Menstrual disorders

Question 1

age of menarche

Answer 1

13

Question 2

history in menstrual disorders

Answer 2

o Subjective
o Clots/flooding/pads and tampons
o ?pain with heavy flow or premenstrual
o Ask about effect of symptoms on life

Question 3

investigations of menstrual disorders

Answer 3

o FBC – menorrhagia
o Endometrial biopsy - >45/persist intermenstrual bleeding/high risk
o Chlamydia - esp. IMB, PCB, <25 with a new partner
o Only check thyroid/coagulation if other symptoms
o Pregnancy test
o TV USS
o Hysteroscopy
laparoscopy

Question 4

causes of menstrual disorders: early teens

Answer 4

anovulatory cycles
(congenital anomaly)
(coagulation problems)

Question 5

causes of menstrual disorders: teens - 40

Answer 5

chlamydia
contraception related
endometriosis/adenomyosis
fibroids
endometrial or cervical polyps
dysfunctional bleeding

Question 6

causes of menstrual disorders: 40 - menopause

Answer 6

teens - 40 +
perimenopausal anovulation
endometrial ca
warfarin
thyroid dysfunction

Question 7

FIGO classification of abnormal uterine bleeding

Answer 7

1. Polyp
2. Adenomyosis
3. Leiomyoma
4. Malignancy/hyperplasia
5. Coagulation e.g. von Willebrand’s
6. Ovarian e.g. PCO/perimenopausal anovulatory cycles
7. Endocrine e.g. thyroid
8. Iatrogenic e.g. warfarin
9. Not yet classified

Question 8

what is dysfunctional uterine bleeding?

Answer 8

This is abnormal bleeding but there is no structural, endocrine, neoplastic or infectious cause found for complaint (yet). It is subjective and 50% of women who complain of heavy periods loss less than 80 ml per cycle. 50% of hysterectomies for menorrhagia are for DUB.

Question 9

what is endometriosis and where is it likely to form?

Answer 9

Endometrial type tissue is found outside the uterine cavity, most commonly the ovary, pouch of
Douglas and pelvic peritoneum.

Question 10

endometriosis: symptoms

Answer 10

premenstrual pain
dysmenorrhoea
deep dyspareunia
subfertility

Question 11

endometriosis: signs

Answer 11

may be none
tender nodules in rectovaginal septum
limited uterine mobility
adnexal mass

Question 12

endometriosis: diagnosis + what may be seen

Answer 12

laparoscopy
MRI
(USS endometrioma)
chocolate cysts, powder burn, red flame endometriosis

Question 13

endometriosis: treatment

Answer 13

• Medical
o Progestogen – oral / inject / Mirena, combined pill 3 months
at a time
o GnRH analogues – leuprorelin
o Danazol/gestrinone are no longer used
• Surgical
o Excision of deposits from peritoneum/ovary
o Diathermy/laser ablation of
deposits
o Hysterectomy and oophorectomy

Question 14

what is adenomyosis?

Answer 14

endometrial tissue found deep int he myometrium

Question 15

adenomyosis: signs and symptoms

Answer 15

dysmenorrhagia

bulky tender uterus

Question 16

adenomyosis: imaging and what ill be seen

Answer 16

USS, laparoscopy, hyteroscopy - normal

MRI - may suggest

Question 17

what are fibroids?

Answer 17

SM growths - leiomyomas

Question 18

fibroids types

Answer 18

1. Sub mucous
   a. Protrude into uterine cavity
2. Intramural
   a. Within uterine wall
3. Sub serous
   a. Project out of uterus into peritoneal cavity

Question 19

symptoms of fibroids

Answer 19

If the fibroids are large they cause pressure symptoms. If they cause the uterine cavity
surface area they may cause menorrhagia. Submucous or polyps may cause intermenstrual bleeding. The rest are classed as innocent. They may grow fast in pregnancy causing pain, malpresentation and obstruction.

Question 20

treatment of fibroids

Answer 20

1. Nothing
2. Standard menorrhagia treatment if the cavity is not too distorted
3. GnRH analogues causing temporary shrinkage
4. Ulipristal oral – antiprogestogen
5. Transcervical resection submucous fibroids
6. Myomectomy risk haemorrhage and hysterectomy
   a. Will need C-section
7. Uterine artery embolization
8. Hysterectomy