Menstrual disorders Flashcards
Define menorrhagia
> 80ml menstrual loss/period
Etiology (3 categories and most common)
- Systemic
- >Thyroid
- >Coagulopathies
- >PCOS - Local
- >Fibroids
- >PID
- >Endometrial Ca
- >Endometriosis/adenomyosis
- >DUB
- >Endometrial polyps, endometritis
- >Miscarriage - Iatrogenic
- >IUCD
- >Iron deficiency anaemia
- >anticoagulants
Most commonly:
- > PCOS
- > Fibroids
- > Miscarriage
- > Endometritis
- > PID
- > DUB
- > Polyp
Important history in menorrhagia
Gynaecological history->LMP, menarche, cycle length/regularity, heaviness, pap smear, surgical/procedural Obstetric history Frequency, inter-menstrual/post coital Clots, floodigs, ++double sanitary protection Lethargy, breathless Sexual history Contraceptive use Menstural pain Dysmenorrhea Premenstural pain (endoM) Hx PCOS + risk of endoM Ca Thyroid symptoms, clotting Missed periods, hot flushes
Possible explanation to woman who has had tubal ligation, prior was on OCP and now has heavy periods
OCP reduces menstrual loss so may have been hiding her menorrhagia.
Many women blame tubal ligation for heavy periods
Is D&C therapeutic
No, it is a diagnostic procedure
Physical examination in menorrhagia
General-> including vitals Thyroid- obese, dry skin, breathless, edema, goiter, Anemia, PCOS, Stigmata of liver disease/coagulopathy Abdominal Vaginal/bimanual/pap smear if overdue Visual fields
Investigations in menorrhagia
FBC
Iron studies
Depending on presentation->
LFTs, coagulation
TSH
Prolactin
Gonorrhea/chlamydia
VWF, Factor 7/8 deficiency->important to exclude in the young patients
Pelvic USS/Hysteroscopy/Biopsy in older and younger w/ risk factors (InterM/post-coital bleeding)
Management overview for menorrhagia
- Correct anemia
- Treat systemic disorders or focal pathology
- Attempt control by medical therapy
- If fails consider->ablation, hysterectomy
Medical management of menorrhagia
- Tranexamic acid (80% reduction, taken on heavy bleeding days) + mefenamic acid (50% reduction, commence 5-7 days before menstruation)
- COCP, Mirena (most effective, 95% reduction in blood loss), long acting progestogens
- Danazol
- GnRH agonist
Surgical options for menorrhagia
- Endometrial ablation-> 50% amenorrheic, 40% reduced, 10% unchanged. For mid-late 40s
- Hysterectomy
Role of GnRH agonists in menorrhagia
produce reversible, temporary menopausal. Preoperative state= corrects iron deficiency, -ve size of fibroids, -ve surgical blood loss
Side effects and mechanism of mirena
5 years
Low dose progestogen
Thins endometrium
94% reduction MBL after 3 month
SE:
PV spotting, weight gain, breast tenderness,
expulsion of devices, increased ovarian cysts
formation
Following up patient with menorrhagia
2 weeks->review results
Remind to have routine pap smear
If iron deficient->oral iron supplements until heavy bleeding controlled
Review again in 3 months unless problems
Requirements for normal menstruation
Hypothalmic function Pituitary function Ovarian function Endometrial function Patent cervix and vagina
Etiology of dysfunctional uterine bleeding
Anovulatory cycles-> Functional ovarian tumor PCOS Obesity Malnutrition Systemic illness Thyroid Adrenal
Other->
OCP
Post/perimenopausal changes
Mechanism of DUB
+estrogen proliferation w/o progesterone countering effect
inadequate luteal phase->low progesterone, early menses
Pathophysiology of amenorrhea in hypothyroidism
+TRH–> +prolactin=
inhibition of LH/FSH=
anovulation
also +SHBG,
+Testosterone
-ve clearance of estrogen
Is a vaginal examination performed on a virgin
No- an abdominal examination is all that is required
Managing menorrhagia in adolescent patient
- Iron-folate supplementation 2-3 months
- 50ug ethynyl estradiol COCP->be sure to check BP, ask about migraines with aura, history of VE/family
- Pill has other roles other than contraception
- Initial SE of N, headache- will generally resolve with continued use
- Must take every day, same time, pissed pill will lead to breakthrough bleeding
- Also helpful with menstrual pain, can add mefenamic acid/NSAIDs
- Other alternative is tranexamic acid, but OCP is easiest. Takes 2-3 cycles to judge effectiveness
- Review in 3 months. Can continue on the pill until want to have a baby. When becomes sexual active should return to understand contraceptive effects
Define primary and secondary dysmenorrhea
Primary->not associated with pelvic patholgy
Secondary->due to pelvic pathology
Presentation of primary dysmenorrhea
6-12 months post menarche
Lower abdominal, cramping, ay radiate to back/inner thigh
8-72 hours
Can be associated with nausea, vomiting, diarrhea, fatigue and headache
Usually subsides once menses commences
Presentation of secondary dysmenorrhea
Years after menstruation, new complaint in 30s and 40s.
Not always with menstruation alone
May worsen as menses progresses
May be accompanied by irregular heavy bleeding, discharge and dysparaneuria
Etiology of secondary dysmenorrhea
Endometriosis Chronic PID Polyps Fibroids IUCD
Congenital uterine abnormalities
Cervical stenosis
Ovarian pathology
History in dysmenorrhea
Age of menarche
Onset
Characetristics
Timing/duration
Associated->fatigue, irritability, dizziness, HA, MV
Exacerbating/relieving->secondary more commonly resistant to NSAIDs
Severity, interference with daily activity
Menstrual history
Post-coital, intermenstrual, vaginal discharge
Sexual history
Obstetric history
Medical, family, social
Examination in dysmenorrhea
General inspection Abdominal Pelvic Speculum Bimanual
Not necessary in young when most likely primary
Investigations in dysmenorrhea
Primary->nil required TVUS Chlamydia/gonorrhea swabs/serology FBC Pregnancy test Laparoscopy->PID, endometriosus, adhesions Ca-125 if ovarian mass MRI/CT if USS equivocal Hysteroscopy Pipelle biopsy
Red flags in dysmenorrhea
PID
Ovarian cyst with hemorrhage
Ovarian torsion
Management of primary dysmenorrhea
- Reduce risk->smoking cessation, reduce alcohol, maintain healthy weight
- Ensure not to see menstruation in negative light
- NSAIDs->naproxen, mefenamic acid or ibuprofen: start day before menses, continue for 48-72 hours
- COCP->ethinylestradiol30ug COCP
- Heat packs
Pathogenesis of primary dysmenorrhea
Prostaglandins released by endometrial cells at the start of menstruation cause vasoconstriction, muscle contraction and compression of the spiral arteries, leading to myometrial ischaemia. The severity of primary dysmenorrhoea is directly related to the prostaglandin concentration in the menstrual fluid.
Dosing of NSAID in primary dysmenorrhea
Ibuprofen->200-400mg PO 3-4 times daily. Max 1600g
Mefenamic acid 500mg tds
Naproxen 500mg PO initial, then 250mg every 6-8 hours
Risk factors for primary dysmenorrhea
Early menarche Prolonged menstrual flow Smoking Alcohol Obesity
