Menstrual Disorders Flashcards
What is normal menstruation?
Age 13-51 from monarch-menopause
Cycle 4-5/21-35
4-5 days bleeding
21-35 cycle length, time from start of one period to start of the next
Menstruation is triggered by a fall in progesterone 2 weeks after ovulation if not pregnant
Mean blood loss 30-40ml
What is menorrhagia?
Heavy periods - > 80ml per cycle
What is dysmenorrhoea?
Painful periods
What is intermenstrual bleeding?
Bleeding between periods
What is postcoital bleeding?
Bleeding after sexual intercourse
What is oligomenorrhoea?
Infrequent periods e.g. 45-90
What percentage of gynaecology outpatient referrals are accounted for by menstrual abnormality?
20%
What percentage of women see their GP with menstrual problems in any year?
3% of women aged 30-49
What are the important features of history in a woman with a menstrual problem?
Subjective - what is normal for that woman
Clots/flooding - pads and tampons used together, will give an idea of how “heavy”
Pain - with heavy flow or premenstrual, premenstrual may be endometriosis
Ask about effect of symptoms on lifestyle/quality of life
What are the appropriate examinations to do for a woman with menstrual problems?
General e.g. anaemic
Abdominal - large fibroids
Speculum - polyps
Bimanual pelvic - size of uterus, adnexal masses
What are the investigations that you might do for a woman with menstrual problems?
FBC if menorrhagia Endometrial biopsy Chlamydia test Thyroid/coagulation if other symptoms Pregnancy test Transvaginal US scan Hysteroscopy Laparoscopy
What are the likely causes of menstrual problems in early teens?
Anovulatory cycle
Congenital anomaly
Coagulation problems
Always consider pregnancy and always look at cervix
What are the likely causes of menstrual problems in teens-40s?
Chlamydia Contraception-related Endometriosis/adenomyosis Fibroids Endometrial or cervical polyps Dysfunctional bleeding
Always consider pregnancy and always look at cervix
What are the likely causes of menstrual problems in 40s-menopause?
Perimenopausal anovulation Endometrial cancer (rare in premenopausal women) Warfarin Thyroid dysfunction Chlamydia Contraception-related Endometriosis/adenomyosis Fibroids Endometrial or cervical polyps Dysfunctional bleeding
Always consider pregnancy and always look at cervix
According to the FIGO classification, what are the causes of abnormal uterine bleeding?
Palm Coe In
P - polyp A - adenomyosis L - leiomyoma M - malignancy C - coagulation e.g. Von Willebrand's O - ovarian e.g. PCO, perimenopausal anovulatory cycles E - endocrine e.g. thyroid I - iatrogenic e.g. warfarin N - not yet classified
What is dysfunctional uterine bleeding?
Abnormal uterine bleeding but no structural, endocrine, neoplastic or infectious cause found (yet)
What percentage of women who complain of heavy periods lose < 80ml per cycle?
50%
What percentage of hysterectomies are done for dysfunctional uterine bleeding?
50%
What is endometriosis?
Endometrial type tissue outside the uterine cavity
Usually in ovary, pouch of Douglas or pelvic peritoneum
May be asymptomatic
May resolve without treatment
What kind of bleeding can endometriosis cause?
Retrograde bleed
What are the symptoms of endometriosis?
Premenstrual pain, particularly 1 week before period starts
Dysmenorrhoea
Deep dyspareunia
Sub-fertility
What are the signs of endometriosis?
May be none
Tender nodules in rectovaginal septum
Limited uterine mobility
Adnexal mass
What are the investigations done to diagnose endometriosis?
Laparoscopy
MRI
USS endometrioma
What is the medical treatment of endometriosis?
Progestogen - oral, injection or Mirena IUS, coil will have fewer general side-effects
Combined pill or patch for 3 months (9 weeks) at a time
GnRH analogues e.g. leuprorelin
What is the surgical treatment of endometriosis?
Laparoscopic excision of deposits from peritoneum/ovary
Diathermy/laser ablation of deposits
Hysterectomy alone won’t treat endometriosis as ovaries are still there producing hormones, so combined hysterectomy and oophorectomy
What is adenomyosis?
Endometrial tissue found deep in the myometrium
Heavy painful periods
Bulky tender uterus
How is adenomyosis diagnoses?
USS - probably normal
Laparoscopy - normal
Hysteroscopy - normal
MRI may suggest diagnosis but limited availability
Histology of uterine muscle - not endometrial biopsy
What is the treatment of adenomyosis?
Mirena may help
Often failed medical treatment/ablation and diagnosed on pathology at hysterectomy
What are fibroids?
Smooth muscle benign tumours - leiomyoma
Benign
Common, usually asymptomatic
What percentage of fibroids are leiomyosarcoma?
0.01%
What percentage of 40 year olds have fibroids?
60%
In what ethnic group is there a higher incidence/younger age of fibroids?
Afro-Caribbean women
How are fibroids diagnosed?
Clinical exam
Ultrasound
Hysterectomy
What are the types of fibroid?
Submucous - protrude into uterine cavity
Intramural - within uterine wall
Subserous - project out of uterus into peritoneal cavity
What are the symptoms of fibroids?
May cause pressure symptoms if large
May cause menorrhagia if they cause enlargement of uterine cavity surface area
Intermenstrual bleeding if submucous or polyp
Asymptomatic
May grow fast in pregnancy and cause pain, malpresentation and obstruction
What is the treatment of fibroids?
No treatment if incidental finding and asymptomatic
Standard menorrhagia treatment if cavity is not too distorted
GnRH analogues for temporary shrinkage/preparation
Ulipristal oral treatment (antiprogestogen)
Transcervical resection of submucous fibroids
Myomectomy
Uterine artery embolisation
Hysterectomy
What are the disadvantages of myomectomy?
Risk of haemorrhage and hysterectomy
Need Caesarean section if pregnancy occurs after due to risk of uterine rupture
What is the treatment for dysfunctional uterine bleeding?
Reassure patients that there is no sinister pathology
Fertility-conserving treatment - non-hormonal or hormonal tablets, progestogen, IUD, Mirena
Endometrial ablation or hysterectomy if family is complete
What are the fertility conserving treatments?
Tranexamic acid - reduces blood loss by 60% but does not regulate cycle (anti-fibrinolytic)
Mefenamic acid - reduces blood loss by 30% and pain but does not regulate cycle (prostaglandin inhibitor)
Combined contraception reduces bleeding, pain and regulates cycle
Mirena progestogen IUD reduces bleeding (initial 3-4 months irregular bleeding)
Oral progestogens e.g. Provera 10mg od, day 5-25 of cycle, reduces bleeding and regulates, day 15-25 may regulate cycle but does not reduce amount of bleeding
What is endometrial ablation?
One-off removal of endometrium to below the basal layer
Can use diathermy/thermal balloon
Not possible if grossly distorted cavity or thin myometrium at CS scar
Treatment done through cervix
What is the recovery time from endometrial ablation?
approx 1 week
What is the effect of endometrial ablation on ovarian hormones and bladder?
No effect
What percentage of women following endometrial ablation;
- have no periods
- are satisfied with treatment
- go on to have hysterectomy?
60% have no periods
85% satisfied
15% go on to have hysterectomy
What is hysterectomy?
Surgical removal of uterus
What are the routes for hysterectomy?
Vaginal or abdominal
What are the types of surgical procedures that can be done when performing hysterectomy?
Laparoscopically assisted vaginal hysterectomy
Total laparoscopic hysterectomy
Laparoscopically assisted subtotal hysterectomy
What is a total hysterectomy?
Cervix and uterus removed
What is a subtotal hysterectomy?
Uterus removed, cervix left
What is a salpingo-oophorectomy?
Removal of Fallopian tubes and ovaries
What do you need to do if ovaries are removed?
Immediate menopause - need to give HRT until age 50 to minimise risk of subsequent cancer
What symptoms will persist if the ovaries are not removed?
Pre-menstrual symptoms and ovarian pain
How many days are spent in hospital after open or vaginal hysterectomy?
3-5
How many days are spent in hospital after laparoscopic hysterectomy?
2-3
What is the recovery time from hysterectomy?
2-3 months full recovery
What are the risks of hysterectomy?
Infection
DVT
Bladder/bowel/vessel injury
Altered bladder function and adhesions
