Menstrual Disorders Flashcards
Define Menorrhagia [2], Dysmenorrhoea, oligomenorrhoea, IMB & PCB?
Menorrhagia = Heavy periods, technically >80ml but its subjective Dysmenorrhoea = painful periods Oligomenorrhoea = Irregular periods > 35 days apart IMB = Intermenstrual bleeding PCB = Post-coital bleeding
What questions might you ask when a patient complains of heavy or painful periods? [5]
Clots? Size?
Tampons, pads?
Pain - heavy flow onset or premenstrual onset?
Do you ever flood (bleed through clothes)?
QOL questions - 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? [2]
Probably anovulatory cycles, which is quite normal as they go through puberty
Or a coagulation disorder ( but unlikely to develop later)
What problems might you expect in someone from puberty up to their 40s? (fertile age) [4]
Chlamydia, contraception issues
Endometriosis or adenomyosis, Fibroids
Endometrial or cervical polyps
Dysfunctional Bleeding
What problems might you expect in someone >40s? [4]
Perimenopausal anovulation
Endometrial cancer
Iatrogenic bleeding - warfarin
Thyroid disfunction
So if a woman comes to you with a bleeding problem what kind of blood tests would you like to do? [5]
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)
What accompanying history would warrant a test for chlamydia
Any patient with IMB and/or PCB, especially if they’re in adolescent age group
What investigations are worth considering in a menstrual disorder? [2]
Transvaginal US
Hysteroscopy for endometrial pathology e.g. polyps, fibroids or cancer
When would a hysteroscopy be indicated? [2]
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? [2]
Sites [3]
When endometrial tissue is found outside the uterine cavity
A chronic estrogen-dependant condition
Sites: ovary, pouch of Douglas, pelvic peritoneum
Endometriosis can be asymptomatic but
how might it present otherwise?
Symptoms [4]
Signs [3]
Symptoms: Premenstrual pelvic pain Dysmenorrhea - severe Deep dyspareunia Subfertility
On exam you may find tender nodules in rectovaginal septum, adnexal masses or limited uterine mobility.
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? [3]
Start with an exam Then: - Laparoscopy is gold standard - US for endometriomas (chocolate cysts) - MRI for deep endometriosis
You give a diagnosis of endometriosis, what medical treatments will you suggest? [3]
Hormonal contraceptives to control the symptoms:
- cOCP
- Progestogen (pill, injection, IUS)
- GnRH analogues Gosorelin
What surgical treatments could you offer for endometriosis? [3]
Can excise the endometrial deposits
Can do diathermy or laser ablation
Can go as far as oophorectomy +/- hysterectomy
Adenomyosis is found to be very common in parous women and may co-exist with endometriosis
Define Adenomyosis?
Presentation [2]
Endometrial tissue appearing in the myometrium.
Menorrhagia and dysmenorrhea
Bulky tender uterus of 12 week size
The diagnosis of adenomyosis is difficult. Give 2 ways in which it is done
Harder than endometriosis, generally its done by histology after a hysterectomy is done.
An MRI can suggest it but can’t differentiate from fibroids
Uterine muscle biopsy
So if we suspect adenomyosis how can we treat them?
3 Rx
2 procedural treatments
Start with symptom control using hormonal contraceptives:
- cOCP
- Progestogens
- LNG-IUS
Endometrial Ablation
Most cases these will fail and you’ll end up doing a hysterectomy
Define a Fibroids or Leiomyoma? [2]
Higher incidence in which ethnic group
A smooth muscle growth in the uterine wall
Afro-carribean women
Types of fibroid? [3]
Classified according to how they protrude in the abdominal space
Sub-mucosal project into uterine cavity
Intramural
Sub-serous project into peritoneal cavity
May be asymptomatic and incidental finding.
What presentations could suggest fibroids? [5]
- Pressure symptoms
- Menorrhagia (increased uterine surface area)
- IMB
- Pain
- Malpresentation (transverse) or obstructed labour in pregnancy (cervical)
How do we test for a fibroid? [5]
Exam: irregularly abdominal mass TVUSS Endometrial biopsy Colour flow doppler ddx from myometrium in pregnancy Hysteroscopy
Medical treatment of DUB [3]
- Reassure that no sinister pathology if appropriate
- Transexamic acid or mefanimic acid
- Hormonal treatments: contraception
What if a woman with a fibroid has a distorted uterine cavity? [5]
Treat surgically:
- Transcervical resection for submucosal fibroids
- Myomectomy
- Uterine Artery Embolisation
- Hysterectomy
Can use GnRH analogues neo-adjuvantly to shrink them for surgery
Theories of pathogenesis in endometriosis [4]
Retrograde menstruation - menstrualblood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity
Coelomic metaplasia - both peritoneum and endometrium have common precursor, peritoneum can turn into endometrium
Haematogenous spread
Direct transplantation
Hormonal treatments of DUB - 3 options
Which is first line?
Emergency management of excessive uterine bleeding [2]
LNG IUS, other progestogen - first line
COCP - regulates and lightens periods (add-on)
IV estrogen and/or surgery
Fibroid management If desiring fertility [2] If family complete [2] If patient wants to preserve uterus [1] Surgical mx for sub mucous fibroids [1]
If desiring fertility: myomectomy + GnRh analogue
If family complete: TAH
If patient wants to preserve uterus - uterine artery embolisation
Surgical mx for sub mucous fibroids - transcervical resection (hysteroscopy)
Complications of fibroid: red degeneration in pregnancy [4]
Capsular vessel thrombosis then venous engorgement
- causes abdo pain, vomiting and low grade fever with peritoneal tenderness
- in last ½ pregnancy or puerperium
- mx is bed rest and expectant mx
