Menstrual disorders Flashcards
NICE recommended 1st choice treatment for menorrhagia?
IUD-levonorgestrel releasing intrauterine system (LNG-IUS) (Mirena)
as long as long term contraception is acceptable to the patient (anticipated minimum use of 1 year)
what questions in the history can be asked to quantify menstrual blood loss?
does the patient have to wear both pads and tampons? how many changes do they need during the day?
do they pass clots?
is there flooding onto clothes and bed sheets?
impact on daily life? e.g. days taken off work to cope?
differentials for menorrhagia?
dysfunctional uterine bleeding (DUB) von willebrand's disease-most common inherited coagulopathy, lack/abnormal function of vWF necessary for PLT plugging and to stop factor VIII from being cleared from the plasma. ask about easy bruising or bleeding gums. fibroids hypothyroidism endometrial polyps (adenomas) endometriosis, adenomyosis endometritis and PID endometrial cancer IUCD
1st line diagnostic tool for detecting structural abnormalities in patients with menorrhagia?
transvaginal ultrasound scan
when is a transvaginal ultrasound indicated in patients with menorrhagia?
1st line for structural abnormality e.g. fibroids diagnosis, should image if palpable uterus abdominally, vaginal examination reveals a pelvic mass of uncertain origin or if treatment failure.
advantages of the LNG-IUS?
- more effective than oral treatment, results in more reduction in bleeding and more improvement in QOL, more acceptable long term. 96% effectiveness.
- avoids complications of major surgery e.g. major bleeding, infection and VTE.
disadvantages if the LNG-IUS?
- less effective than a hysterectomy
- more minor adverse effects than oral treatment
- irregular bleeding and spotting within the 1st 6 mnths
- desired effects may not be achieved until 6 mnths, need to persevere through 6 cycles to see the benefits
- hormonal symptoms e.g. headaches, acne, breast tenderness, nausea
- 5% risk of EP if woman becomes pregnant
- contraceptive, and should be used LT (at least 1 year) so unsuitable if woman wants to become pregnant in the near future
- risk of PID
- risk of perforation with insertion
- risk of lost coil threads
hormonal treatments for menorrhagia?
- LNG-IUS=1st line when no structural or histological abnormality present, or fibroids less than 3cm causing no distortion of the uterine cavity, and LT use is anticipated and woman doesn’t want to get pregnant in near future.
- COCP-can reduce menstrual blood loss by up to 50%. makes periods lighter, can relieve dysmenorrhoea, make cycles more regular, improve premenstrual symptoms, reduce risk of PID and protect ovaries and endometrium from cancer.
- progestogens e.g. norethisterone 5mg TDS from day 5 to 26, and injected long acting progestogens. less effective than other medical options and less acceptable to patients.
- GnRH analogues-can be used before surgery to shrink fibroids or when all other treatments for fibroids are CI. if use for more than 6mnths will require add back therapy (HRT).
non-hormonal medical management of menorrhagia?
- tranexamic acid-can reduce menstrual blood loss by up to 50% but associated with more side effects than mefenamic acid e.g. N+V, diarrhoea, and thrombosis in predisposed individuals. is taken for up to the 1st 5 days of the cycle.
- mefenamic acid (NSAID)-can reduce menstrual blood loss by around 25%. Preferred if also dysmenorrhoea.
often used in combination
stop if has not improved symptoms after 3 menstrual cycles
surgical management option for menorrhagia?
endometrial ablation e.g. novasure-radiofrequency ablation
uterine artery embolisation
myomectomy
hysterectomy
contraindications to endometrial ablation?
large fibroids
suspected malignancy
woman not completed her family
indications for a hysterectomy for menorrhagia?
other treatment options have failed, are CI or have been declined
desire for amenorrhoea
woman is fully informed and requests it
no desire to retain uterus and fertility
complications of a hysterectomy?
long recovery time intraoperative haemorrhage infection VTE ureteric damage bladder or bowel damage, overactive bladder, incontinence menopause despite retaining the ovaries
treatment of fibroids which are 3cm or more in diameter?
- ulipristal acetate 5mg (up to 4 courses) in menorrhagia plus Hb less than 102g/L. Consider in those with Hb above this.
- GnRH analogues-can be used for 3-4mnths before surgery if fibroids causing an enlarged or distorted uterus, or if all other tment options e.g. surgery and uterine artery embolisation, are CI.
- uterine artery embolisation (UAE), myomectomy or hysterectomy should be considered if fibroids causing significant impact on QOL. consider UAE and myomectomy can allow fertility to be retained. hysterectomy for fibroids assoc. with increased risk of IO haemorrhage and organ damage. hysterectomy can be abdo-open or lap, or vaginal, and if abdo can be total or subtotal (cervix preserved).
in addition to US, what other investigation may be required before UAE or myomectomy for large fibroids to assess their number, size, position and vascularity?
MRI
