Menstrual disorders

Question 1

describe normal menstruation

Answer 1

The menstrual cycle is the time from the first day of period to the day before her next period
Normal loss: less than 80 ml over 7 days(16 tsp)
Average loss: 30-40 ml (6-8tsp)
Average duration 2-7 days
Length of cycle -28 days (average 24-35 days)
Menarche : 10-16years, average -12 years
Menopause: 50-55years

Question 2

how can heavy menstrual bleeding present

Answer 2

Difficult to measure/quantify
Bleeding>80 ml over 7 days, regular cycle
AND/OR the need to change menstrual products every one to two hours
AND/OR passage of clots greater than 2.5 cm
Bleeding through the clothes
AND/OR ‘very heavy’ periods as reported by the patient/affecting quality of life
Can occur alone or in combination with symptoms like dysmenorrhea.
5% HMB consultations with GP by patients aged 30-49
HealthImplications e.g. anaemia
20% hysterectomies in UK aged <60 due to HMB

Question 3

uterine and ovarian pathologies that can cause heavy bleeding

Answer 3

Uterine fibroids (HMB/dysmenorrhoea, pelvic pain)
Endometrial polyps (HMB/ intermenstrual bleeding).
Endometriosis and adenomyosis (HMB/dysmenorrhoea, dyspareunia, pelvic pain, difficulty conceiving
Pelvic inflammatory disease and pelvic infection (for example chlamydia — may also present with vaginal discharge, pelvic pain, intermenstrual and postcoital bleeding, and fever
Endometrial hyperplasia or carcinoma (postcoital bleeding, intermenstrual bleeding, pelvic pain).
Polycystic ovary syndrome (causes anovulatory menorrhagia and irregular bleeding).

Question 4

systemic diseases and disorders that can cause heavy bleeding

Answer 4

Coagulation disorders (for example von Willebrand disease).
Hypothyroidism (which may also present with fatigue, constipation, intolerance of cold, and hair and skin changes)
Liver or renal disease.

Question 5

iatrogenic causes of heavy bleeding

Answer 5

Anticoagulant treatment.
Herbal supplements (for example ginseng, ginkgo, and soya) — these may cause menstrual irregularities by altering oestrogen levels or coagulation parameters.
Intrauterine contraceptive device(CU IUD).

Question 6

PALM COEIN

causes of heavy bleeding

Answer 6

polyp
adenomyosis
leiomyoma
malignancy

coagulopathy
ovulation dysfunction
endometrium/hyperplasia
iatrogenic
not yet classified

Question 7

what are fibroids

Answer 7

Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma

Question 8

what is the typical presentation of fibroids

Answer 8

May be asymptomatic
can cause HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage

Question 9

how are fibroids diagnosed

Answer 9

US

Question 10

how is fibroids managed

Answer 10

symptom based.

For HMB +/- small fibroids-COCP, POP, Mirena

large fibroids & fertility preservation desired- Fibroid embolisation ,myomectomy
submucosal fibroids - Hysteroscopic fibroid resection

Declined or failed medical treatment & fertility preservation not required-Hysterectomy

Question 11

what is endometriosis

Answer 11

Defined as endometrial tissue present outside the lining of uterus .During menstruation this ectopic tissue behaves the same as endometrium and bleeds.

Affects women of reproductive age. 1.5 million patients in UK affected.

Question 12

what is the typical presentation of endometriosis

Answer 12

May present with HMB
Most often pelvic pain .
Multi-system involvement .
severely affects quality of life -can be devastating.
in addition to pelvic symptoms , can cause infertility, fatigue and systemic symptoms

Severity of deposits may not correspond with symptoms .

Question 13

four stages endometriosis

Answer 13

1 - minimal
2 - mild (infiltration pelvic organs)
3 - moderate (peritoneum/pelvic side walls)
4 - severe (infiltrative affect pelvic organs and ovaries

Question 14

diagnosis of endometriosis

Answer 14

Pelvic examination
Ultrasound scan, Diagnostic laparoscopy

Question 15

how is endometriosis managed

Answer 15

Management Options: Analgesia, Medical, Surgical
Medical —COCP, POP, Mirena IUS , Depot provera, GnRH Analogues
Surgical-Ablation,Hysterectomy endometrioma excision, pelvic clearance, Hysterectomy
Surgical management may be required as part of fertility treatment.

Question 16

what is adenomyosis

Answer 16

A condition where endometrium becomes embedded in myometrium .
Heavy menstrual bleed.
May have significant dysmenorrhea.

Question 17

how is adenomyosis treated

Answer 17

May respond to hormones partially
Definitive treatment is hysterectomy

Question 18

what are endometrial polyps

Answer 18

Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium
mostly benign.

Question 19

how is endometrial polyps diagnosed

Answer 19

Diagnosis by Ultrasound or hysteroscopy

Question 20

management for endometrial polyps

Answer 20

polypectomy

Question 21

Management of Heavy menstrual bleeding

Answer 21

Thorough history
Pelvic examination (Speculum,Bimanual) remember to look at cervix
Clotting profile, thyroid function
Pelvic Ultrasound scan
Laparoscopy if endometriosis suspected
Management options depend on
Impact on quality of life
Underlying pathology
Desire for further fertility
Women’s preferences Hysteroscopy

Endometrial Biopsy from all patients aged 44 or above with HMB, refractory to medical treatment.

Question 22

if a patients wants treatment what hormonal and non hormonal methods are offered

Answer 22

hormonal
- mirena
- COCP
- depot provera

non hormonal
- mefenamic acid
- tronexemic acid
- gnrh analogues
- endometrial ablation
- fibroid embolisation
- hysterectomy

Question 23

Tranexamic aci

Answer 23

(antifibrinolytic) reduces blood loss 60%

Question 24

Mefenamic acid

Answer 24

(prostaglandin inhibitor) reduces blood loss 30% and pain
Both of them are taken at the time of periods , Do not regulate cycles
Suitable for those trying to conceive

Question 25

LNG IUS and Depo-Provera

Answer 25

reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic

Question 26

Oral progestogens

Answer 26

eg Provera10mg od
day 5-25 cycle reduce bleeding +regulate
day 15-25 may regulate cycle but does not reduce amount of bleeding

Question 27

Endometrial ablation

Answer 27

ermanent destruction of endometrium using different energy sources
First generation ablation: under hysteroscopic vision – uses diathermy
Second generation ablation: thermal balloon, radio frequency
Pre-requisites:
Uterine cavity length <11 cm
Sub mucous fibroids < 3cm
Previous normal endometrial biopsy
60% will have no periods, 85% are satisfied, 15% will have subsequent hysterectomy

Question 28

Hysterectomy

Answer 28

Surgical removal of uterus
Abdominal
Vaginal
Laparoscopic
Laporoscopically assisted vaginal hysterectomy (LAVH)
Total laparoscopic hysterectomy TLH
Laparoscopically assisted subtotal hysterectomy

Total hysterectomy: cervix and uterus removed
Subtotal hysterectomy: uterus removed, cervix left

Question 29

risks hysterectomy

Answer 29

Major surgery
3-5 days in hospital (open / vaginal)
1-2 days laparoscopic approach
2-3 months full recovery
Risks: infection/DVT/bladder/bowel/vessel injury/ altered bladder function / adhesions
Guarantees amenorrhoea

Question 30

Removal of ovaries with uterus

Answer 30

Salpingo-oophorectomy’ removal tubes + ovaries

Ovaries may be removed with uterus in women with endometriosis or presence of ovarian pathology

Disadvantages of oophorectomy
immediate menopause – recommended HRT till age 50
Advantages
Reduces risk of subsequent ovarian cancer

high risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply

Question 31

Oligo/amennorhea

Answer 31

Infrequent, absent or abnormally light menstruation
Important to check if its normal to a person

Question 32

causes amennorhea

Answer 32

Life changes:stress, eating disorders/malnourishment, obesity, Intense exercise
Hormones:POP, Mirena, depot injection
Primary ovarian insufficiency
Polycystic ovarian syndrome ,
Hyperprolactinemia (elevated levels of prolactin in the blood)
Prolactinomas (adenomas on the anterior pituitary gland)
Thyroid disorders (Graves’s disease)
Obstructions of the uterus, cervix, and/or vagina
Investigate and treat the cause

Question 33

Polycystic Ovary Syndrome

Answer 33

Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met

Question 34

symptoms polycystic Ovary syndrome

Answer 34

Ultrasound appearance of ovary
Biochemical hyperandrogegism
Clinical hyperandrogegism
associated with infertility and obesity
Results in oligo menorrhea /amenorrhea

Question 35

PCOS management

Answer 35

management includes lifestyle adjustment with aim to achieve normal BMI
Symptom based treatment
At least 3 withdraws bleeds required per year to prevent hyperplasia
achieved with either COCP,POP, mirena IUS

Question 36

Dysfunctional Uterine bleeding

Answer 36

Dysfunctional uterine bleeding (DUB) is a common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases.
underlying pathophysiology is believed to be due to ovarian hormonal dysfunction
Exclude common causes PALM COEIN
Conservative /Medical Surgical treatment based on severity of symptoms and patient’s wishes
GnRh analogues could be good bridging for patients who are nearly menopausal and have not responded to or declined other medical treatment and surgical management not desirable. GnRH analogues work as ant estrogen and produce a pseudo menopause .
upto 6 month therapy. If further desired by patient and no contraindication, should be given add back HRT till patient confirmed menopausal.