Menstrual disorders Flashcards
What is colposcopy ?
This is a procedure to examine an illuminated magnified view of the cervix & tissues of the vagina & vulva
Define what menstruation is
This is the process of discharging blood & other material from the linning of the uterus (shedding of endometrial layer)
What is the menstrual cycle defined as ?
It is defined as the first day from one period to the first day of the next period
What is day 1 of the menstrual cycle ?
The first day of menstruation
What is the average length of the menstrual cycle ?
28 days
What is the average range of menstrual cycle duration ?
21 - 35 days
How long does menstruation (menstrual flow) usually last ?
4-6 days
How long does peak flow of menstruation usually last ?
1-2 days
What is normal blood loss defined as during menstruation ?
< 80ml per menstruation with no clots (so in total loose < 80ml)
Is it normal to have Intermenstrual bleeding (IMB) or post-coital bleeding (PCB)?
No
Define what IMB is
This is vaginal bleeding (other than PCB) at any time during the menstrual cycle except during menstruation
Define what PCB is
This is non-menstrual bleeeding that occurs immediately after sexual intercourse
Define what menhorragia is
This is increased blood loss > 80ml per menstruation
Define what metrorrhagia is
This regular IMB
Define polymenhorrhea ?
menses occurring at < 21 day interval (think poly as many as they will have more frequent periods essentially)
Define what polymenhorragia means
increased bleeding and frequent cycle (menhorragia + polymenorrhoea)
Define menometrorrhagia
Prolonged menses & IMB
Define dysmenorrhoea
painful periods
What can amenorrhea be classified as ?
Primary or secondary
Define primary amenorrhoea
Failure to start menstruating
When does primary amenorrhoea require management ?
- Girls who have no secondary sexual characteristics who have not started menstruating by 14. OR.
- Girls with normal secondary sexual characteristics who have not started menstruating by 16
Define secondary amenorrhoea
Absence of menstruation for > 6months, other than that caused by pregnancy
Define oligomenorrhoea
menses at intervals > 35 days (infrequent periods)
What are the 2 main types of causes of menorrhagia ?
- Organic = when there is pathology causing it
- Non-organic = when there is absence of pathology (so all possible pathologies ruled out), this accounts for 50% of cases
List the local organic cause of menorrhagia
- Fibroids
- Endometriosis
- Endocervical or endometrial polyp
- Cervical ectropion
- Endometrial hyperplasia
- Intrauterine contraceptive device (IUD)
- Pelvic inflammatory disease
- Malignancy of the cervix or uterus
- Hormone producing tumours
- Trauma e.g. rape/sexual assault
- Others e.g. arteriovenous malformations
What are fibroids ?
They are benign smooth muscle tumours (of the myometrium), they are often multiple & vary greatly in size
What are the typical presenting features of fibroids ?
Often asymptomatic but can cause:
- Fertility problems
- Pain
- Mass (large ones may be felt abdominally)
- May press on the bladder causing increased frequency
- Menorrhagia
What is endometriosis ?
This is a foci of endometrial glandular tissue, (inner linning of the uterus) which looks like the head of a burnt match stick, occuring outside the uterine cavity in other parts of the body e.g. on an ovary, in rectovaginal pouch, uterosacral ligaments, pelvic peritoneum, rarley in the umbilicus, lower abdo scars or other organs e.g. lungs
What is a endocervical or endometrial polyp ?
It is a mass of tissue projecting from a mucous membrane such as the cervix or endometrium
What is a cervical ectropion (cervical eversion)
This is a condition in which the cells from the inside of the cervical canal (columnar epithelium or ‘glandular cells’) are present on the outside i.e. vaginal portion of the cervix, these cells are more prone to bleeding
Note - squamous epithelium is what usually lines the outside portion of the cervix
What is endometrial hyperplasia due to and what does it result in?
This is a result of high oestrogen levels, it results in the eventual breakdown of the endometrium ==> causing irregular bleeding
What does endometrial hyperplasia carry a small increased risk of ?
Endometrial carcinoma
What is pelvic inflammatory disease ?
- This is an infection of the female upper genital tract - the fallopian tubes & ovaries can be affected
- 90% of these infections are sexually aquired with chlamydia being the most common cause
- the other 10% are caused by childbirth or instrumentation (IUD, TOP)
List some of the systemic disorders which can cause menorrhagia
- Endocrine disorders e.g. hyper/hypothyroidism (more so hypo), DM, adrenal disease, prolactin disorders
- Disorders of homeostasis - von willebrands disease, immune thrombocytopenia, factor II, V, VII &XI deficiency
- Liver disorders
- Renal disease
- Drugs e.g. anti-coagulants
List some of the causes of menorrhagia specific to pregnancy
- Msicarriage
- Ectopic pregnancy
- GTD (gestational trophoblastic disease)
- PPH
Define what Dysfunctional Uterine Bleeding (DUB) is
This is heavy &/or irregular bleeding in the absence of recognisable pelvic pathology
How is a diagnosis of DUB made ?
Exlcuding other pathologies
How is DUB subdivided ?
Into anovulatory & ovulatory
Describe what causes anvoulatory DUB
- The women does not properly develop & release a mature egg (dont ovulate). When this happens the corpus luteum (which produces progesterone) does not form.
- As a result oestrogen is produced continuously causing an overgrowth of the endometrial lining of the uterus.
- The period is delayed in such cases (==> irregular cycle) & when it does occur menstruation can be very long & prolonged
Describe the features suggestive of an anovulatory DUB is (include when it occurs usually)
- This is DUB when ovulation is not occuring
- Accounts for 85% of DUB
- It occurs most commonly at the exstremes of reproductive life (ealry puberty or perimenopausal) and is more common in the obese
- Irregular cycle
What is ovulatory DUB ?
It is DUB which occurs in women who ovulate but there is inadequate production of progesterone by the corpus luteum
Describe the features suggestive of a ovulatory DUB is (include when it occurs usually)
- It is more common in women 35-45
- They get regular heavy periods
What are the investigations which should be carried out in women with potential DUB ?
- FBC - rule out iron def. anaemia,
- Cervical smear
- Coagulation screen - for coag disorders e.g. von willebrands etc
- Renal/liver function tests
- Transvaginal USS - check thickness of endometrium (if > 4mm then endometrial sampling done) & to look for polyps or other pelvic masses
When should coagulation disorders be considered in women with menhorragia ?
It should be considered for those who have a history of menhorragia since menarche & a personnel or fam history of a coagulation disorder
What is the 1st line treatment option for DUB ?
1st line = LNG-IUS esp for those needing contraception
What are the second line options for treatment of DUB?
2nd line = Tranexamic acid, or NSAID’s, or combined oral contraceptives
How do you decide between the 3 different 2nd line options for DUB treatment ?
- Tranexamic acid is chosen if regular cycle but heavy periods
- NSAID’s are used if they have dysmenorrhoea as well
- COC used if they have cycle problems (as it makes them more regular)
What is the 3rd line option for treatment of DUB ?
3rd line = Progestogens (long acting progestogen only injectable) or Norethisterone
Progestogens used if cycle problems
What is the 4th line treatment option DUB ?
Surgical management: (esp for fibroids as if >3cm size pharma has limited effect)
- 1st line = endometrial resection/ablation
- 2nd line = hysterectomy
GnRH anagloues e.g. Goserelin may be used pre-op to help de-bulk or in those unfit for surgery
