Menstrual Disorders Flashcards
What is the normal ages for menarche and menopause?
13-51
How long do periods tend to last? How long is the normal cycle of a period?
4-5 days
21-35 days
What triggers menstruation?
Fall in progesterone 2 weeks after ovulation if the egg is not fertilised
What is the mean blood loss for a period?
30-40ml + mucosa of endometrial and secretion from other halnds
What things may cause period abnormalities that are not pathologic?
Stress/medications etc. that disrupt hormones
Define menorrhagia
Heavy periods
Blood loss >80ml/cycle (or as the woman perceives)
In which conditions would you get menorrhagia?
Adenomyosis
Fibroids
Define dysmenorrhoea
Painful periods (recurrent lower ab pain during/shortly before period begins)
What may cause dysmenorrhoea?
Primary - normal pain occurring on first 1/2 days of period
Secondary - IUD, PID, endometriosis, fibroids, adenomyosis
What is intermenstrual bleeding?
Bleeding between periods
In which conditions would you get IMB?
Ovarian insufficiency, cervical/endometrial cancer, OCP use
What is post-coital bleeding?
Bleeding after sex
What is oligomenorrhoea?
Infrequent periods (45-90 day cycle)
What causes oligomenorrhoea?
Pregnancy, ectopic pregnancy, PCOS, insufficient calorific intake
What is amenorrhoea?
Absence of menses
What can cause amenorrhoea?
Pregnancy, ovarian disorders, e.g. PCO, endometriosis, endocrine disorders
What is mittelschmerz?
Midcycle pain that occurs with ovulation
Enlargement/rupture of follicle –> peritoneal irritation –> recurrent, unilateral lower abdominal pain
NORMAL
What investigations should you do for heavy periods?
FBC Thyroid function Coagulation testing if Hx suggestive Endometrial biopsy Pregnancy test TVUS Hysteroscopy
When would you do an endometrial biopsy?
> 45y, persistent IMB/irreg perimenopausal bleeding, other RFs for endometrial hyperplasia/endometrial thickness 4+cm
to rule out endometrial cancer/hyperplasia
What additional test should you do for IMB/PCB?
Chlamydia testing
What would you do a TVUS for?
PCO, assess endometrial thickness, adnexa, fibroids
What would you do a hysteroscopy for?
Persistent IMB, suspected endometrial pathology on USS
What is likely to be the menstrual disorder in early teens?
Coagulation problems
Anovulatory cycles
What are the likely menstrual disorders from teens to 40s?
Chlamydia (esp IMB) Contraception related Endometriosis/adenomyosis Fibroids (menorrhagia) Endometrial/cervical polyps (IMB/PCB) Dysfunctional bleeding
What are the likely menstrual disorders in 40s-menopause?
Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction
What is the main complaint in endometriosis?
PAIN
What is the main compliant in adenomyosis?
MENORRHAGIA
What is an anovulatory cycle?
Menstrual cycle with absence of ovulation leading to menstrual irregularities
When is it most common to get anovulatory cycles?
In first few months/years after menarche
Why do woman get anovulatory cycles?
HPO axis not fully established yet
What are the symptoms of hypothyroidism?
Menorrhagia, tiredness, cold tolerance, wt gain, dry skin and hair etc.
What are the symptoms of hyperthyroidism?
Olgiomenorrhoea/amenorrhoea, tachycardia, palpitations, HTN, excess sweating, diarrhoea, wt loss, hyperreflexia
What is the PALM-COEIN FIGO classification for abnormal uterine bleeding?
Polpys Adenomyosis Leiomyoma Malignancy/hyperplasia Coagulation, e.g. vWF dx Ovarian, e.g. PCOs/anovulatory cycles Endocrine, e.g. thyroid Iatrogenic, e.g. warfarin Not yet classified
What is DUB?
Dysfunctional unterine bleeding
Abnormal bleeding with no structural/endocrine/neoplastic/infectious cause found as of yet
A lot can be different subjective opinion
How many hysterectomies are for DUB?
50%
Define endometriosis
Endometrial tissue outside the uterine cavity
Why does endometriosis lead to symptoms?
This endometrial tissue is still oestrogen responsive so will grow and shed like normal endometrial tissue
–> inflammation, scarring, pain
Where does this endometrial tissue in endometriosis tend to be found?
Ovary, pouch of Douglas, Fallopian tubes, pelvic peritoneum
Can be extra pelvic, e.g. lung/brain
What are the theories for explaining the pathogenesis of endometriosis?
Retrograde menstruation - backflow of menstrual fluid containing endometrial tissue which implants in the tubes/ovaries etc.
Coelomic metaplasia: peritoneal cells & endometrial cells from same embryonic precursor so cells thought to undergo metaplasia
Haematogenous spread - menstrual blood enters BV and endometrial cells implant in various organs
Direct transplantation: e.g. scar endometriosis - endometrial cells implant on C-section/episitomy scars
What are the symptoms of endometriosis?
Premenstrual pelvic pain
Dysmenorrhoea (2 days before periods - several days)
Deep dyspareunia
Subfertility
Why do you get subfertility in some cases of endometriosis?
Adhesions/inflammation affect egg quality and implantation
What signs do you get in endometriosis?
May be none
Tender nodules in rectovaginal septum if advanced
Limited uterine mobility
Adnexal masses
What is used to diagnose endometriosis?
Laparoscopy - gold standard
MRI for deep endometriosis
USS to diagnose endometrioma
How is endometriosis graded?
1–>4
1 = superficial lesions
4 = deep lesions
What are chocolate cysts?
AKA endometriomas
Cyst like structures in ovaries containing blood, fluid and menstrual debris
What is powder burn in endometriosis?
Mild endometriosis appears like superficial burn
How does the appearance of the endometrial deposits change?
Red (flame red endometriosis) in active bleeding stage –> blue/back –> white and fibrous with the stages of the menstrual cycle
What is involved in treatment of endometriosis?
Progesterone - POP/LNG-IUS/depoProvera COCP - tricycle (as symptoms predominantly during menstruation) GnRH analogues (leuprorelin) - induce perimenopause so implants regress
Surgery
Excision of deposits
Diathermy/laser ablation of deposits
Hysterectomy +/- oophorectomy
What are the signs/symptoms of adenomyosis?
Heavy, painful periods
Bulky, tender uterus
Uniformly enlarged uterus
How do you diagnose adenomyosis?
MRI may suggest diagnosis
Tend to diagnose post-hysterectomy via histology
How do you treat adenomyosis?
LNG-IUS, POP, COCP
Often failed medical Rx/endometrial ablation –> hysterectomy
What are fibroids?
Smooth muscle growths
AKA leiomyomas
What are risk factors for fibroids?
Afro-caribbean, obesity, nulliparity, early menarche
How do you diagnose fibroids?
Ex - irreg, enlarged uterus
TVUS/ab USS
Hysteroscopy (if think inside uterine cavity)
What are the different kinds of fibroids?
Submucous - protruding into uterine cavity
Intramural - in uterine wall
Subserous - projecting into peritoneal cavity
May be called a polyp if it has a stalk
What symptoms are associated with fibroids?
Often asymptomatic
Large fibroids –> pressure symptoms (constipation, urinary frequency/retention)
Menorrhagia (due to increased SA of endometrium)
Submucosal fibroids –> IMB
How can fibroids complicate pregnancy?
Can grow rapidly in pregnancy and cause pain, malpresentation and obstruction in labour
When do you treat fibroids?
Only if symptomatic
How do you treat fibroids?
GnRH analogues/ulipristal acetate to temporarily shrink them before surgery
Submucous fibroids can be removed transcervically
Myomectomy (intramural/subserous)
Uterine artery embolization (block artery supplying fibroid so it dies)
Hysterectomy
What are risk factors for adenomyosis?
Early menarche, increased parity, previous uterine surgery
What are risk factors for endometriosis?
Retrograde menstruation
How do you treat DUS?
Non-hormonal if trying to conceive: tranexamic acid/mefenamic acid
Hormonal: COCP, POP, LNG-IUS, Depo
Surgery: endometrial ablation/hysterectomy
What is tranexamic acid?
Anti-fibrinolytic
Reduces blood loss by 60%
What is mefenamic acid?
Prostaglandin inhibitor
Inhibits pain and reduces blood loss by 30%
When is COCP CI?
Migraine, >35, smoker, high BMI
Why might you not go for depo?
Stimulates appetite –> wt gain
What are the different for endometrial ablation?
First gen: diathermy
Second gen: thermal balloon (85 degree water in balloon), radiofrequency
What are the pre-requisites for endometrial ablation?
Uterine cavity length <11cm
Submucous fibroids <3/4cm
Previous normal endometrial biopsy (ensure no cancer which we may leak into the peritoneum –> spreading)
What are the different ways a hysterectomy can be done?
Abdominally
Vaginally
Laparoscopically
What are the different types of hysterectomy?
Subtotal: uterus only
Total: uterus and cervix
Total + bilat salphino-oophorectomy
Wertheim’s hysterectomy (T + BSO + upper vagina and parametrial tissue)
What are the risks of hysterectomy?
Infection, DVT, bladder/bowel/vessels damage, altered bladder function, adhesions
What are the disadvantages and advantages of oophorectomy?
Adv - reduces risk of ovarian cancer
Disadv - immediate menopause (HRT recommended until 50y)
