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Obstetrics & Gynaecology > Menstrual disorders > Flashcards

Menstrual disorders Flashcards

1
Q

What are the possible locations of endometrial foci?

A
  1. Ovary
  2. Rectovaginal pouch
  3. Rectum
  4. Uterosacral ligaments
  5. Umbilicus
  6. Bladder
  7. Vagina
  8. Lower abdominal scars
  9. Lungs
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2
Q

How does endometriosis bring about pain?

A

Foci bleed during menstruation, the blood causing irritation, provoking fibrosis, adhesions and subfertility

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3
Q

What are the possible causes of endometriosis?

A
  1. Retrograde menstruation
  2. Genetics
  3. Manual removal of the placenta/failure of proper CCT
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4
Q

Cycles of what length are considered ‘normal’?

A

25-35 days

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5
Q

A normal length of menstruation would be:

A

<8 days

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6
Q

How may an irregular period be defined?

A

Too frequent, or infrequent (less or more than 25-35 days) or of variable length

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7
Q

What are irregular and inter-menstrual bleeding caused by in the absence of pathology?

A

Anovulatory cycles. Treated with COCP or IUS

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8
Q

What are the possible causes of PCB?

A

Vagina causes = vaginitis; carcinoma

Cervical causes = carcinoma; cervicitis; trauma; ectropion; polyps

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9
Q

How is HMB technically defined?

A

> 80ml blood loss per period (i.e. the max a woman can tolerate w/out becoming iron-deficient anaemic)

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10
Q

How should HMB actually be assessed in clinic? (i.e. don’t use the technical definition because menstrual blood loss is rarely measured)

A

Subjectively, based on how the HMB affects her QoL

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11
Q

What proportion of hysterectomies do HMB account for?

A

> 50%

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12
Q

What are the vaginal causes of PCB?

A

Vaginitis and carcinoma

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13
Q

What are the cervical causes of PCB?

A

Carcinoma, cervicitis, trauma, ectropion, polypos

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14
Q

What are the causes of HMB?

A

Systemic causes = hypothyroidism + platelet disorders, e.g. von Willebrand’s

Pelvic causes =

1) Fibroids (30%)
2) Polyps (10%)
3) Endometriosis
4) Adenomyosis
5) Pregnancy/incomplete miscarriage (esp. in young girls and when they present with only one episode)
6) Endometrial cancer

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15
Q

What are the systemic causes of HMB?

A

Hypothyroidism + platelet disorders, e.g. von Willebrand’s

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16
Q

What are the pelvic causes of HMB?

A

1) Fibroids (30%)
2) Polyps (10%)
3) Endometriosis
4) Adenomyosis
5) Pregnancy/incomplete miscarriage (esp. in young girls and when they present with only one episode)
6) Endometrial cancer

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17
Q

When is an endometrial biopsy indicated in HMB?

A

1) Endometrial thickness >10mm (on TVUS)
2) Polyp suspected
3) >40 with recent onset menorrhagia
4) >40 + IMB
5) Not responded to treatment

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18
Q

What is the management for women with HMB who are TRYING TO CONCEIVE?

A

Tranexamic acid + NSAIDs

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19
Q

How does tranexamic acid work?

A

An anti-fibrinolytic, taken during menstruation only, it reduces fibrinolytic activity and can reduce blood loss by >50%

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20
Q

What is the management for women with HMB who are NOT trying to conceive?

A

1st = Progestogen IUS (will both reduce volume loss and regulate the loss)
2nd = Tranexamic acid + NSAIDs / COCP
3rd =Progestogens (high OS dose or IM) / GnRH analogs +/- ‘add-back’ HRT
4th = hysteroscopy (endometrial ablation) /hysterectomy

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21
Q

How may endometriosis present?

A

1) Deep dyspareunia
2) Dysmenorrhoea
3) HMB
4) Asymptomatic - first presentation might be the acute pain of a ruptured chocolate cyst
5) Subfertility
6) Chronic pelvic pain
7) Dysuria at menses
8) Dychezia at menses

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22
Q

How may endometriosis appear on laparoscopy?

A

1) Red dots
2) Black ‘powder-burn’
3) White scarring

Black powder-burn and white scarring indicate less active lesions

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23
Q

What is adenomyosis?

A

Presence of endometrium within the myometrium

24
Q

In whom are fibroids more common?

A

1) Older women
2) Those with a FHx
3) Afro-Carribbean women

25
Q

What are the different classification of fibroids based on site?

A

1) Intramural
2) Subserosal
3) Submucosal
4) Cervical

26
Q

What drives fibroid growth?

A

Oestrogen + progesterone (hence repression post-menopause)

27
Q

How may fibroids present?

A

1) Asymptomatic
2) Menorrhagia
3) Dysmenorrhoea
4) IMB
5) PCB
6) Pain (torsion/red degeneration)
7) Subfertility

28
Q

What type of fibroid might cause IMB?

A

Submucosal

29
Q

When might fibroids cause pain?

A

1) Torsion of pedunculate fibroids
2) Red degeneration - that is degeneration of the fibroid due to inadequate blood supply that then causes haemorrhage and necrosis resulting in pain and uterine tenderness

30
Q

How should fibroids be investigated?

A

USS, laparoscopy or MRI if difficulty in distinguishing them from an ovarian mass or adenomyosis + a FBC

31
Q

What is fibromatous erythrocytosis syndrome?

A

When fibroids secrete EPO (only occurs in some instances), and this causes polycythaemia

32
Q

What are the complications of fibroids?

A

1) Calcification post-menopause
2) Torsion
3) Red degeneration
4) Malignant transformation

33
Q

What proportion of fibroids malignantly transform?

A

0.1% will transform into leiomyosarcoma

34
Q

How can fibroids be managed medically?

A

GnRH agonists - e.g. goserelin. Shrinks the fibroid

35
Q

How can fibroids be managed surgically?

A
  1. Hysteroscopic resection
  2. Hysteroscopic/open myomectomy (if fertility desired)
  3. Uterine artery embolization (UAE)
  4. Microwave endometrial ablation (MEA)
  5. Hysterectomy
36
Q

What should be given with the GnRH agonists for the medical management of fibroids?

A

Tibolone (HRT) or raloxifene (SERM), because bone demineralisation can occur

37
Q

How long can fibroid be medically managed for?

A

6-12 months. Therefore, only tend to be used in women whom are peri-/near-menopausal, for pre-op debulk or in those unfit for surgery since upon stopping the medication, the fibroids return

38
Q

What is primary dysmenorrhoea?

A

Pain during menstruation in the absence of pathology. Therefore tends to be seen in women where the pain begins soon after the onset of menarche, i.e. in adolescence

39
Q

What is secondary dysmenorrhoea?

A

Pain during menstruation due to pelvic pathology. Therefore tends to be seen in women whom have previously had years of painful periods

40
Q

What are the Sx associated with primary dysmenorrhoea?

A

Non-gynaecological - e.g. N+V, bloating, migraine

41
Q

What are the Sx associated with secondary dysmenorrhoea?

A

Gynaecological - e.g. dyspareunia, IMB, HMB

42
Q

What causes should be considered for secondary dysmenorrhoea?

A

1) Fibroids
2) Endometriosis
3) PID
4) Adenomyosis

43
Q

What is primary amenorrhoea?

A

Menstruation that has not occurred by age 16
If secondary sexual characteristics have not developed by age 14, cause = likely delayed puberty, but if secondary sexual characteristics have developed cause might be imperforate hymen, transverse vaginal septum, absent vagina or absent/non-functional uterus

44
Q

What is secondary amenorrhoea?

A

When previously normal menstruation ceases for >6/12

45
Q

What is oligoamenorrhoea?

A

Menstruation every 35 days to 6 months

46
Q

What are the causes of secondary amenorrhoea?

A

Non-pathologcial = 1) Pregnancy; 2) Lactation; 3) Menopause; 4) Drugs

Pathological = 1) Anorexia; 2) Hyperprolactinaemia; 3) Hypo/hyperthyroidism; 4) Adrenal tumours; 5) PCSO; 6) Premature ovarian failure; 7) Asherman’s syndrome; 8) Cervical stenosis

47
Q

What investigations should be carried out to investigate amenorrhoea?

A 
Prolactin
TFTs
FSH
Androgens
USS
Pregnancy test
48
Q

What are the diagnostic criteria of PCOS?

A

2 or more of:

1) Polycystic morphology on USS - multiple (>12), small (2-8mm) follicles in an enlarged ovary (>10ml volume)
2) Irregular periods >5 weeks part
3) Hirsutism

49
Q

What are the reasons a person may be referred for hysteroscopy?

A
  1. PMB
  2. Bleeding on tamoxifen
  3. Unscheduled bleeding on HRT
  4. IMB
  5. HMB
  6. Subfertility and recurrent miscarriage
  7. Insertion/removal of coils + lost coils
  8. Assessment/resection of known polyps/fibroids
  9. Thickened endometrium
  10. Sterilisation
  11. Division of adhesions
50
Q

What are the benefits of flexible hysteroscopy?

A

1) Reduced pain

51
Q

What are the benefits of rigid hysteroscopy?

A

1) Shorter procedure time
2) Better quality images
3) Cheaper
4) Fewer failure procedures

52
Q

What are the risks of hysteroscopy?

A
  1. Bleeding
  2. Fainting
  3. N&V (cervical irritation)
  4. Uterine/cervical trauma (uterine perforation rate = 0.002-1.7%)
53
Q

How should the cervix be prepared for hysteroscopy?

A

LA may be used - although it does not appear to reduce the pain associated with the procedure, it does appear to reduce the risk of vasovagal episodes (+ used to ‘soften’ the cervix’). Alternative cervical softeners (prostaglandins) may be used, but you didn’t see that in clinic, even those with very resistant, stenosed cervices

54
Q

What is the most common cause of procedural failure in hysteroscopy?

A

Cervical stenosis

55
Q

What are the common causes of cervical stenosis?

A

1) Atrophy
2) Null-parity
3) Prior surgery

56
Q

Whom is most likely to be affected by cervical stenosis?

A

Post-menopausal women

57
Q

How should the uterus be distended in hysteroscopy?

A

Normal saline (rather than carbon dioxide) - 1) it appears to reduce the risk of vasovagal episodes, 2) the procedure time is quicker and 3) the images are of better quality

Obstetrics & Gynaecology (14 decks)

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