Menstrual Disorders Flashcards
First of all define Menorrhagia, Dysmenorrhoea, oligomenorrhoea, IMB & PCB?
Menorrhagia = Heavy periods, technically >80ml but its subjective Dysmenorrhoea = painful periods Oligomenorrhoea = Irregular periods IMB = Intermenstrual bleeding PCB = Post-coital bleeding
What questions might you ask when a patient complains of heavy or painful periods?
Are they clots & how large?
Do you use tampons or pads or both?
What type do you use and how often do you change them?
Do you ever flood (aka bleed through clothes)?#
QOL questions like does it affect your work, hobbies or ability to go out in public?
Age is a good way of narrowing down the likely cause of abnormal bleeding, What problems might you expect in an early teenager?
Probably anovulatory cycles, which is quite normal as they go through puberty
Or a coagulation disorder (unlikely to develop later)
What problems might you expect in someone from puberty up to their 40s? (fertile age)
Chlamydia Contraception issuesEndometriosis or adenomyosis Fibroids Endometrial or cervical polyps Dysfunctional Bleeding
What problems might you expect in someone >40s?
Perimenopausal anovulation
Endometrial cancer
Iatrogenic warfarin
Thyroid disfunction
So if a woman comes to you with a bleeding problem what kind of blood tests would you like to do?
FBC Thyroid function (if history indicates) Coagulation screen (if younger) Endometrial biopsy (if >45, persistent IMB or obese) Pregnancy test (important to ALWAYS consider pregnancy)
Who would you test for chlamydia?
Any patient with IMB and/or PCB, especially if they’re younger
What non-blood tests are worth considering in a menstrual disorder?
Transvaginal US
Hysteroscopy for endometrial pathology e.g. polyps, fibroids or cancer
When would a hysteroscopy be indicated?
Persistant IMB
Or if the US showed up a suspected endometrial pathology
What acronym do we use to remember the causes of abnormal uterine bleeding?
PALM-COEIN (FIGO classification):
- Polyps
- Adenomyosis & Endometriosis
- Leiomyoma (fibroid)
- Malignancy
- Coagulation disorder
- Ovarian (e.g. PCOS)
- Endocrine (e.g. Thyroid)
- Iatrogenic (e.g. Warfarin)
- Not Classified
What is Endometriosis?
When endometrial tissue is found outside the uterine cavity e.g. in pouch of douglas, pelvic peritoneum or ovary
Its a chronic oestrogen-dependant condition
How might endometriosis present
Pre-menstrual pelvic pain and dysmennorhoea
Deep Dyspareunia
Subfertility
On exam you may find tender nodules in rectovaginal septum, adnexal masses or limited uterine mobility.
They may also be asymptomatic
So a 25yr old woman comes in complaining that her periods are painful and hurts before, she also experiences pain during intercourse, how would you test her for endometriosis?
Start with an exam to get some more evidence.
Then:
- Laparoscopy is gold standard
- US for endometriomas (chocolate cysts)
- MRI can be helpful in deep endometriosis
You give a diagnosis of endometriosis, what medical treatments will you suggest?
Hormonal contraceptives to control the symptoms:
- cOCP
- Oral/injectable progestogens
- GnRH analogues
- LNG-IUS (progestogen)
What surgical treatments could you offer for endometriosis?
Can excise the endometrial deposits
Can do diathermy or laser ablation
Can go as far as oophorectomy +/- hysterectomy
Define Adenomyosis?
Endometrial tissue appearing in the myometrium
How might adenomyosis present?
Menorrhagia & Dysmenorrhoea
The uterus may feel bulky and tender
Generally the woman will be parous and you may find it co-exists with endometriosis
How can we diagnose adenomyosis?
Harder than endometriosis, generally its done by histology after a hysterectomy is done.
An MRI can suggest it but can’t differentiate from fibroids
So if we suspect adenomyosis how can we treat them?
Start with symptom control using hormonal contraceptives:
- cOCP
- Oral/injectable Progestogens
- LNG-IUS
Try Endometrial Ablation
Most cases these will fail and you’ll end up doing a hysterectomy
Define a Fibroids or Leiomyoma?
A smooth muscle growth in the uterine wall, its very common and generally asymptomatic
Who’s more at risk of fibroids?
Afro-carribean women
Types of fibroid?
Sub-mucosal project into uterine cavity
Intramural
Sub-serous project into peritoneal cavity
What presentations could suggest fibroids?
- Pressure symptoms
- Menorrhagia (increased uterine surface area)
- IMB
- Pain, malpresentation or obstructed labour in pregnancy
How do we test for a fibroid?
You may find the uterus to be irregularly enlarged on exam
US & Hysteroscopy
So If a woman has a fibroid and is symptomatic but the uterine cavity isn’t distorted how would you treat her?
Medically with hormonal contraceptives
What if a woman with a fibroid has a disorted uterine cavity?
Treat surgically:
- Transcervical resection for submucosal fibroids
- Myomectomy
- Uterine Artery Embolisation
- Hysterectomy
Can use GnRH analogues neo-adjuvantly to shrink them for surgery
