Menstrual disorders

Question 1

what volume of blood loss would you consider abnormal during a menstrual period?

Answer 1

> 80 mls over 7 days

Question 2

what factors define the heavy menstrual bleeding?

Answer 2

affecting someones quality of life
changing sanitary products ever 2 hours or less
passing blood clots > 2mm / 10p coin
>80mls over 7 days

Question 3

what are the causes of heavy menstrual bleeding / menorrhagia?

Answer 3

pelvic inflammatory disease 
adenomyosis / endometriosis 
leiomyoma / uterine fibroids 
malignancy (cervical, endometrial) 
coagulopathy i.e. Von Willibrands/ anti-coagulation therapy 
ovulatory disturbance
idiopathic 
not otherwise identified

hypothyroidism
PCOS
liver and renal disease

Question 4

what is the difference between endometriosis and adenomyosis?

Answer 4

endometriosis is when endometrial tissue is found in other places outwith the uterine cavity

adenomyosis is when the endometrium becomes embedded in the myometrium

Question 5

what is the difference between fibroids and uterine polyps?

Answer 5

uterine polyps are outgrowths of the endometrium

fibroids are benign growths arising from the myometrium

Question 6

what is the presentation of adenomyosis?

Answer 6

heavy/prolonged menstrual bleeding (menorrhagia)
severe cramping/pain during menstruation (dysmenorrhagia)
chronic pelvic pain

Question 7

what is the presentation of endometriosis?

Answer 7

menorrhagia
intermenstrual bleeding  
dysmenorrhagia 
chronic pelvic pain 
lower back pain
dyspareunia 
infertility 
fatigue 
nausea
diarrhoea 
painful bowel movements
pain during urination

Question 8

what is the gold standard investigation for diagnosing endometriosis?

Answer 8

laparoscopy

Question 9

what is the main investigation for diagnosing adenomyosis?

Answer 9

pelvic MRI
(definitive diagnosis is only made by pathology after hysterectomy but MRI can show signs of adenomyosis)

Question 10

what is the treatment options for endometriosis?

Answer 10

medical: COCP, POP, mirena IUS, depo- provera, GnRH analogue
surgical: laparoscopy (ablation, pelvic clearance) or hysterectomy

Question 11

what are the complications associated with endometriosis?

Answer 11

adhesions
bowel and bladder complications
ovarian cyst
endometriomas

Question 12

what other pelvic condition is endometriosis commonly associated with?

Answer 12

adenomyosis

Question 13

what is the driving force behind the growth of fibroids/leiomyomas?

Answer 13

too high levels of oestrogen

Question 14

what are the risk factors for fibroids?

Answer 14

increasing age
black ethnicity
obesity

Question 15

what is the presentation of fibroids?

Answer 15

menorrhagia 
irregular, firm central pelvic mass
pressure symptoms i.e. constipation
pelvic pain
bloating

Question 16

what investigations would you carry out if you suspected fibroids?

Answer 16

pelvic USS

endometrial biopsy to rule out endometrial carcinoma

Question 17

what are the treatment options for fibroids in a patient who wants to preserve fertility?

Answer 17

1st line: mifepristone, GnRh analogues or myomectomy

Question 18

what are the treatment options for fibroids in someone who’s fertility isn’t desired?

Answer 18

uterine artery embolisation

hysterectomy

Question 19

what are the complications associated with fibroids?

Answer 19

breech presentation
dysfunctional labour
increased risk of miscarriage
increased risk of c-section

Question 20

if someone presents with heavy menstrual bleeding, what investigations would you carry out?

Answer 20

pelvic examination - bimanual, speculum, abdo
pelvic USS
thyroid function tests
clotting screen
FBC (anaemia ?)
laparoscopy (if suspicion of endometriosis)
MRI (if suspicion of adenomyosis)

Question 21

what are the treatment options for heavy menstrual bleeding / menorrhagia?

Answer 21

hormonal: COCP, POP, mirena IUS, depo-provera

non-hormonal: hysterectomy, mifenamic acid, tranexamic acid, GnRH

Question 22

what is the first line treatment of heavy menstrual disorders?

Answer 22

mirena coil (Levneogestrel IUS)