenorrhoea associated with heavy menstrual bleeding?

A

Levonorgestrel Intrauterine System (Mirena)

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21
Q

Mirena coil

A

Levonorgesterl intrauterine system

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22
Q

Definition of endometriosis

A

Presence of endometrial tissue outside the uterine cavity.

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23
Q

What happens if the endometrial tissue implants in the ovaries?

A

Results in the formation of endometriomas

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24
Q

presentation of endometriosis

A

Severe cyclical abdominal pain
May be associated with heavy menstrual bleeding
Deep dyspareunia
Dyschezia (pain on defecation)

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25
cyclical abdominal pain
endometriosis
26
dyschezia
pain on defecationI
27
Investigations of endometriosis
Bedside Bimanual Examination Imaging & Other Ultrasound Scan (poor sensitivity for small areas of endometriosis) MRI Diagnostic Laparoscopy
28
Management of endometriosis
Diagnostic Laparoscopy If performed, ectopic endometrial tissue can be removed using surgical diathermy or excision Medical and Surgical Management 1st Line: NSAIDs (e.g. mefenamic acid) and/or Paracetamol Alternative: COCP or Progestogens (e.g. intrauterine system) 2nd Line: GnRH Analogues Alternative: GnRH Antagonist 3rd Line: Danazol (anti-androgen) 4th Line: Surgical Management Fertility-Sparing Surgery (ablation or excision during laparoscopy) Hysterectomy and Bilateral Salpingo-oophorectomy Should only be considered in women who have completed their family and fail to respond to medical treatment
29
What can be done if diagnostic laparoscopy is carried out for endometriosis?
GOLD STANDARD INVESTIGATION If performed, ectopic endometrial tissue can be removed using surgical diathermy or excision
30
Medical and surgical maangement of endometriosis
1st Line: NSAIDs (e.g. mefenamic acid) and/or Paracetamol Alternative: COCP or Progestogens (e.g. intrauterine system) 2nd Line: GnRH Analogues Alternative: GnRH Antagonist 3rd Line: Danazol (anti-androgen) 4th Line: Surgical Management Fertility-Sparing Surgery (ablation or excision during laparoscopy) Hysterectomy and Bilateral Salpingo-oophorectomy Should only be considered in women who have completed their family and fail to respond to medical treatment
31
1st line management for endometriosis
1st Line: NSAIDs (e.g. mefenamic acid) and/or Paracetamol Alternative: COCP or Progestogens (e.g. intrauterine system) Followed by: 2nd Line: GnRH Analogues Alternative: GnRH Antagonist 3rd Line: Danazol (anti-androgen) 4th Line: Surgical Management
32
Surgical management options for endometriosis (4th line)
Fertility-Sparing Surgery (ablation or excision during laparoscopy) Hysterectomy and Bilateral Salpingo-oophorectomy Should only be considered in women who have completed their family and fail to respond to medical treatment Preceded by: 1st Line: NSAIDs (e.g. mefenamic acid) and/or Paracetamol Alternative: COCP or Progestogens (e.g. intrauterine system) 2nd Line: GnRH Analogues Alternative: GnRH Antagonist 3rd Line: Danazol (anti-androgen)
33
When should hysterectomy and bilateral salpingo-oophorectomy be considered in endoemtriosis?
Should only be considered in women who have completed their family and fail to respond to medical treatment
34
defintion of fibroid
Benign tumour of uterine smooth muscle.
35
How are fibroids classified?
Classification (based on location) Intramural Subserosal Submucosal Cervical
36
RFs for fibroids
Excess oestrogen exposure (e.g. early menarche, nulliparity) Afro-Caribbean Ethnicity
37
What gynaecological condition is being afro-caribbean a risk factor for?
fibroids
38
Presentation of fibroids
Often asymptomatic (may be identified upon ultrasound scanning) Heavy menstrual bleeding Lower abdominal pain (especially during menstruation) Deep dyspareunia Urinary symptoms (due to extrinsic compression of the urinary tract) Subfertility
39
When may fibroids be identified incidentally?
on ultrasound scanning
40
Investigations of fibroids
Bedside Bimanual Examination Imaging & Other Transvaginal Ultrasound Scan Hysteroscopy MRI
41
management of fibroids <3cm
1st Line: Levonorgestrel Intrauterine System 2nd Line Non-Hormonal Measures Tranexamic Acid NSAIDs (e.g. mefenamic acid) 2nd Line Hormonal Measures COCP Cyclical Oral Progestogens Surgical Endometrial Ablation Hysterectomy
42
1st line management of fibroids <3cm
1st Line: Levonorgestrel Intrauterine System Followed by: 2nd Line Non-Hormonal Measures Tranexamic Acid NSAIDs (e.g. mefenamic acid) 2nd Line Hormonal Measures COCP Cyclical Oral Progestogens Surgical Endometrial Ablation Hysterectomy
43
Management of fibroids >3cm
Non-Hormonal Management Tranexamic Acid NSAIDs Hormonal Management Levonorgestrel Intrauterine System NOTE: this may be difficult in patients with large fibroids that are distorting the uterine cavity COCP Cyclical Oral Progestogens GnRH Analogues (e.g. Zoladex) Often used to shrink tumours before surgical management Ulipristal Acetate Considered as a pre-operative intervention to stop bleeding and reduce fibroid size Surgical or Interventional Management Transcervical Resection of Fibroids Myomectomy Hysterectomy Uterine Artery Embolisation Endometrial Ablation Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)
44
Non-hormonal management options for fibroids >3cm
Tranexamic Acid NSAIDs
45
Hormonal management of fibroids >3cm
Levonorgestrel Intrauterine System COCP Cyclical Oral Progestogens GnRH Analogues (e.g. Zoladex) Ulipristal Acetate
46
When may a levonorgestrel intrauterine system be difficult in management of fibroids?
in patients with large fibroids that are distorting the uterine cavity
47
What is used to shrink fibroids before surgical management?
Zoladex (GnRH analogue)
48
GnRH analogue
Zoladex
49
Role of GnRH analogue in management of fibroids
shrink tumours before surgical management
50
myomectomy
removal of fibroid
51
Uterine artery embolisation
cuts off blood supply to fibrodi
52
menorrhagia
heavy mesntrual bleeding
53
Definition of menorrhagia
heavy or prolonged menstrual bleeding as perceived by the patient
54
Causes of menorrhagia
Dysfunctional Uterine Bleeding (idiopathic) Endometriosis Adenomyosis Fibroids Pelvic Inflammatory Disease Contraception (in particular, the copper intrauterine device) Bleeding Disorders Polycystic Ovarian Syndrome
55
dysfunctional uterine bleeding
idioapthic menorrhagia
56
What contraceptive device can cause menorrhagia?
copper IUD
57
Presentation of menorrhagia
Heavy menstrual bleeding Periods may be painful If severe, patients may develop symptoms of anaemia
58
What symptoms may patients develop if they have severe menorrhagia?
If severe, patients may develop symptoms of anaemia
59
Investigations for menorrhagia
Bedside Bimanual Examination Speculum Examination Endocervical and high vaginal swabs may be taken if infection is suspected Bloods FBC (check for anaemia) Coagulation Screen TFTs Imaging & Other Transvaginal Ultrasound Scan Hysteroscopy
60
Important blood test to do in menorrhagia
FBC (check for anaemia)
61
Acute management of menorrhagai
A to E Assessment and Resuscitation Correct Coagulopathy
62
Management of menorrhagia if no identified pathology, adenomyosis or fibroids <3cm
1st Line: Levonorgestrel Intrauterine System 2nd Line Non-Hormonal Measures Tranexamic Acid NSAIDs (e.g. mefenamic acid) 2nd Line Hormonal Measures COCP Cyclical Oral Progestogens Surgical Endometrial Ablation Hysterectomy
63
1st line management in menorrhagia
1st Line: Levonorgestrel Intrauterine System Followed by: 2nd Line Non-Hormonal Measures Tranexamic Acid NSAIDs (e.g. mefenamic acid) 2nd Line Hormonal Measures COCP Cyclical Oral Progestogens Surgical Endometrial Ablation Hysterectomy
64
Rotterdam criteria
PCOS
65
What is required for diagnosis of PCOS
A syndrome defined by the Rotterdam criteria. Two of the following are required for a diagnosis of PCOS: Oligo/Anovulation Hyperandrogenism - Clinical (hirsutism) or Biochemical (raised androgens) Polycystic Ovaries on Ultrasound
66
Signs of hyperandrogenism in PCOS
Clinical (hirsutism) or Biochemical (raised androgens)
67
Associated conditions in PCOS
Type II Diabetes Mellitus Obesity Dyslipidaemia
68
Presentation of PCOS
Menstrual irregularities (oligo- or amenorrhoea) Infertility Hirsutism Weight gain Acne
69
Investigations of PCOS
Bloods Gonadotropins: High LH and FSH Associated with a raised LH: FSH Ratio Androgens: High Sex Hormone Binding Globulin: Low HbA1c Serum Prolactin TFTs Midnight Cortisol and Dexamethasone Suppression Test Imaging Transvaginal Ultrasound Scan
70
Important blood tests to do for PCOS
Gonadotropins: High LH and FSH Associated with a raised LH: FSH Ratio Androgens: High Sex Hormone Binding Globulin: Low
71
high LH:FSH ratio
PCOS
72
Management of PCOS
Management of Menstrual Irregularity COCP Cyclical Oral Progesterone Management of Subfertility Encourage Weight Loss (if overweight) Clomiphene Induces ovulation and can be used for up to 6 months Increased risk of multiple pregnancy Metformin may be given alongside clomiphene Laparoscopic Ovarian Drilling Management of Complications Dietary modification and exercise (to counteract the risk of developing type 2 diabetes mellitus and cardiovascular disease) Treatment of Hirsutism/Androgenic Symptoms: Topical Eflornithine Cream Co-Cyprindiol (contraceptive pill with antiandrogenic effects) Cyproterone Acetate (antiandrogen) Metformin GnRH Analogues Surgical Treatment (e.g. laser)
73
Management of menstrual irregularity of PCOS
COCP Cyclical Oral Progesterone
74
Most important management point in subfertility in PCOS
REDUCE WEIGHT IF OVERWEIGHT --> HIGH % LIKELIHOOD OF SPONTANEOUS RETURN OF FERTILITY
75
Management of subfertility in PCOS
Encourage Weight Loss (if overweight) Clomiphene Induces ovulation and can be used for up to 6 months Increased risk of multiple pregnancy Metformin may be given alongside clomiphene Laparoscopic Ovarian Drilling
76
What does clomiphene increase the risk of?
multiple pregnancy
77
What may be given alongside clomiphene in PCOS?
metformin
78
Treatment of hirsutism/androgenic Sx in PCOS
Topical Eflornithine Cream Co-Cyprindiol (contraceptive pill with antiandrogenic effects) Cyproterone Acetate (antiandrogen) Metformin GnRH Analogues Surgical Treatment (e.g. laser)
79
Anti-androgen example
Cryptoperone
80
Contraceptive pill with antiandrrogenic effects
Co-cyprindiol

Gynae (8 decks)

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