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%
How do fibroids impact pregnancy (9)
- Infertility or recurrent miscarriage (submucosal mainly, intramural likely but unclear if myomectomy improves fertility)
- PTL
- Malpresentation
- Obstructed labour
- PPH
- Difficult CS
- Puerperal infection
- Abruption
- FGR
What are the complications associated with fibroids (5)
- Red degeneration
- Torsion
- Prolapse through cervix
- Infection - pyometra
- Malignancy 1-2:1000 undergo malignant transformation
What are the optimal imaging techniques for evaluating fibroids (3) RANZCOG guidelines
- MRI
- Sonohysterography
- Hysteroscopy
How should fibroids be managed in infertile couples (RANZCOG guidelines) - (7)
- Avoid medical management as delays fertility
- Avoid Ulipristal acetate
- Intramural fibroids - may impact fertility and miscarriage rate but insufficient evidence for intervention benefit
- Submucosal fibroids should be resected if undergoing ART
- Infertile women with symptomatic fibroids should have these resected
- Couples with multiple failed ART cycles should have IM fibroids resected
- UAE should only be done in research setting
Discuss uterine artery embolisation:
-Procedure
-Complications (procedural (3), Early (4), Late (3)
-Outcomes and complications compared to surgery (7)
- Procedure:
-Place catheter into uterine arteries via common femoral artery
-Inject embolic particles until the flow through the artery becomes sluggish - Complications
Procedural - Groin haematoma, arterial thrombosis, pseudoaneurysm
Early - Embolisation syndrome - fever, nausea, pain, malaise - 4%, Vaginal discharge - 4%, Pelvic infection, expulsion of necrotic submucosal fibroid (requirement to retrieve these)
Late - Ovarian insufficiency 3% if <40, 40% if >40, Failure of response 3%, reintervention - Outcomes compared to surgery
-No significant difference in patient satisfaction
-Similar intraoperative complications
-No difference in early or late major complication rates
-No difference in long term ovarian failure rates
-UAE - shorted time in hospital, shorter procedural time, shorter recovery time
-UAE increased minor complications, increased number of unplanned reviews, increased re-intervention rate
-Myomectomies better option for women wanting to achieve pregnancy
Discuss UAE and reproduction
-Fertility
-Pregnancy
- Fertility
-Pregnancy rates lower and miscarriage rates higher in UAE vs myomectomy
-May impact ovarian reserve. AMH recovers if <40yrs by 3 months. Doesn’t if >40
-May decrease endometrial health and impact implantation
-May impact myometrial contractility - Pregnancy
-Increased CS, PPH and miscarriage rates when compared to untreated fibroids
How should patients be counselled about uterine artery embolisation (5 points) RANZCOG guidelines
- Avoid UAE in young women if they are wishing to concieve
- Disclose possibility of missing malignancy and avoid if concern or risk factors for leiomyosarcoma
- Counsel patients about requiring hysteroscopic or laparoscopic retrieval
- Counsel patients about alternative options
- Counsel patients wanting to conceive that UAE impact on miscarriage and pregnancy are uncertain
What is the cause / mechanism of PCOS
- Multifactorial with genetic component
-Likely autosomal dominant with low penetration and variable expressivity.
-Heritability 70%
-Likely environmental component - Key element is insulin resistance - seen in 50-70% of women with PCOS.
- Insulin resistance is likely due to abnormal post receptor signalling
- Insulin resistance results in hyperinsulinemia which results in:
-increased release of fatty acids
-Increased LH and decreased FSH release from pituitary
-Augments activity of LH on theca cells to induce more androgen production from ovary
-Stimulates the adrenal glands to produce more androgens
-Reduces SHBG which results in more free androgens - The increased androgens:
-Disrupt folliculogenesis resulting in multiple small follicles and increased follicular atresia
-Acts peripherally to cause signs of hyperandrogenism
What is the criteria for the diagnosis of PCOS
-In Adults
-In Adolescence
Diagnosis is based on Rotterdam criteria
1. Oligomenorrhoea or anovulation (>35/28, <21/7 or <8/yr)
2. Clinical and/or biochemical signs of hyperanderogenism
-High free testosterone and total testosterone
3. Polycystic ovaries on USS
>12 follicles 2-9mm or ovary >10mL without CL, cysts, dominant follicle
4. PCOS is dx of exclusion. Need to r/o
->CAH, Androgen secreting tumour, Cushings, thyroid abnormalities, hyperprolactinemia central causes)
5. In Adolescents
-Oligo/Anovulation. Up to 90 day cycles in yr one tolerable
-3yrs post menarche can use adult def of oligomenorrhoea
-Biochemical hyperandrogenism. Mild acne and alopecia do not apply in adolescence
-USS not recommended in Dx if <8yrs post menarche
What is the incidence of PCOS (2) and how does it present (6)
- Incidence
-Most common endocrine condition in women
-8-13% of women affected
-70% under diagnosed - Presentation
Heterogeneous condition with multiple presentations
Hyperandrogenism -70% hirsutism, Acne 30%, Alopecia 10%
Menstrual disturbance - 60-70%
Infertility - 70%
Truncal obesity - 35-50%
PCOS on USS - 30%
Acanthosis nigricans - 1-3%
What investigations should be ordered for PCOS
1. For Dx (2)
2. Post Dx (4)
3. To rule out other causes of symptoms/signs (8)
4. Considerations in testing
- For Dx
-FSH, LH, E2, testosterone
-TV USS - Post Dx
-OGTT or HbA1c
-Lipids
-BMI and waist circumference
-Annual BP - To rule out other causes
-Prolactin
-TSH
-17 Hydroxy progesterone
-DHEAS - marks adrenal androgen production (Ltd use)
-Androstenedione - marker of ovarian androgen production (Ltd use)
-24hr urine cortisol - Cushings - Considerations
-Cannot test testosterone if on hormonal contraceptive. Need to have 3 month period off this.
-USS in those who are <8yrs post menarche should be avoided
What are the typical biochemical findings in PCOS (8)
- Raised free testosterones
- Low SHBG
- Raised LH/FSH ratio
- Raised DHEAS and androstenedione
- Raised LH
- Increased oestrogen
- Decreased progesterone
- Mildly elevated prolactin
What are the key aims for PCOS management (6)
- Correct hyperandrogenism
- Restore menstrual function
- Manage cosmetic symptoms
- Restore fertility
- Improve long term health
-Diabetes
-CVD
-Hyperlipidemia
-Endometrial protection - Manage mental health - Increased depression / anxiety
Discuss management for PCOS
-Lifestyle
-Cosmetic
-Pharmacological
-fertility
- Lifestyle management
Interventions which result in weight loss
-5-10% weight loss will improve menstrual regulation and fertility
-Not required in BMI normal
Firstline diet and exercise with psychological support if required
In very obese women recalcitrant to first line = Bariatric surgery - Cosmetic
-For Hirsutism - bleaching, waxing, laser
-COCP with cyproterone - hirsutism and Acne
-Spironolactone or cryptoproterone actate for hirsutism takes 6-9 months to work. Are teratogenic - must be on contraception. Try if no improvement after 6/12 COCP - Pharmacological - not desiring fertility
-First line COCP - for hyperandrogenism, menstrual irregularity, endometrial protection. Consider contra-indication
-Second line - Progesterone only if contra-indicated to COCP. For menstrual irregularity and endometrial protection
-Metformin - off-label use. Not as effective as COCP
- Consider in high risk groups for diabetes in combo with POP or COCP
-Sht term improvement in insulin resistance, reduces androgen by 11%, may have modest impact on wt - Infertility
- Lifestyle changes = first line
- Ovulation induction
-Letrozole (first line) or clomiphene
-Metformin can be considered - less effective
-Ovarian drilling - improves ovulation and androgen normalisation in 60%
What are the long term health outcomes for women with PCOS (6)
- Obesity
- CVD
- manage modifiable risk factors.
-Annual GP reviews - to check for risk factors
-Insufficient evidence to commence of statin - Diabetes
-Increased risk of GDM (RR 2.0), T2DM, metabolic syndrome
-Assess glycemic status 1-3yrs. OGTT best
-HBA1c not validated in PCOS. Might miss T2DM
-OGTT between 24-28/40 weeks recommended - OSA - assess for symptoms and refer as appropriate
- Endometrial hyperplasia and cancer
-2-6 fold increased risk of endometrial cancer
-Consider endometrial protection. May reduce risk if cycle >90 days
-Have a low threshold to investigate AUB / Thickened ET
-Routine screening with ET is not recommended - Psychological
- increased depression and anxiety - screen for PHQ and GADS7
-Increased psychosexual dysfunction and poor body image - screen for.
-Offer psychological support
What is the definition of secondary amenorrhoea
- Absence of menstruation for >3 months if previously regular cycles
- Absence of menstruation for >6 months if previously irregular cycles
What are the causes of secondary amenorrhoea (8 categories)
- Hypothalamus - 35%
-Functional - stress, wt los, low BMI, excess exercise
-Lesions -craniopharyngeioma, glioma
-Infiltrative disease - TB, sarcoidosis
-Head injury / radiation
-Chronic illness - Pituitary - 17%
-Hyperprolactinemia - almost always adenoma causes decreased GnRH release
-Sheenhan’s syndrome - hypoxic insult to pituitary (after PPH)
-Trauma to pituitary stalk stopping dopamine control of prolactin = hyperprolactinemia - Ovarian - 40%
-PCOS 30%
-POI - Genital tract abnormalities 7%
-Asherman’s syndrome
-Cervical stenosis - Adrenal
-Late onset CAH
-Virilising adrenal tumour - Drugs
-Progestogens / HRT
-Dopamine antagonists, metocloprimide
-Long term steroids - Chronic illness
-Chronic illness affecting HPO axis - renal/liver /thyroid disease. Diabetes, Cushing’s - Physiological
-Pregnancy - most common cause
-Lactation
-Menopause
What investigations should be done to investigate secondary amenorrhoea
- Bloods
FSH/LH
- Low/Low = hypogonadatrophic hypogonadism
-High in ovarian causes
-High LH/FSH ratio PCOS
Oestradiol
-Low in ovarian causes
-High where hyperandrogenism occurs as converts in peripheral tissue
Prolactin
-Hyperprolactinemia but can but raised for many other reasons
Thyroid function
Testosterone
-High in PCOS
DHEAS
-High in adrenal androgen secretion
SHBG
-Decreased in PCOS
17 hydroxyprogesterone
-High in late onset CAH - Imaging
-USS - PCOS / Adrenal masses
-MRI if suspecting prolactinoma / Tumour - Hysteroscopy if suspecting Ashermans
How should secondary amenorrhoea be managed
Management depends on cause
1. Hypothalamic
-Increase calories, decrease stress, decrease exercise
-GnRH if wanting fertility
-HRT
2. Pituitary
-Dopamine agonist - Carbergoline
-Transphenoidal transection if recalcitrant to medical management
3. Ovarian
-Management for PCOS
-Management for POI
4. Genital tract
-Hysteroscopic resection of adhesions
-Cervical dilitation
5. Adrenal
-Resection of androgen secreting tumour
-Hydrocortisone for CAH
6. Stop drugs contributing to issue
7. Optimise chronic disease management
What are the classifications of premenstrual syndrome (6)
PMS is an umbrella term for a range of disorders
1. Premenstrual syndrome
2. Premenstrual dysmorphic disorder
3. Premenstrual exaccerbation
-symptoms of an underlying disorder are worsened during luteal phase of cycle
4. Non-ovulatory PMD - due to follicular activity
5. Progesterone induced PMD - due to exogenous progesterone
6. PMD with absent menstruation (hysterectomy / Mirena)
What is the definition of premenstrual syndrome
- Cyclical disorder with symptoms in the luteal phase
- Includes physical and psychological symptoms
- Timing and severity of sx support dx not type of sx
- Must impact quality of life
What is the diagnostic criteria for premenstrual dysphoric disorder
-5 points
-11 symptoms
- Must have 5 of 11 symptoms
- One symptom must be mood
- symptoms must be in luteal phase and abate when menstruation begins
- Must be severe enough to disrupt daily function
- Must be present during at least 2 consecutive cycles
Symptoms:
-Depression
-Anxiety
-Affect lability
-Anger or irritation
-Decreased interest in usual activities
-Difficulty concentrating
-Lack of energy, fatigue
-Change in appetite, cravings
-Change in sleep - hypersomnia or insomnia
-Feeling overwhelmed or out of control
-Physical symptoms: breast tenderness, headaches, joint or muscle aches, weight gain, bloating
Discuss premenstrual syndrome
-incidence
-aetiology
- Incidence
-40% of women experience PMS
-2-5% have Premenstrual dysmorphic disorder - Aetiology (Theories)
-Sensitivity to progesterone
-Serotonin receptors are responsive to oestrogen and progesterone
-GABA levels are modulated by metabolites of progesterone
-Possible genetic component
Discuss premenstrual syndrome
-Diagnosis
-Management
- Diagnosis
-Symptom diary over at least 2 consecutive cycles. Can use DRSS Questionnaire (Daily record of severity of symptoms)
-If diary inconclusive GnRH for 3 months with resolution of symptoms confirms diagnosis
-Need to rule out other causes. Examination and investigations should be normal - Management
-Holistic approach with MDT
-Aims to eliminate cyclical fluctuations, modify neurotransmitter response, improve coping strategies
-Conflicting evidence regarding efficacy of alternative therapies
-Calcium + vit D, exercise, chaste berry, saffron work
First line:
-Exercise, CBT (as effective as fluoxetine), Vit B6
-Low dose SSRI continuously or in luteal phase
-Continuous new generation COC (Drospiridone)
Second line
-Transdermal estrogen with micronised progesterone or LNG-IUS.
-Higher dose SSRI continuous or in luteal phase 60-70% sx improvement
Third line:
-GnRH analogues + add back HRT if >6 months or tibolone
Fourth line
-Surgery - if severe and recalcitrant to medical management and previous success with GnRH management. TH + BSO better as avoids need for progesterone in HRT.
