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Gynae > Menstrual Disorders > Flashcards

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
Q

cyclical abdominal pain

A

endometriosis

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26
Q

dyschezia

A

pain on defecationI

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27
Q

Investigations of endometriosis

A

Bedside
Bimanual Examination

Imaging & Other
Ultrasound Scan (poor sensitivity for small areas of endometriosis)
MRI
Diagnostic Laparoscopy

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28
Q

Management of endometriosis

A

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

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29
Q

What can be done if diagnostic laparoscopy is carried out for endometriosis?

A

GOLD STANDARD INVESTIGATION

If performed, ectopic endometrial tissue can be removed using surgical diathermy or excision

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30
Q

Medical and surgical maangement of endometriosis

A

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

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31
Q

1st line management for endometriosis

A

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

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32
Q

Surgical management options for endometriosis (4th line)

A

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)

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33
Q

When should hysterectomy and bilateral salpingo-oophorectomy be considered in endoemtriosis?

A

Should only be considered in women who have completed their family and fail to respond to medical treatment

34
Q

defintion of fibroid

A

Benign tumour of uterine smooth muscle.

35
Q

How are fibroids classified?

A

Classification (based on location)
Intramural
Subserosal
Submucosal
Cervical

36
Q

RFs for fibroids

A

Excess oestrogen exposure (e.g. early menarche, nulliparity)
Afro-Caribbean Ethnicity

37
Q

What gynaecological condition is being afro-caribbean a risk factor for?

A

fibroids

38
Q

Presentation of fibroids

A

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
Q

When may fibroids be identified incidentally?

A

on ultrasound scanning

40
Q

Investigations of fibroids

A

Bedside
Bimanual Examination

Imaging & Other
Transvaginal Ultrasound Scan
Hysteroscopy
MRI

41
Q

management of fibroids <3cm

A

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
Q

1st line management of fibroids <3cm

A

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
Q

Management of fibroids >3cm

A

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
Q

Non-hormonal management options for fibroids >3cm

A

Tranexamic Acid
NSAIDs

45
Q

Hormonal management of fibroids >3cm

A

Levonorgestrel Intrauterine System
COCP
Cyclical Oral Progestogens
GnRH Analogues (e.g. Zoladex)
Ulipristal Acetate

46
Q

When may a levonorgestrel intrauterine system be difficult in management of fibroids?

A

in patients with large fibroids that are distorting the uterine cavity

47
Q

What is used to shrink fibroids before surgical management?

A

Zoladex (GnRH analogue)

48
Q

GnRH analogue

A

Zoladex

49
Q

Role of GnRH analogue in management of fibroids

A

shrink tumours before surgical management

50
Q

myomectomy

A

removal of fibroid

51
Q

Uterine artery embolisation

A

cuts off blood supply to fibrodi

52
Q

menorrhagia

A

heavy mesntrual bleeding

53
Q

Definition of menorrhagia

A

heavy or prolonged menstrual bleeding as perceived by the patient

54
Q

Causes of menorrhagia

A

Dysfunctional Uterine Bleeding (idiopathic)
Endometriosis
Adenomyosis
Fibroids
Pelvic Inflammatory Disease
Contraception (in particular, the copper intrauterine device)
Bleeding Disorders
Polycystic Ovarian Syndrome

55
Q

dysfunctional uterine bleeding

A

idioapthic menorrhagia

56
Q

What contraceptive device can cause menorrhagia?

A

copper IUD

57
Q

Presentation of menorrhagia

A

Heavy menstrual bleeding
Periods may be painful
If severe, patients may develop symptoms of anaemia

58
Q

What symptoms may patients develop if they have severe menorrhagia?

A

If severe, patients may develop symptoms of anaemia

59
Q

Investigations for menorrhagia

A

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
Q

Important blood test to do in menorrhagia

A

FBC (check for anaemia)

61
Q

Acute management of menorrhagai

A

A to E Assessment and Resuscitation
Correct Coagulopathy

62
Q

Management of menorrhagia if no identified pathology, adenomyosis or fibroids <3cm

A

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
Q

1st line management in menorrhagia

A

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
Q

Rotterdam criteria

A

PCOS

65
Q

What is required for diagnosis of PCOS

A

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
Q

Signs of hyperandrogenism in PCOS

A

Clinical (hirsutism) or Biochemical (raised androgens)

67
Q

Associated conditions in PCOS

A

Type II Diabetes Mellitus
Obesity
Dyslipidaemia

68
Q

Presentation of PCOS

A

Menstrual irregularities (oligo- or amenorrhoea)
Infertility
Hirsutism
Weight gain
Acne

69
Q

Investigations of PCOS

A

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
Q

Important blood tests to do for PCOS

A

Gonadotropins: High LH and FSH
Associated with a raised LH: FSH Ratio

Androgens: High

Sex Hormone Binding Globulin: Low

71
Q

high LH:FSH ratio

A

PCOS

72
Q

Management of PCOS

A

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
Q

Management of menstrual irregularity of PCOS

A

COCP
Cyclical Oral Progesterone

74
Q

Most important management point in subfertility in PCOS

A

REDUCE WEIGHT IF OVERWEIGHT –> HIGH % LIKELIHOOD OF SPONTANEOUS RETURN OF FERTILITY

75
Q

Management of subfertility in PCOS

A

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
Q

What does clomiphene increase the risk of?

A

multiple pregnancy

77
Q

What may be given alongside clomiphene in PCOS?

A

metformin

78
Q

Treatment of hirsutism/androgenic Sx in PCOS

A

Topical Eflornithine Cream
Co-Cyprindiol (contraceptive pill with antiandrogenic effects)
Cyproterone Acetate (antiandrogen)
Metformin
GnRH Analogues
Surgical Treatment (e.g. laser)

79
Q

Anti-androgen example

A

Cryptoperone

80
Q

Contraceptive pill with antiandrrogenic effects

A

Co-cyprindiol

Gynae (8 decks)

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