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MD3 Women's Health > Menstrual disorders > Flashcards

Menstrual disorders Flashcards

1
Q

What causes menstruation?

A

Progesterone withdrawl, in the presence of oestrogen primed endometrium

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2
Q

What symptoms is menstruation commonly associated with?

A

Mood changes, breast tenderness, libido changes, migraines

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3
Q

What is thought to cause 1’ dysmenorrhoea?

A

PG production→ increased uterine tone + contractions→ ischaemia→ stimulation of C-type pain fibres→ pain

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4
Q

What is PMS?

A

Physical, psychological or behavioural Sx occurring in luteal phase of menstrual cycle, where Sx resolve completely by cessation of menstruation, which impair daily activities in some way.

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5
Q

What is the incidence of dysmenorrhoea?

A

50-90%

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6
Q

What is the incidence of PMS?

A

30% (PMDD 5%)

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7
Q

What is the incidence of heavy menstrual bleeding (EMB)?

A

10% (more common in perimenopause)

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8
Q

What are the 3 main causes of HMB?

A

1) Local pathology/ anatomical causes- e.g. fibroids
2) Hormone dysfunction- e.g. anovulation
3) Medical conditions- e.g. bleeding disorder

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9
Q

What is the 1 thing you must do in PMB?

A

Rule out malignancy

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10
Q

What is 1’ dysmenorrhoea?

A

Development of recurrent crampy, lower abdominal pain at the time of menstruation, in the absence of organic pelvic disease.

Affects 50% of women between 15-24 years (peak incidence); severe in 15%

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11
Q

What are some causes of 2’ dysmenorrhoea?

A

2’ usually occurs later in life, related to organic pelvic disorders→

  1. Endometriosis
  2. Adenomyosis
  3. Chronic pelvic inflammation
  4. Acquired cervical stenosis
  5. Fibroids
  6. Polyps
  7. IUD
  8. NB: non- gynae pathology can also mimic menstrual pain
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12
Q

What are some features on Hx for dysmenorrhoea?

A
  1. Pain
    - Commonly bilateral, localised to lower abdo// back
    - +/- Radiation down inner and front aspects of thighs
    - Crampy pain
    - Usually worse on the first days of menstruation
  2. If severe:
    - Diarrhoea, N + V, fainting, headaches
  3. Usually occurs in most/ all cycles
  4. Should always see the impact on pt’s life
    - Limiting activity, missing school/ work
  5. Clinical exam→ usually unremarkable
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13
Q

Rx for dysmenorrhoea?

A
  • A) Medical (non-hormonal)
    o NSAIDs= first line
    • Inhibit PG synthesis and thus reduce uterine contractions + pressure
    • Start Rx BEFORE period occurs for better Sx control
    • Mefenamic acid slightly more effective than naproxen, ibuprofen
  • B) Medical (hormonal)
    o OCP= effective (+ offers contraception)
    o Works by thinning endometrium⇒ reduced arachadonic acid (precursor to PG→ so less PG)
    o Continuous use can provide better Sx control
    o P- only (POP, DMPA, Implanon, IUS)→ also effective→ thin endometrium
  • C) Surgery
    o If medical Rx fails after several months→ consider laparoscopy to exclude endo
  • D) Other Rx
    o Rest, relaxation, heat pack, general exercise can help
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14
Q

What is first line Rx for dysmenorrhoea?

A
  • NSAIDs- especially Mefenamic acid- blocks synthesis of PG and action of PG (reduced uterine contractions and pressure= reduced pain).
  • Start BEFORE period occurs for better Sx control
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15
Q

RFs for endometrial Ca

A
  1. Hx of chronic anovulation (PCOS)
  2. Exposure to unopposed oestrogen
  3. Exposure to Tamoxifen
  4. Lynch syndrome
  5. Nulliparity
  6. Obesity
  7. HTN
  8. DM
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16
Q

Anatomical causes of HMB

A

1) Fibroids
2) Adenomyosis
3) Copper IUD
4) Endometrial hyperplasia/ malignancy
5) Cervical abnormalities (polyps, dysplasia, malignancy)

17
Q

Medical causes of HMB

A

1) Hypothyroidism

2) Bleeding disorders→ haemophilia, vWb disease

18
Q

What can DUB be classified as?

A

Ovulatory and anovulatory (common in PCOS and perimenopausal years)

19
Q

What is the Rx for HMB?

A

1) Medical: non hormonal
a) Tranexamic acid→ antifibrinolytic → 1st line for HMB
• Reduced bleeding by 40-60%
• Does not help regulate bleeding
• Only taken on heaviest 3-4 days of cycle
• Safe even in women at high thrombotic risk
b) NSAIDs
• Reduce local PG→ may be of some benefit
c) Iron supplements
• For women who are deficient
• IDA may need 200mg PO iron/ day
• Can have significant SE→ explain and Mx to ensure compliance
• Blood transfusion may be needed when Sx anaemia

2) Medical: hormonal
a) Oral progesterone (norethisterone)
• Effective Rx to reduce bleeding→ creates thin endometrium
• Can be used immediately in emergency situation to reduce bleeding or used in long-term Rx
• P may be used in a short cyclic (10 days/ month during luteal phase) or long cyclic (days 5-26)
• Continuous use of P⇒ irregular bleeding almost always
• Most women don’t want to be on oral P long-term bc of SE: mood, bloating, irregular bleeding
b) DMPA or implant
• Can also help improve HMB + less irregular bleeding
c) IUS
• 20mcg of Levonorgestrel daily for 5 years= HIGHLY effective in Rx of DUB
• May be less effective in those with anovulatory DUB c.f. ovulatory
d) COCP
• Thins endometrium→ reduced bleeding
• Because of oestrogen→ not suitable for women in their 40’s (especially if RFs for thrombosis/ CVD)
e) Danazol
• Very good for HBM but potential androgenic SE (some irreversible)
• Limited use
f) GnRH agonists (goserelin)
• Effective in reducing loss but needs add-back HRT

3) Surgical
a) Endometrial ablation
• Not compatible with desire for future pregnancy + effective contraception must be used (bc increased risk of ectopics)
b) Diathermy
c) Thermal balloon
d) Hysterectomy
• When none of the above Rx worked + no desire to preserve fertility

20
Q

What is the treatment for special cases of HMB (organic disorder, fibroids)?

A

1) Organic disorder
• Rx the cause
• Endometrial polyps → surgical removal (operative hysteroscopy)

2) Fibroids
• Surgical Rx→ hysteroscopic resection (submucosal), myomectomy (large, intramural) or hysterectomy (multiple fibroids, no longer desire for ongoing fertility)
• Interventional radiology→ Embolisation and MRI-guided focused US→ cause fibroid necrosis

21
Q

What are some Ex you would like to do for HMB?

A

o External inspection→ vulva, vagina and cervix

o Pap smear + swabs

22
Q

What are some Ix you would like to do for HMB?

A
  • Bloods
    o FBE→ establish presence of anaemia, and measure platelet count
    o Iron studies
    o TFTs→ because hypothyroidism can be missed from Hx and Ex
    o If ?bleeding disorder→ coagulation profile, clotting factors and vWF measurements
    o Other tests→ depend on Hx and Ex
    • E.g. full hormone profile in woman with Hx suggesting PCOS
  • Imaging
    o Pelvic US routinely used to detect uterine anatomical abnormalities→ fibroids, polyps + measure endometrial thickness
  • Biopsy
    o Outpatient endometrial biopsy= high accuracy in Dx endo Ca and hyperplasia
    • Use when serious endo disease suspected
    • Indicated if pts have endo thickness between 4-12mm
  • Hysteroscopy
    o Accompanied by endo sampling
    o Useful in excluding endo Ca with thickened endo
23
Q

What are some features on Hx for HMB?

A 
o	Severity
•	Duration of maximal bleeding
•	Clots passed?
•	How often pads/ tampons changed
•	Effect of bleeding on life

o Associated features
• Pain
• Dyspareunia
• Sx of anaemia

o Exclude pregnancy

o Exclude endocrine causes
• Hypothyroidism

o Exclude haem causes

24
Q

In anovulatory DUB, what happens?

A

In anovulatory- high oestrogen unopposed by P→ thickened endometrium→ outgrows blood supply→ necrosis + partial shedding→ irregular bleeding

MD3 Women's Health (3 decks)

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