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Menstrual Disorders Flashcards

1
Q

What is normal in terms of menstruation?

A
  • Menarche> menopause aged 13-51 on average
  • Cycle: 4-5/21-35
  • Mean blood loss 30-40ml
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2
Q

What triggers menstruation?

A

Fall in progesterone 2 weeks after ovulation if not pregnant

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3
Q

Menorrhagia

A

Heavy periods (>80ml loss per cycle)

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4
Q

Dysmenorrhoea

A

Painful periods

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5
Q

Inter-menstrual bleeing

A

Bleeding between periods

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6
Q

Postcoital bleeding

A

Bleeding after intercourse

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7
Q

Oligomenorrhoea

A

Infrequent periods

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8
Q

What is important to obtain in a menstrual history?

A

Remember it is subjective, patient’s perspective

  • Clots/flooding/number of tampons and pads
  • Pain (with heavy flow or premenstrual)
  • Ask about effect of symptoms on lifestyle and quality of life
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9
Q

What examination should be carried out for menstrual problems?

A
  • General
  • Abdominal
  • Speculum
  • Bimanual
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10
Q

What investigations may be carried out for heavy bleeding?

A
  • Full blood count
  • Thyroid function and Coagulation only if history suggestive
  • Endometrial biopsy (over 45 /persistent IMB/ obesity)
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11
Q

What should you test for with a history of IMB and PCB?

A

Chlamydia

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12
Q

What investigations may be carried out for menstrual problems?

A
  • FBC
  • Biopsy
  • Other blood tests as required
  • Pregnancy test
  • STI testing
  • Transvaginal ultrasound
  • Hysteroscopy
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13
Q

When should a hysteroscopy be performed?

A

For persistent IMB, suspected endometrial pathology on US

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14
Q

What are the likely causes of menstrual problems in the early teens?

A
  • Anovulatory cycles
  • Coagulation problems
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15
Q

What are the likely causes of menstrual problems from late teens to 40?

A
  • Chlamydia
  • Contraception related
  • Endometriosis/ adenomyosis
  • Fibroids
  • Endometrial or cervical polyps
  • Dysfunctional bleeding
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16
Q

What are the likely causes of menstrual problems from 40 to the menopause?

A
  • Perimenopausal anovulation
  • Endometrial cancer
  • Warfarin use
  • Thyroid dysfunction
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17
Q

What is the FIGO classification of abnormal bleeding?

A

PALM COEIN

  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy/hyperplasia
  • Coagulation
  • Ovarian
  • Endocrine
  • Iatrogenic
  • Not yet classified
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18
Q

What is dysfunctional uterine bleeding?

A

Abnormal bleeding but no structural / endocrine /neoplastic / infectious cause found for (yet)

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19
Q

What accounts for 50% of hysterectomies for menorrhagia?

A

DUB (dysfunctional uterine bleeding)

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20
Q

What is endometriosis?

A
  • Endometrial type tissue outside the uterine cavity
  • Oestrogen dependent chronic condition
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21
Q

Where does endometriosis commonly affect?

A
  • Ovary
  • Pouch of Douglas
  • Pelvic peritoneum
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22
Q

What are the theories of endometriosis pathogenesis?

A
  • Retrograde menstruation
  • Coelomic metaplasia
  • Haematogenous spread
  • Direct transplantation
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23
Q

What are the symptoms of endometriosis?

A
  • May be asymptomatic
  • Premenstrual pelvic pain
  • Dysmenorrhoea
  • Deep dyspareunia
  • Subfertility
24
Q

What are the signs of endometriosis?

A
  • May be none
  • Tender nodules in rectovaginal septum
  • Limited uterine mobility
  • Adnexal mass
25
Q

How is endometriosis diagnosed?

A
  • Gold standard is laparoscopy (clear, red, bluish, black or white lesions)
  • MRI for deep endometriosis
  • Ultrasound can diagnose endometrioma (chocolate cyst)
26
Q

How is endometriosis treated medically?

A
  • Hormonal treatment and analgesics
    • Progestogen oral/injection/
    • Levonorgesterel Intrauterine system (LNG-IUS)
    • Combined oral contraceptive pill
    • GnRH analogues (eg leuprorelin)
27
Q

How is endometriosis treated surgically?

A
  • Excision of deposits from peritoneum/ovary
  • Diathermy / laser ablation of deposits
  • Removal of ovaries with or without hysterectomy
28
Q

Adenomyosis

A

The presence of endometrial tissue in the myometrium

29
Q

What are the signs and symptoms of adenomyosis?

A
  • Heavy painful periods
  • Bulky tender uterus
  • Usually in parous women
  • May co-exist with endometriosis
30
Q

How is adenomyosis diagnosed?

A
  • MRI may suggest diagnosis but limited availability
  • Histology of uterine muscle – generally post hysterectomy
31
Q

How is adenomyosis treated?

A
  • Treat symptoms of heavy and painful periods with hormonal contraception
    • LNG IUS (Mirena)
    • Progestogens
    • Combined oral contraceptive pill
32
Q

What are fibroids?

A

Smooth muscle growths also known as leiomyoma

33
Q

What is the epidemiology of fibroids?

A
  • Common and usually asymptomatic
  • Up to 60% of 40 year olds have fibroids of varying size
  • Higher incidence in Afro-Caribbean women
34
Q

How are fibroids diagnosed?

A
  • Clinical exam: irregularly enlarged uterus
  • Ultrasound
  • Hysteroscopy (if inside uterine cavity)
35
Q

What are the types of fibroids?

A
  • Sub mucous - Protrude into uterine cavity
  • Intramural - Within uterine wall
  • Sub serous - Project out of uterus into peritoneal cavity
36
Q

What are the symptoms of fibroids?

A
  • Pressure symptoms (dependent on location)
  • Menorrhage: enlarge the uterine cavity
  • Submucous or firboud polyps may can IMB
  • Asymptomatic
  • Can rapidly increase in size in pregnancy causing pain, malpresentation or obstruction in labour (cervical fibroid)
37
Q

How are fibroids treated?

A
  • Standard menorrhagia treatment if cavity not too distorted
  • GnRH analogues or Ulipristal acetate may be used temporarily to shrink the fibroids – usually preoperatively
  • Submucous fibroids: Transcervical resection hysteroscopically
  • Myomectomy
  • Uterine artery embolisation
  • Hysterectomy
38
Q

When are fibroids treated?

A

Only if symptomatic

39
Q

What treatment is there for dysfunctional uterine bleeding?

A
  • Reassurance there is no sinister pathology
  • Medical treatment
    • Non hormonal: Tranexamic acid or Mefanamic acid
    • Hormonal: Progestogen only tablets, injections (Depo Provera), Levonorgesterel Intrauterine System, Combined pill
  • Surgical treatment (if family complete)
    • Endometrial ablation
    • Hysterectomy
40
Q

Why are tranexamic and mefenamic acid used in DUB?

A
  • Tranexamic acid (antifibrinolytic) reduces blood loss 60%
  • Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain
  • Both of them are taken at the time of periods
  • Suitable for those trying to conceive
  • Do not regulate cycles
41
Q

What are the pre-requisites for endometrial ablation for DUB?

A
  • Uterine cavity length <11 cm
  • Submucous fibroids < 3cm
  • Previous normal endometrial biopsy
42
Q

What are the possible outcomes of endometrial ablation?

A
  • 60% no periods
  • 85% satisfied
  • 15% will have subsequent hysterectomy
43
Q

What does endometrial ablation for DUB involve?

A
  • Permanent destruction of endometrium using different energy sources
  • First generation ablation: under hysteroscopic vision: uses diathermy
  • Second generation ablation: thermal balloon, radiofrequency
44
Q

How can surgical removal of the uterus be performed?

A
  • Abdominal
  • Vaginal
  • Laparscopic
45
Q

What types of laparascopic hysterectomy are there?

A
  • Laporoscopically assisted vaginal hysterectomy (LAVH)
  • Laparoscopic hysterectomy
  • Total laparoscopic hysterectomy (TLH)
  • Laparoscopically assisted subtotal hysterectomy
46
Q

What is a total hysterectomy?

A

Cervix and uterus removed

47
Q

What is a subtotal hysterectomy?

A

Uterus removed but cervix left

48
Q

What are the risks of hysterectomy?

A
  • Infection
  • DVT
  • Bladder injury
  • Bowel injury
  • Vessel injury
  • Altered bladder function
  • Adhesions
49
Q

What does hysterectomy guarantee?

A

Amenorrhoea

50
Q

How long is recovery from a hysterectomy?

A
  • 3-5 days in hospital (open / vaginal)
  • 1-2 days laparoscopic approach
  • 2-3 months full recovery
51
Q

What is a total hysterectomy with salpingo-oophrectomy?

A

Removal of uterus, cervix, fallopian tubes and ovaries

52
Q

When may a woman’s ovaries be removed?

A

May be removed in a woman with endometriosis or presence of ovarian pathology

53
Q

What are the disadvantages of an oophorectomy?

A

Immediate menopause so HRT recommended until age 50

54
Q

What are the advantages of an oophorectomy?

A

Reduces risk of subsequent ovarian cancer

55
Q

Why is there high risk of menopause following hysterectomy with sparing of ovaries?

A

High risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply

56
Q

What does management on menstrual problems depend on?

A
  • Impact on quality of life
  • Underlying pathology
  • Desire for further fertility
  • Women’s preferences

Reproduction (34 decks)

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