Menstrual disorders Flashcards
Discuss abnormal uterine bleeding
1. Incidence (2)
2. Definitions:
-AUB
-HMB
-Normal duration of bleeding
-Normal frequency of bleeding
-Normal regularity in cycle
- Incidence
-1 in 20 women seek medical services for AUB
-3-30% of all women of reproductive age affected - AUB - bleeding that is abnormal in frequency, duration, amount, regularity or any unscheduled bleeding
- HMB - bleeding which is considered excessive by the women and interferes with her life
- Normal duration of bleeding <8 days
- Normal frequency of bleeding - between 24-38 day cycle
- Normal cycle variation - >9 days at extremes of reproductive age, >7 between 26-41yrs
What are the causes of AUB
PALM COIEN
1. Polyps
2. Adenomyosis
3. Leiomyoma
4. Malignancy
5. Coagulopathy - VWD most common
6. Ovulatory
7. Iatrogenic
8. Endometrial - overactive fibrinolysis, higher levels of prostaglandins, adolescence
9. Not otherwise explained - isthomocele, AVM
What are the investigations for AUB
- Bloods:
-FBC, coag screen if Hx suggests so
-Fe and TFT
-Hormone testing NO recommended - Cervical smear
- HVS + LVS to investigate infection
- TVUSS - best done in follicular phase
- Endometrial Bx - do if thickened ET, risk factors for hyperplasia, persistence of bleeding despite conservative measures
NB: MRI, Saline sonography, D&C not firstline investigations
Discuss management of AUB
1. Considerations (4)
2. Non-hormonal
3. Hormonal
4. Surgery
- Considerations
-Pathology
-Co-morbidities
-Fertility desires
-Treatment preferences - Non-Hormonal
-TXA - reduces bleeding by 50%
-NSAIDS - reduces prostaglandin synthesis. Reduced blood loss by 25% - Hormonal
-Mirena:
AUB NOS, Primary endometrial, Fibroid <3cm, adenomyosis.
Decrease blood flow by 96% in first yr
-COCP - reduces menstural blood loss by 50%
-Progesterone
-GnRH - Surgical
-Hysteroscopy D&C, Myomectomy, polypectomy, ablation, hysterectomy
Discuss endometrial ablation
-Indication
-Contra-indications
-Relative (8)
-Absolute (6)
- HMB.
-Best done within 5 yrs of menopause transition
-Most effect in women >45yrs - Relative contraindications
-Congenital uterine abnormalities
-Uterine cavity >10cm
-Risk of endometrial hyperplasia (on tamoxifen, Lynch, Cowden)
-Submucosal fibroids that distorts the cavity
-Adenomyosis
-Previous ablation
-Post menopausal
-Acutely retroverted or anteverted uterus - Absolute contraindications
-Fertility incomplete
-Pregnancy
-Active genital tract infection
-Weakened myometrium - classical CS or myomectomy
-Malignancy or endometrial hyperplasia
-Uterine cavity <4cm long or uterine cavity width <2.5cm
What are the pre-operative requirements of endometrial ablation (7)
- USS in last 6 months
- Recent endometrial sampling, preferably prior to procedure or at very least at time of procedure
- Discuss contraception- poor pregnancy outcomes post ablation
- Informed consent
- Negative pregnancy test
How is endometrial ablation undertaken
-Types of ablation
-Procedure for Novasure (7 steps)
- Types of ablation:
-First generation: roller ball, diathermy loop ablation
-Second generation: fluid filled ablation balloon, microwave ablation, impedence controlled ablation (Novasure) - Novasure procedure
-Hysteroscopy first to assess cavity
-Curettage to collect tissue
-Determine length of uterus
-Place novasure wand into the cavity and rotate for sizing of cavity
-Novasure uses bipolar radiofrequency electrical energy passed through a porous metal fabric to vaporise and coagulate the endometrium
-Radio frequency ablation terminates after 2 mins or when increasing tissue impedance is noted
-Hysteroscope check
What are the success rates o endometrial ablation (3)
-Amenorrhoea at 1 yr - 37% at 2-5yrs 53%
-Patient satisfaction - 91% at 1 yr, 93% at 2-5 yrs
-Hysterectomy within 2-5yrs - 14%
What are the complications of endometrial ablation (8)
- PATSS - Post ablation tubal sterilisation syndrome
-Pain 6-8% secondary to proximal tube swelling - Ectopic pregnancy if become pregnant 26%
- Crampy pain 38%
- Treatment failure 9%
- Thermal injury to adjacent tissue - 1:10,000
- Uterine perforation 0.3%
- Haemorrhage - 1.2%
- infection 1-2%
Discuss endometrial polyps
-Cause
-Histology
-Risk factor (5)
-Natural history
-Impact on fertility (3)
-Management options (3)
- Hyperplastic overgrowth of endometrial glands and stroma
- dilated endometrial glands embedded in markedly fibrous stroma
- Risk factors
-Tamoxifen, obesity, HRT, Lynch syndrome, PM - Natural history
-10% regression, less likely to regress if >1cm
-Progression to malignancy 5% - increased risk with age, Tamoxifen, if present with AUB - Impact on pregnancy
-Polypectomy can improve fertility rates
-Not associated with miscarriage rates
-No obstetric implications - Management
-Expectant with reimaging in 6 months if premenopausal, polyp <1.5cm, single polyp, aSx, not on tamoxifen
-Surgery - hysteroscopy + polypectomy / Resection (reduces recurrence as coagulation to base)
-If polyps recurrent consider mirena placement concurrently
Discuss fibroids
-Definition
-Incidence
-Risk factors (6)
- Def: Benign, monoclonal tumours of the myometrium formed from smooth muscle and fibroblasts
- Most common pelvic tumour. 30% of women have
- Risk factors
-Increased estrogen exposure - early menarche, late menopause, PCOS, COC, Nulliparity, obestiy
-Race 2-3 x higher in Black women, genetics, DES exposure, Prior uterine infection, physical and sexual abuse
How does FIGO classify fibroids (8)
Submucosal 0-2
0 - pedunculated intracavity
1 - <50% intramural
2 - >50% intramural
Intramural 3-4
3 - 100% intramural
4 - intramural
Subserosal 5-7
5 - >50% intramural
6 - <50% intramural
7 - Pedunculated subserosal
8 - Other - cervical etc
How do fibroids present (5)
- 50% asx
- AUB
- Pain
- Pressure sx
- Infertility or obstetric complications
What are the options for fibroid management (4)
- Conservative - if aSx, slow growing and small
-Consider growth monitoring annually - Medical - Less effective if fibroid >3cm
-TXA/NSAIDS - not very effective
-Mirena if fibroid <3cm and not submucosal
-COC effective. POP, Jadelle, Depo - not effective
-GnRH - only if other methods contra-indicated
-Use pre-surgery
-If>6/12 need HRT add-back
-SPRM - ulipristal - apoptosis within fibroid
-Mifepristone - reduction in size by 25-75% - Surgery
-Hysteroscopic resection if submucosal
-Myomectomy -10% recurrence, 17% require further surgery
-Use inconjunction with 3/12 GnRH inhibitor
-Myolysis - directed electrical current or laser
-Hysterectomy - IR
-UAE
NB: Hysterocscopy / myomectomy/ Myolysis if desiring infertility
Discuss uterine artery embolization efficacy (3)
- Relief of pressure sx 60%
- Relief of AUB - 70-90%
- Relief of pain 80%