Menstrual Disorders Flashcards
What is endometriosis?
Presence of endometrial tissue outside of the uterus, inducing a chronic inflammatory reaction
What is adenomyosis?
Endometrial tissue within the myometrium of the uterus
Describe the pathophysiology of endometriosis
Exact cause is unclear, but there are many theories
Retograde mestruation
Lymphatic spread
Metaplasia
Embryonic cells remain in areas outside the uterus and develop later
What are the most common sites of endometrial lesions?
Ovary
Pouch of Douglas
Pelvic peritoneum
How does endometriosis present?
Premenstrual/cyclical abdominal and pelvic pain
Dysmenorrhoea
Deep dyspareunia
N&V
Infertility
Cyclical bleeding from other sites, such as haematuria
Urinary or bowel symptoms
Tenderness on examination
What investigations are used in endometriosis diagnosis?
Pelvic USS
- Endometrioma
- Chocolate cysts (endometrioma in the ovaries)
- But often unremarkable
Pelvic laparoscopy and biopsy, diagnostic gold standard
- Clear, red, bluish black or white lesions
MRI
- For deep endometriosis and surgical planning
What is the management of endometriosis?
Analgesia as required
- NSAIDs and paracetamol are first line
Progestogen
- Oral, injection or IUS
COCP
GnRH analogues
Surgical management
- Laparoscopic excisions
- Hysterectomy and bilateral salpingo-opherectomy
Give an example of a GnRH analogue
Goserelin
Leuprorelin
What endometriosis management improves fertility?
Surgery, not hormonal treatment
Give complications of a hysterectomy
Infection
DVT
Bladder and bowel damage
Vessel injury
Altered bladder function
Adhesions
Guarantees amenorrhoea
What are fibroids?
Oestrogen sensitive benign smooth muscle growths arising from the myometrium of the uterus
What are the types of fibroids?
Submucosal, protrude into uterine cavity
Subserosal, project out of the uterus and into peritoneal cavity
Intramural, stay within uterine wall/myometrium
Give risk factors for fibroids
Obesity
>Age
FH
Afro-Caribbean ethnicity
Nulliparity
Early menarche
How do endometrial fibroids present?
Often asymptomatic
Menorrhagia, is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain worsening with menstruation
Urinary or bowel symptoms due to pressure
Deep dyspareunia
Palpable pelvic mass on examination
What investigation is used in fibroid diagnosis?
Pelvic USS, investigation of choice for large fibroids
Hysteroscopy, for submucosal fibroids
MRI considered before surgery
How are endometrial fibroids managed?
If asymptomatic, no treatment
Standard menorrhagia treatment
- Mirena IUS
- COCP
- POP
- NSAIDS
- Tranexaminc acid
GnRH analogues
- Used to temporarily shrink the fibroid post-operatively
Uterine artery embolisation
Resection, if submucosal
Edometrial ablation
Hysterectomy
What is the general management of menorrhagia/dysfunctional uterine bleeding?
Paracetamol
Tranexamic Acid
Mefenamic acid/NSAIDS
COCP
POP
Mirena IUS
What is the only effective treatment for large fibroids causing fertility problems?
Myomectomy
Give complications of myomectomy
Adhesions, most common
Bladder injury
Uterine perforation
Give complications of fibroids
Iron deficiency anaemia
Infertility
Miscarriage, premature labour and obstructive delivery
Urinary outflow obstruction and UTI
Fibroid torsion
Red degeneration of fibroid
What is red degeneration of fibroid?
Refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply, most likely to occur in larger fibroids during pregnancy
What are endometrial polyps?
Overgrowth of endometrial lining which can lead to the formation of pedunculated structures known as polyps
What is the diagnostic criteria for PCOS?
Rotterdam criteria
Describe the Rotterdam criteria
Diagnose if 2/3
PCO morphology on US, 12 or more peripheral follicles
Clinical or biochemical hyperandrogenism
- Hirsute
- Acne
- Increased testosterone
Oligoovulation or anovulation, presenting as irregular or abscent periods
What investigations are used in PCOS diagnosis?
Pelvic US, intial imaging
Transvaginal US, gold standard
Raised testosterone
Sex hormone binding globulin
Raised LH compared to FSH (raised LH:FSH ratio)
Normal or raised oestrogen levels
Raised insulin
OGTT
What US sign can be seen in PCOS?
String of pearls sign
How is PCOS managed, for those not wishing to conceive?
Co-cyprindrol, useful for hirtuism reduction and inducing regular menstruation
COCP, reduces irregular bleeding and protects against endometrial cancer
Metformin, helps with menstrual irregularity, hirtuism and acne
How is PCOS managed, for those wishing to conceieve?
Weight loss
Clomifene, induces ovulation and improves conception rates
Metformin, can be used with/without clomifene to improve chances
Ovarian drilling
Gonadotrophins
Give complications of PCOS
Obstructive sleep apnoea
Endometrial hyperplasia and cancer
DM/insulin resistance
CVS disease and hypercholesterolaemia
Acne
Obesity
Miscarriage and infertility
Acanthosis nigricans, occurs due to insulin resistance
What are women with PCOS who undergo IVF at risk of?
Ovarian hyperstimulation syndrome
