Menstrual disorders Flashcards
describe normal menstruation
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
how can heavy menstrual bleeding present
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
uterine and ovarian pathologies that can cause heavy bleeding
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).
systemic diseases and disorders that can cause heavy bleeding
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.
iatrogenic causes of heavy bleeding
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).
PALM COEIN
causes of heavy bleeding
polyp
adenomyosis
leiomyoma
malignancy
coagulopathy
ovulation dysfunction
endometrium/hyperplasia
iatrogenic
not yet classified
what are fibroids
Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma
what is the typical presentation of fibroids
May be asymptomatic
can cause HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage
how are fibroids diagnosed
US
how is fibroids managed
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
what is endometriosis
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.
what is the typical presentation of endometriosis
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 .
four stages endometriosis
1 - minimal
2 - mild (infiltration pelvic organs)
3 - moderate (peritoneum/pelvic side walls)
4 - severe (infiltrative affect pelvic organs and ovaries
diagnosis of endometriosis
Pelvic examination
Ultrasound scan, Diagnostic laparoscopy
how is endometriosis managed
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.
what is adenomyosis
A condition where endometrium becomes embedded in myometrium .
Heavy menstrual bleed.
May have significant dysmenorrhea.
how is adenomyosis treated
May respond to hormones partially
Definitive treatment is hysterectomy
what are endometrial polyps
Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium
mostly benign.
how is endometrial polyps diagnosed
Diagnosis by Ultrasound or hysteroscopy
management for endometrial polyps
polypectomy
Management of Heavy menstrual bleeding
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.
if a patients wants treatment what hormonal and non hormonal methods are offered
hormonal
- mirena
- COCP
- depot provera
non hormonal
- mefenamic acid
- tronexemic acid
- gnrh analogues
- endometrial ablation
- fibroid embolisation
- hysterectomy
Tranexamic aci
(antifibrinolytic) reduces blood loss 60%
Mefenamic acid
(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
LNG IUS and Depo-Provera
reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
Oral progestogens
eg Provera10mg od
day 5-25 cycle reduce bleeding +regulate
day 15-25 may regulate cycle but does not reduce amount of bleeding
Endometrial ablation
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
Hysterectomy
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
risks hysterectomy
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
Removal of ovaries with uterus
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
Oligo/amennorhea
Infrequent, absent or abnormally light menstruation
Important to check if its normal to a person
causes amennorhea
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
Polycystic Ovary Syndrome
Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met
symptoms polycystic Ovary syndrome
Ultrasound appearance of ovary
Biochemical hyperandrogegism
Clinical hyperandrogegism
associated with infertility and obesity
Results in oligo menorrhea /amenorrhea
PCOS management
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
Dysfunctional Uterine bleeding
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.
