Menstrual disorders Flashcards
how much blood is lost in average menstruation?
30-40ml, over 2-7 days.
what age is menarche and menopause at?
menarche: 10-16yo, menopause: 50-55yo
when does LH, FSH and osestrogen peak?
just before ovulation
when does progesterone peak?
after ovulation till the stage of a regressing corupus luteum
what are the mentrual parameters?
frequency, regularity, duration, volume
Define Menorrhagia, Dysmenorrhoea, Intermenstrual bleeding, Postcoital bleeding, Oligomenorrhoea
Menorrhagia = heavy periods
Dysmenorrhoea = painful periods
Intermenstrual bleeding = bleeding between periods
Postcoital bleeding = bleeding after intercourse
Oligomenorrhoea = infrequent periods e.g. 45-90
how is heavy menstrual bleeding (Menorrhagia) defined?
bleeding over 80ml over 7 days AND/OR the need to change menstrual products every one to two hours AND/OR passage of clots greater than 2.5 cm, Bleeding through the clothes, AND/OR ‘very heavy’ periods as reported by the woman/affecting quality of life, it can also occur with dysmenorrhea. health implications (anaemia), 20%women in UK have hysterectomy aged <60 due to HMB.
what are the common causes of HMB?
ovarian dysfunction, uterine fibroids, endometrial polyps, endometriosis,
pelvic inflammatory disease, endometrial cancer, cervical cancer, adenomyosis,
coagulation disorders, hypothyroidism, liver/renal disease, anticoag treatments, IUD causes it too, herbal supplements.
what are the common causes of HMB? USING PALMCOEIN…
polyp, adenomyosis, leiomyoma/fibroid, malignancy, coagulopathy, ovulation dysfunction, endometrium/hyperplasia, iatrogenic, not yet classified
What are Fibroids?
Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma, Common and usually asymptomatic – 60% of 40 year olds have fibroids, Higher incidence in Afro-Caribbean women
who has a higher incidence of Fibroids? also what are the RF’s?
Afro-carribean women!
obesity
fhx
age
Sy/sx of fibroids
HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage, Enlargement of the uterine cavity surface area may cause menorrhagia, Submucous or polyp may cause intermenstrual bleeding
types of fibroids and diagnosis…
Diagnosis: Clinical exam, Ultrasound, Hysteroscopy, Laparoscopy.
Types:
Sub mucous = protrude into uterine cavity,
Intramural = within uterine wall,
Sub serous = project out of uterus into peritoneal cavity
Tx of fibroids
Myomectomy
uterine artery embolisation
Hysterectomy
Usually no treatment needed, Standard menorrhagia Rx (NSAID’S AND NAPROXEN) if uterine cavity is not too distorted, Transcervical resection of submucous fibroids, Uterine artery embolisation, Hysterectomy.
What is Endometriosis?
Endometrial type tissue outside the uterine cavity, Common sites = ovary, pouch of Douglas (rectouterine pouch), pelvic peritoneum, May be asymptomatic and resolve without Rx. During menstruation this ectopic tissue behaves the same as endometrium and bleeds.
ENDOMETRIOSIS Sy/sx
Symptoms: Premenstrual pain, Dysmenorrhoea, Deep dyspareunia (difficult/painful sex), Subfertility, pelvic pain, cramps worse over time, intermenstrual bleeding and spotting, diarrhea, nausea, painful bowel movements and urinaiton, lower back pain.
(PELVIC PAIN BEFORE AND DURING MENSTURATION, IRREGULAR UTERINE BLEEDING, POST-COITAL BLEEDING, DYMENORRHOEA.)
REDUCED FERTILITY, DYSPARENURIA, SHORTER CYCLE LENGTH, MENORRHAGIA, USE OF OCP INCREASES RISK OF ECTROPION, FHX OF CERVICAL CANCER, AGE OF FIRST SEXUAL INTERCOURSE, SMEAR HX
Signs: Tender nodules in rectovaginal septum, Limited uterine mobility, Adnexal mass.
SX: FIXED RETROVERTED UTERUS, ADNEXAL MASS, THICKENING OF UTEROSACRAL LIGAMNENTS, POSSIBLE CYSTIC SWELLINGS
ddx of endometriosis?
cervical cancer, fibroids.
stages 1-4 of endometriosis
1 - patches, surface lesions or inflammation on or around organs on the pelvic cavity,
2 - widespread, infiltrating pelvic organs,
3 - peritoneum, scarring and adhesions,
4 - infiltrative and affecting many pelvic organs and ovaries,often anatomical distortion and adhesions.
ENDOMETRIOSIS - Diagnosis/ Ix
Laparoscopy, MRI, pelvic exam. Bloods (FBC - anaemia, TFT’s - hypothyroidism, CLOTTING- abnormality may lead to increased blood loss)
Complication of an exploratory laproscopy?
Bowel perforation, major vessel perforation
ENDOMETRIOSIS - Mx
Medical: Progesterone = oral/injection/Mirena, Combined pill, GnRH analogues
Surgical: Excision of deposits from peritoneum/ovary, Diathermy/laser ablation of deposits, Hysterectomy/oophorectomy
SURGICAL EXCISION, COCP, POP, GnRH ANALOGUES
What is Adenomyosis?
Endometrial tissue found deep in myometrium, Thickened wall of uterus can be mistaken for fibroids
sy/sx for ADENOMYOSIS
menorrhagia, bulky tender uterus, dysmeorrhea
Ix for ADENOMYOSIS
Usually normal Us, Laparoscopy, Hysteroscopy, Histology of uterine muscle = not endometrial biopsy
tx for ADENOMYOSIS
Hysterectomy (may partially respond to hormones)
Endometrial Polyps
Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium
dx and tx of endometrial polyps
US, hysteroscopy, mostly benign, Polpectomy
Mx of heavy menstrual bleeding…
hx, pelvic examinaiton, clotting profile, thyroid function, uss, laparoscopy then tx depending on QOL impact, pathology, fertility, prefrences.
tx = nsaids (naproxen), tranexamic acid, coco, pop, iud.
Define (DUB) Dysfunctional uterine bleeding
Abnormal bleeding but no structural/endocrine/neoplastic/infectious cause found for complaint, Subjective – 50% women who complain of heavy periods actually only lose <80ml per cycle, 50% hysterectomies for menorrhagia are because of DUB
Medical tx to control DUB
Mefenamic acid (prostoglandin inhibitor) - reduces blood loss, suitable for those trying to conceieve.
Tranexemic acid (antifibrinolytic) - reduces blood loss
GnRh Analogues
Combined contraceptive pill (COCP)makes periods lighter, regular and less painful
Oral Progesterone - regulates cycle more
Surgical tx OF DUB
Endometrial abalaiton - permenant destruction of the endometrium to below basal layer, Can use diathermy/thermal balloon, Treatment done through cervix, No effect on ovarian hormones/bladder, 60% will have no periods.
Hysterectomy - surgical removal of the uterus, abdominal or vaginal, laproscopic, (total = cervix and uterus removed) (wertheims = total + salpingo-oophorectomy)
hysterectomy complications
infection/DVT/bladder/bowel/vessel injury/ altered bladder function / adhesions
what is FIGO?
Classification of Abnormal Uterine Bleeding
age predictors of the cause of menstrual disorders
• Early teens: Anovulatory cycle = menstrual cycle without release of oocyte, Congenital anomaly
• Teens – 40: Chlamydia, Contraception related, Endometriosis/adenomyosis, Fibroids, Endometrial or cervical polyps, Dysfunctional bleeding
• 40-menopause: Perimenopausal anovulation, Endometrial cancer, Warfarin, Thyroid dysfunction
ALWAYS CONSIDER PREGNANCY
ALWAYS LOOK AT THE CERVIX
Ix to do for these disorders in general
Full blood count if menorrhagia, Endometrial biopsy, Chlamydia, Thyroid/coagulation if other symptoms, Pregnancy test, TV (trans-vaginal) ultrasound, Hysterectomy, Laparoscopy.
FBC, BIOPSY OF ENDOMETRIUM, PREGNANCY TEST, TVUSS, HYSTEROSCOPY, LAPAROSCOPY.
what is Amennorhea and what are its causes?
infrequent or very light periods, causes: 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, Investigate and treat the cause.
What is Polycystic Ovary Syndrome?
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age.
sy/sx OF PCOS
subfertility and infertility, menstrual disturbances: oligomenorrhea and amenorrhoea, hirsutism, acne (due to hyperandrogenism), obesity, acanthosis nigricans (due to insulin resistance).
(OLLIGOMENORRHAGIA, MENORRHAGIA, ERRATIC PERIODS)
DDX for PCOS?
Hypothryroidism, endometriosis, coagulopathy, uterine polyps, dysfunctional uterine bleeding.
questions to ask pt with PCOS to differentiate betweenm the ddx?
bleeding regularlity, bleeding from other places, fhx of coagulopathy, any sy of hypothyroidism (weight gain, lethargy, constipation). Hirsutism, acne, DM? dysmenorrhea? dysparenuria?
Ix for PCOS
PELVIC USS: multiple cysts on the ovaries
BLOODS - LH:FSH RATIO, INCREASED SERUM ANDROGEN INDEX, DECREASED SEX HORMONE BINDING GLOBULIN, INCREASED PROLACTIN, DECREASED HB DUE TO MENORRHAGIA, (FSH, LH) prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes. check for impaired glucose tolerance.
Tx for PCOS
Lose weight, COCP, POP, metformin, clomiphene (induces ovulation), Mirena IUS
What are 2 long term sequalae of PCOS?
infertility, T2DM, increased risk of endometrial hyperplasia and endometrial carcinoma, increased risk of CHD.
questions to ask to confirm or refute fibroids?
hx if miscarriage, increased urinary frequency infertility change in bowel habit post-coital bleeding? dyspareunia?
