Menstrual Disorders Flashcards
How long is the average menstrual cycle?
28 days
How long does menstruation last?
2-7 days
How much blood is lost during average menstruation?
30-40mls but less than 80mls over seven days is considered normal
Menarche?
First time a girl starts her period
What is the usual age for menarche?
10-16yrs
->average 12yrs
When does menopause usually happen?
50-55yrs
For menstrual cycle to be termed frequent, normal and infrequent, how may days would the cycle need to last?
Frequent = <24 days
Normal= 24-38 days
Infrequent= >38 days
Heavy menstrual bleeding?
Difficult to quantify but some of the following:
-80mls over 7 days in someone with a regular cycle
-needing to change a menstrual product every 2 hours
-passage of clots >2.5cm
-bleeding through clothes
If someone is passing a lot of clots throughout the day, what are they at risk of?
Anaemia
List some uterine/ovarian pathologies which can cause heavy menstrual bleeding.
Uterine fibroids
Endometrial polyps
Endometriosis
Pelvic inflammatory disease
Endometrial hyperplasia/carcinoma
Polycystic ovarian syndrome
List some systemic diseases and disorders which can cause heavy menstrual bleeding.
Coagulation disorder (e.g. Willebrand disease)
Hypothyroidism
Liver or renal disease
What are some other potential causes of heavy menstrual bleeding?
Anticoagulant treatment
Herbal supplements (ginseng, gingko and soya)
Intrauterine contraceptive device
What are fibroids?
Non-cancerous growths made of muscle and fibour tissue
What are the symptoms of fibroids?
Can be asymptomatic
Heavy menstrual bleeding
Pelvic pain
Urinary symptoms
Pressure symptoms
Backache
Infertility
Miscarriage
What investigation is used to make a diagnosis of fibroids?
Ultrasound
Management of fibroids?
Symptom based
For HMB +/- small fibroids- COCP, POP Mirena
Large fibroids and fertility preservation- fibroid embolization, myomectomy
Submucosal fibroids- hysteroscopic fibroid resection
If medical treatment of fibroids fails or the patient refuses, which procedure can be done?
Hysterectomy
Endometriosis?
Endometrial tissue present outside the lining of the uterus
->during menstruation, this ectopic tissue behaves the same as endometrium and bleeds
How can endometriosis present?
HMB
Most often presents with pelvic pain
->multi-system involvement, can be devastating as greatly affects quality of life
What can endometriosis cause?
Infertility
Symptoms of endometriosis?
Painful menstrual cramps that get worse over time
Lower back pain
Abnormal bleeding or spotting between periods
Pain during and after sex
Painful bowel movements/urination
Diarrhoea
Nausea
Blotting
->very hard to diagnose due to the symptoms. Commonly said it’s normal or heavy periods, often IBS if bowel symptoms but need to remember IBS is a diagnosis of exclusion so need to rule out endometriosis first
Summarise the stages of endometriosis.
Stage 1- minimal
Stage 2- mild, more widespread and starting to infiltrate pelvic organs
Stage 3- moderate, peritoneum or other structures. Sometimes scarring and adhesions
Stage 4- severe, infiltrative, affecting many pelvic organs and ovaries, often with distortion of the anatomy and adhesions
How is a diagnosis of endometriosis made?
Ultrasound
Diagnostic laparoscopy
What are the management options for endometriosis?
Medical
Surgical
Analgesia
Medical management of endometriosis?
COCP
POP
Mirena IUS
Depot prvera
GnRH Analogues
Surgical management of endometriosis?
Ablation
Hysterectomy endometrioma excision
Pelvic clearance
Hysterectomy
Adenomyosis?
A condition where the endometrium becomes embedded in the myometrium
Symptoms of adenomyosis?
Heavy menstrual bleed
May be significant dysmenorrhoea (cramps)
What is the definitive treatment of adenomyosis?
Hysterectomy
->may respond to hormone treatment partially
Endometrial polpys?
Overgrowth of the endometrial lining, mostly benign
How is diagnosis of endometrial polyps made?
Ultrasound or hysteroscopy
Management of endometrial polyps?
Polypectomy
What are some things to do when a patient presents with heavy menstrual bleeding?
Thorough history
Pelvic examination
Clotting profile
Thyroid scan
Pelvic ultrasound
Laparoscopy if endometriosis is suspected
What are some of the hormone treatment options for menstrual disorders?
Mirena IUS
COCP
POP
Depot provera
What are some of the non-hormone treatment options for menstrual disorders?
Mefenamic acid
Tranexamic acid
GnRh analogues
Endomometrial ablation
Fibroid embolization
Hysterectomy
What is the purpose of tranexamic/mefenamic acid?
Reduces blood loss
->TA by 60%, MA by 30%
They do not regulate cycles
What are the benefits of hormonal contraception in the management of menstrual conditions?
Makes period light, more regular and less painful
What are the benefits of IUS or Depo-Prevera in the management of menstrual conditions?
Reduces bleeding
May cause irregular bleeding
Some women will be amenorrhagic
What happens in endometrial ablation?
Permanent destruction of endometrium using different energy sources
What are some of the pre-requisites for endometrial ablation?
Uterine cavity length <11cm
Sub mucous fibroids <3cm
Previous normal endometrial biopsy
Hysterectomy?
Surgical removal of the uterus
Total hysterectomy?
Cervix and uterus removed
Subtotal hysterectomy?
Uterus removed, cervix left
Hysterectomy can be done abdominally, vaginally or laparoscopically.
What is the preferred choice these days?
Laparoscopic
->especially if smaller uterus and no complications. Recovery is quicker.
If the patient has had a total hysterectomy, do they need to keep getting smears?
No, as cervix has been removed.
Those with subtotal hysterectomy’s still will need smears
Risks of hysterectomy?
Infection
DVT
Bladder/bowel/vessel injury
Altered bladder function
Adhesions
What is one guarantee of a hysterectomy?
Amenorrhoea- no periods
Salpingo-oophorectomy?
Removal fallopian tubes and ovaries
When may the ovaries and the uterus be removed?
Women with endometriosis or presence of ovarian pathology
What is a disadvantage of ooporectomy?
Immediate menopause
Which drug is recommended until the age of 50 for anyone who has to get an oophorectomy?
HRT
What is an advantage of an oophorectomy?
Reduces risk of subsequent ovarian cancer
Oligo/menorrhea?
Infrequent, absent or abnormally light menstruation
There are manyyyyy causes of oligo/amennorhea.
List some for awareness :)
Life changes: stress, ED/malnourishment, obesity, intense exercise
Hormones: POP, mirena, depot injection
Primary ovarian insufficiency
Hyperprolactinemia
Prolactinomas (adenomas on the anterior pituitary gland)
Thyroid disorders: Graves
Obstruction of the uterus, cervix and/or vagina
What is polycystic ovary syndrome associated with?
Obesity
Infertility
What are the three main features of PCOS?
Irregular periods
Excess androgen (hyperandrogegism)
Polycystic ovaries
->2/3 required for diagnosis
What are some features of excess androgen (hyperandrogegism)?
Excess facial or baby hair due to high levels of testosterone
Management of PCOS?
Lifestyle adjustment with aim to achieve normal BMI
Patients with PCOS need to have at least 3 periods a year. Why? How is this done?
To reduce risks of endometrial hyperplasia
Can be done with either COCP, POP or mirena IUS
What is dysfunctional uterine bleeding?
Common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable uterine or systemic disease
->treatment based on severity of symptoms
