Menstrual Disorders Flashcards
What is normal in terms of menstruation?
- Menarche> menopause aged 13-51 on average
- Cycle: 4-5/21-35
- Mean blood loss 30-40ml
What triggers menstruation?
Fall in progesterone 2 weeks after ovulation if not pregnant
Menorrhagia
Heavy periods (>80ml loss per cycle)
Dysmenorrhoea
Painful periods
Inter-menstrual bleeing
Bleeding between periods
Postcoital bleeding
Bleeding after intercourse
Oligomenorrhoea
Infrequent periods
What is important to obtain in a menstrual history?
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
What examination should be carried out for menstrual problems?
- General
- Abdominal
- Speculum
- Bimanual
What investigations may be carried out for heavy bleeding?
- Full blood count
- Thyroid function and Coagulation only if history suggestive
- Endometrial biopsy (over 45 /persistent IMB/ obesity)
What should you test for with a history of IMB and PCB?
Chlamydia
What investigations may be carried out for menstrual problems?
- FBC
- Biopsy
- Other blood tests as required
- Pregnancy test
- STI testing
- Transvaginal ultrasound
- Hysteroscopy
When should a hysteroscopy be performed?
For persistent IMB, suspected endometrial pathology on US
What are the likely causes of menstrual problems in the early teens?
- Anovulatory cycles
- Coagulation problems
What are the likely causes of menstrual problems from late teens to 40?
- Chlamydia
- Contraception related
- Endometriosis/ adenomyosis
- Fibroids
- Endometrial or cervical polyps
- Dysfunctional bleeding
What are the likely causes of menstrual problems from 40 to the menopause?
- Perimenopausal anovulation
- Endometrial cancer
- Warfarin use
- Thyroid dysfunction
What is the FIGO classification of abnormal bleeding?
PALM COEIN
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/hyperplasia
- Coagulation
- Ovarian
- Endocrine
- Iatrogenic
- Not yet classified
What is dysfunctional uterine bleeding?
Abnormal bleeding but no structural / endocrine /neoplastic / infectious cause found for (yet)
What accounts for 50% of hysterectomies for menorrhagia?
DUB (dysfunctional uterine bleeding)
What is endometriosis?
- Endometrial type tissue outside the uterine cavity
- Oestrogen dependent chronic condition
Where does endometriosis commonly affect?
- Ovary
- Pouch of Douglas
- Pelvic peritoneum
What are the theories of endometriosis pathogenesis?
- Retrograde menstruation
- Coelomic metaplasia
- Haematogenous spread
- Direct transplantation
What are the symptoms of endometriosis?
- May be asymptomatic
- Premenstrual pelvic pain
- Dysmenorrhoea
- Deep dyspareunia
- Subfertility
What are the signs of endometriosis?
- May be none
- Tender nodules in rectovaginal septum
- Limited uterine mobility
- Adnexal mass
How is endometriosis diagnosed?
- Gold standard is laparoscopy (clear, red, bluish, black or white lesions)
- MRI for deep endometriosis
- Ultrasound can diagnose endometrioma (chocolate cyst)
How is endometriosis treated medically?
- Hormonal treatment and analgesics
- Progestogen oral/injection/
- Levonorgesterel Intrauterine system (LNG-IUS)
- Combined oral contraceptive pill
- GnRH analogues (eg leuprorelin)
How is endometriosis treated surgically?
- Excision of deposits from peritoneum/ovary
- Diathermy / laser ablation of deposits
- Removal of ovaries with or without hysterectomy
Adenomyosis
The presence of endometrial tissue in the myometrium
What are the signs and symptoms of adenomyosis?
- Heavy painful periods
- Bulky tender uterus
- Usually in parous women
- May co-exist with endometriosis
How is adenomyosis diagnosed?
- MRI may suggest diagnosis but limited availability
- Histology of uterine muscle – generally post hysterectomy
How is adenomyosis treated?
- Treat symptoms of heavy and painful periods with hormonal contraception
- LNG IUS (Mirena)
- Progestogens
- Combined oral contraceptive pill
What are fibroids?
Smooth muscle growths also known as leiomyoma
What is the epidemiology of fibroids?
- Common and usually asymptomatic
- Up to 60% of 40 year olds have fibroids of varying size
- Higher incidence in Afro-Caribbean women
How are fibroids diagnosed?
- Clinical exam: irregularly enlarged uterus
- Ultrasound
- Hysteroscopy (if inside uterine cavity)
What are the types of fibroids?
- Sub mucous - Protrude into uterine cavity
- Intramural - Within uterine wall
- Sub serous - Project out of uterus into peritoneal cavity
What are the symptoms of fibroids?
- 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)
How are fibroids treated?
- 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
When are fibroids treated?
Only if symptomatic
What treatment is there for dysfunctional uterine bleeding?
- 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
Why are tranexamic and mefenamic acid used in DUB?
- 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
What are the pre-requisites for endometrial ablation for DUB?
- Uterine cavity length <11 cm
- Submucous fibroids < 3cm
- Previous normal endometrial biopsy
What are the possible outcomes of endometrial ablation?
- 60% no periods
- 85% satisfied
- 15% will have subsequent hysterectomy
What does endometrial ablation for DUB involve?
- Permanent destruction of endometrium using different energy sources
- First generation ablation: under hysteroscopic vision: uses diathermy
- Second generation ablation: thermal balloon, radiofrequency
How can surgical removal of the uterus be performed?
- Abdominal
- Vaginal
- Laparscopic
What types of laparascopic hysterectomy are there?
- Laporoscopically assisted vaginal hysterectomy (LAVH)
- Laparoscopic hysterectomy
- Total laparoscopic hysterectomy (TLH)
- Laparoscopically assisted subtotal hysterectomy
What is a total hysterectomy?
Cervix and uterus removed
What is a subtotal hysterectomy?
Uterus removed but cervix left
What are the risks of hysterectomy?
- Infection
- DVT
- Bladder injury
- Bowel injury
- Vessel injury
- Altered bladder function
- Adhesions
What does hysterectomy guarantee?
Amenorrhoea
How long is recovery from a hysterectomy?
- 3-5 days in hospital (open / vaginal)
- 1-2 days laparoscopic approach
- 2-3 months full recovery
What is a total hysterectomy with salpingo-oophrectomy?
Removal of uterus, cervix, fallopian tubes and ovaries
When may a woman’s ovaries be removed?
May be removed in a woman with endometriosis or presence of ovarian pathology
What are the disadvantages of an oophorectomy?
Immediate menopause so HRT recommended until age 50
What are the advantages of an oophorectomy?
Reduces risk of subsequent ovarian cancer
Why is there high risk of menopause following hysterectomy with sparing of ovaries?
High risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply
What does management on menstrual problems depend on?
- Impact on quality of life
- Underlying pathology
- Desire for further fertility
- Women’s preferences
