Menstrual Disorders

Question 1

What is the menstrual cycle?

Answer 1

The time from the first day of a woman’s period to the day before the first day of her next period

Question 2

What forms can disturbance of menstruation take?

Answer 2

• Disturbance of menstrual frequency – infrequent or frequent
• Irregular menstrual bleeding – absent or irregular
• Abnormal duration of flow – prolonged or shortened
• Abnormal menstrual volume – heavy or light

Question 3

What are the normal parameters for frequency, regularity, duration and volume of a menstrual cycle?

Answer 3

Frequency- 24-38 days
Regularity- <20 days variation in 12 months
Duration- 2-7 days
Volume- 5-80ml

Question 4

How is heavy menstrual bleeding defined?

Answer 4

As any of the following:
•Bleeding > 8 days
•The need to change menstrual products more often than every two hours
•Passage of clots >2.5cm
•Bleeding through clothes
•Very heavy periods as reported by women or impact on quality of life

Question 5

What are the possible causes of heavy menstrual bleeding?

Answer 5

• Polyps
• Adenomyosis
• Leiomyoma/fibroids
• Malignancy
• Coagulopathies
• Ovulatory dysfunction
• Endometriosis/hyperplasia
• Iatrogenic
• No known cause

Question 6

What are fibroids?

Answer 6

Non-cancerous growths made of muscle and fibrous tissue, also known as myomas or leiomyomas

Question 7

What are the symptoms of fibroids?

Answer 7

Can be asymptomatic
Heavy menstrual bleeding
Pelvic pain
Urinary symptoms
Pressure symptoms
Backache
Infertility
Miscarriage

Question 8

How are fibroids diagnosed?

Answer 8

Ultrasound scan

Question 9

How are fibroids managed?

Answer 9

Symptom based
For HMB or small fibroids- COCP, POP, Mirena
Large fibroids when fertility preservation desired- fibroid embolization, myomectomy
Submucosal fibroids- hysteroscopic fibroid resection
Decline or failed medical treatment and fertility preservation not required- hysterectomy

Question 10

What is endometriosis?

Answer 10

Endometriosis is defined as endometrial tissue being found out with the lining of the uterus. During menstruation, this ectopic tissue behaves as endometrium and bleeds
Affects women of child bearing age

Question 11

What are the symptoms of endometriosis?

Answer 11

• Pelvic pain
• Heavy menstrual bleeding
• Painful menstrual cramps that worsen with time
• Lower back pain
• Abnormal bleeding or spotting between periods
• Pain during and after intercourse
• Painful bowel movements or urination
• Diarrhoea, nausea and vomiting
• Infertility
• Fatigue
• Systemic symptoms

Question 12

What are the four stages of endometriosis?

Answer 12

Minimal- Small patches, surface lesions or inflammation on or around organs within the pelvic cavity
Mild- More widespread and starting to infiltrate pelvic organs
Moderate- Affects peritoneum or other structures. May have scarring and adhesions
Severe- Infiltrative and affecting many pelvic organs and ovaries, often with distortion of anatomy due to adhesions

Question 13

What are the common sites for endometriosis deposits?

Answer 13

• Ovaries
• Pouch of Douglas
• Ligaments of uterus
• Fallopian tubes
• Rectovaginal Septum
• Peritoneum
• Intestines
• Vulva

Question 14

How is endometriosis investigated?

Answer 14

Pelvic examination, an ultrasound scan and a diagnostic laparotomy

Question 15

How is endometriosis managed?

Answer 15

• Medical- analgesia, COCP, POP, Mirena IUS , Depot provera, GnRH Analogues
• Surgical ablation
• Hysterectomy endometrioma excision
• Pelvic clearance
• Hysterectomy

Question 16

What is adenomyosis?

Answer 16

A condition where the endometrium is embedded within the myometrium

Question 17

What are the symptoms of adenomyosis?

Answer 17

Heavy menstrual bleeding

Dysmenorrhoea

Question 18

How is adenomyosis treated?

Answer 18

May respond to hormone therapy but the mainstay of treatment is a hysterectomy

Question 19

What are endometrial polyps?

Answer 19

Endometrial polyps occur when there is an overgrowth of the endometrium which leads to the formation of pediculated structures called polyps that extend into the endometrium

Question 20

How are endometrial polyps investigated and treated?

Answer 20

Diagnosed with and ultrasound or a hysteroscopy

Management is a surgical polypectomy

Question 21

How can heavy menstrual bleeding be managed medically?

Answer 21

Tranexamic acid 
Mefenamic acid 
Hormonal contraception
COCP
LING IUS or Depo-provera
Oral progestogens

Question 22

How can heavy menstrual bleeding be managed surgically?

Answer 22

• Endometrial ablation (permanent destruction of endometrium using different energy sources)
• Hysterectomy (can be total hysterectomy where cervix is removed or subtotal if cervix is left)
• Salpinhoopherectomy

Question 23

What are the risks associated with a hysterectomy?

Answer 23

• Infection
• DVT
• Bladder/bowel/vessel injury
• Altered bladder function
• Adhesions

Question 24

What is oligorrhoea?

Answer 24

Infrequent, absent or abnormally light menstruation

Question 25

What are the causes of oligorrhoea and amenorrhoea?

Answer 25

•Life changes:stress, eating disorders/malnourishment, obesity, Intense exercise
•Hormones:POP, Mirena, depot injection
•Primary ovarian insufficiency
•Polycystic ovarian syndrome ,
•Hyperprolactinemia (elevated levels of prolactin in the blood)
•Prolactinomas (adenomas on the anterior pituitary gland)
•Thyroid disorders (Graves’s disease)
•Obstructions of the uterus, cervix, and/or vagina
The cause should be identified and treated.

Question 26

What is dysfunctional uterine bleeding?

Answer 26

A common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable disease. It is believed to be caused by ovarian hormonal dysfunction

Question 27

What management should be given for dysfunctional uterine bleeding?

Answer 27

Common causes should be excluded, with treatment being based on severity of symptoms and patient wishes