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
when can endometrial ablation be considered for menorrhagia treatment?
where bleeding having significant impact on QOL and pt does not want to conceive in the future
and pt has a normal uterus or fibroids less than 3cm in diameter.
what is endometriosis?
chronic oestrogen dependent condition in which endometrial tissue present in areas outside of the endometrium of the uterus, most commonly in the pelvic cavity e.g. fallopian tubes and ovaries
also the uterosacral ligaments, pouch of douglas, rectosigmoid junction, ureters, bladder, lungs (pleura).
RFs for endometriosis?
- early menarche, late menopause, delayed childbearing, short menstrual cycles or long duration of menstrual flow.
- obstruction to vaginal outflow e.g. defects in uterus or fallopian tubes.
- genetic-1st degree relatives
common symptoms of endometriosis?
may be asymptomatic dysmenorrhoea, pain starting a few days before onset of menstruation cyclical or chronic pelvic pain dyspareunia subfertility
others: bloating, lethargy, constipation, low back pain, menorrhagia, diarrhoea, haematuria, cyclical PR bleeding.
may be cyclical bleeding at other extrapelvic sites e.g. epistaxis, haemoptysis.
causes of secondary dysmenorrhoea?
endometriosis adenomyosis fibroids PID IUD insertion psychosexual uterine anomalies haematometra-septal blockage between exocervix and vagina.
signs of endometriosis?
examination often normal
bimanual vaginal examiantion: may reveal posterior fornix tenderness and adnexal tenderness (appendages of uterus e.g. ovaries and FTs)
palpable nodules in posterior fornix or adnexal masses-ovarian endometriosis-chocolate cysts
bluish haemorrhagic nodules visible in posterior fornix
investigations for endometriosis?
gold standard=laparoscopy
transvaginal US-can diagnose or exclude ovarian endometrioma
MRI-subperiotneal depositis
CA-125
acute setting: FBC, U+Es, CRP pregnancy test beta-hCG urine dip endocervical and high vaginal swabs
treatment of infertility in endometriosis?
laparoscopic ablation of endometrioid lesions and adhesiolysis
IVF
complications of endometriosis?
subfertility and infertility
increased risk of ectopic pregnancy
adhesion formation with disease or following surgery
possibly increased risk of breast and other cancers, and AI and atopic disorders
association with clear-cell low grade serous and endometrioid invasive ovarian cancers
increased risk of IBD
non-surgical management of endometriosis?
analgesia-paracetamol, NSAIDs e.g. mefanamic acid-note in OD increased risk of seizures than other NSAIDs
local heat application and transcutaneous electrical nerve stimulation (TENS)
hormonal contraception-COC, progestogen only e.g. medroxyprogesterone acetate depot
GnRH analogues
surgical management of endometriosis?
laparoscopic surgery-laser ablation or excision of deposits, diathermy, ovarian cystectomy
radical surgery-total abdo hysterectomy and bilateral salpingo-oophrectomy
note relapse following surgery is common
initial investigations for amenorrhoea?
- urinary or serum beta hCG-rule out pregnancy
- TFTs-TSH
- gonadotropins-low levels indicate hypothalamic cause, high indicate premature ovarian failure-FSH,LH
- androgens-raised levels may be seen in PCOS, total testosterone
- prolactin
- oestradiol
causes of primary amenorrhoea?
- turner’s syndrome
- congenital adrenal hyperplasia
- congenital malformations of the genital tract e.g. vaginal septum, imperforate hymen
- testicular feminisation
causes of secondary amenorrhoea?
- pregnancy
- hypothalamic amenorrhoea-stress, excessive exercise, chronic systemic illness
- PCOS
- chemotherapy, pelvic irradiation
- premature ovarian failure
- hyperprolactinaemia
- sheehan’s syndrome
- thyrotoxicosis
- premature ovarian failure
- asherman’s syndrome (intrauterine adhesions)
- cervical stenosis
importance of GnRH agonist use prior to hysterectomy in treatment of fibroids?
reduce size of uterus and risk of post-op blood loss is directly related to the size of the uterus
causes of oligomenorrhoea, and irregular periods?
- lifestyle-stress, excessive exercise
- PCOS
- hyperthyroidism
- contraceptive pill, IUS
most common pathological causes of primary amenorrhoea with secondary sexual characteristics present?
gentio-urinary malformations: imperforate hymen transverse vaginal septum absent vagina absent uterus
most common physiological cause of primary amenorrhoea?
constitutional delay
physiological causes of secondary amenorrhoea?
pregnancy
lactation
menopause
what is asherman’s syndrome? how is it treated?
- this refers to the formation of adhesions within the uterus and/or the cervix. occurs when endometrial trauma triggers the normal wound-healing process, and the damaged areas fuse together.
- occurs most commonly after a dilation and curettage for retained placenta with/without bleeding after delivery, incomplete/missed miscarriage or an elective termination.
- diagnosis-hysteroscopy
- treatment-hysteroscopy-use of scissors to cut away adhesions. oestrogen may stimulate uterine healing.
what should be looked for on examination in case of primary amenorrhoea?
- features of Turner’s-short stature, webbed neck, low set ears, shield like chest with widely spaced nipples
- short stature, low body weight, small parents-constitutional delay
- hirsuitism, acne, obesity-PCOS
- signs of thyroid disease
- visual fields if pituitary tumour suspected (more so in secondary amenorrhoea)
- clitoromegaly-androgen secreting tumour, CAH
- galactorrhoea-prolactinoma
- haematocolpos-if hx of cyclical lower abdo pain-labia separation reveals a bulging blue-coloured membrane and a pelvic mass may be palpable
- features of androgen insensitivity-normal breast development, absence of axillary and pubic hair, tests may be palpable in inguinal regions.
initial investigations for primary amenorrhoea?
- pelvic USS-in place of pelvic examination in young girl not sexually active, or if presence of vagina and cervix cannot be confirmed on pelvic examination
- prolactin-wait at least 48hrs if done breast examination-can cause falsely elevated results
- TSH
- FSH and LH
- total testosterone if features of androgen excess
complications of amenorrhoea?
- osteoporosis
- CVD
- infertility
- psychological distress
