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Year 3 - Repro and Anaesthetics > Menstrual Disorders > Flashcards

Menstrual Disorders Flashcards

1
Q

what is normal menstruation?

A

The menstrual cycle is the time from the first day of a woman’s period to the day before her next period

Normal loss: less than 80 ml over 7 days (16 tsp)

Average loss: 30-40 ml (6-8tsp)

Average duration 2-7 days

Length of cycle -28 days (average 24-35 days)

Menarche: 10-16years, average -12 years

Menopause: 50-55years

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2
Q

picture showing menstrual cycle stages

A

changes in hormonal level, oravian level and laso the endometrial level

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3
Q

what happens at the different days of the menstrual cycle?

A

day 1-5 = menstraul shedding

day 6-10 = uterine lining thickening

day 11-18 (avergae day 14) = ovulation

endometrium conties to thicken and becomes secretory and after day 28 menstruation happens

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4
Q

what are the different categories of disturbances of menstruation?

A

disturbance of menstrual frequency – infrequent or frequent

irregular menstrual bleeding – absent or irregular

abnormal duration of flow – prolonged or shortened

abnormal menstrual volume – heavy or light

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5
Q

picture showing the parameters of mentsraul regularity and irregularity

A
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6
Q

what is heavy menstrual bleeding?

A

Difficult to measure/quantify

Bleeding >8dysmenorrhea 0 ml over 7 days, regular cycle

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

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7
Q

what may the effects of heavy menstrual bleeding be?

A

Can occur alone or in combination with symptoms like dysmenorrhea

5% of women aged 30-49 in UK consult GP each year due to HMB

Health Implications e.g. anaemia

20%women in UK have hysterectomy aged <60 due to HMB

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8
Q

Heavy menstrual bleeding(HMB)-Causes:

Uterine and ovarian pathologies

A

Uterine fibroids (HMB/dysmenorrhoea, pelvic pain)

Endometrial polyps (HMB/ intermenstrual bleeding).

Endometriosis and adenomyosis (HMB/dysmenorrhoea, dyspareunia, pelvic pain, difficulty conceiving

Pelvic inflammatory disease and pelvic infection (for example chlamydia — may also present with vaginal discharge, pelvic pain, intermenstrual and postcoital bleeding, and fever

Endometrial hyperplasia or carcinoma (postcoital bleeding, intermenstrual bleeding, pelvic pain).

Polycystic ovary syndrome (causes anovulatory menorrhagia and irregular bleeding).

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9
Q

Heavy menstrual bleeding(HMB)-Causes:

Systemic diseases and disorders

A

Coagulation disorders (for example von Willebrand disease)

Hypothyroidism (which may also present with fatigue, constipation, intolerance of cold, and hair and skin changes)

Liver or renal disease

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10
Q

Heavy menstrual bleeding(HMB)-Causes:

Iatrogenic causes

A

Anticoagulant treatment

Herbal supplements (for example ginseng, ginkgo, and soya) — these may cause menstrual irregularities by altering oestrogen levels or coagulation parameters

Intrauterine contraceptive device(CU IUD)

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11
Q

Palm Coin can be a good way to remeber the causes of heavy menstrual bleeding

A
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12
Q

fibrois are a cause of heavy menstrual bleeding and other bleeding irregularities

what are fibroids and their effects?

A

Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma

May be asymptomatic

can cause HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage

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13
Q

how are fibroids diagnosed?

A

Ultrasound

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14
Q

what is the management of fibroids?

A

Management: Symptom based.

For HMB +/- small fibroids - COCP, POP, Mirena

large fibroids & fertility preservation desired - Fibroid embolisation, myomectomy

submucosal fibroids - Hysteroscopic fibroid resection

Declined or failed medical treatment & fertility preservation not required - Hysterectomy (sugical rmeoval of uterus)

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15
Q

what is endometriosis?

A

Defined as endometrial tissue present outside the lining of uterus. During menstruation this ectopic tissue behaves the same as endometrium and bleeds

Affects women of reproductive age. 1.5 million women in UK affected

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16
Q

what are the effects of endometriosis?

A

May present with HMB

Most often pelvic pain

Multi-system involvement

severely affects quality of life - can be devastating

in addition to pelvic symptoms, can cause infertility, fatigue and systemic symptoms

Severity of deposits may not correspond with symptoms

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17
Q

what are some of the symptoms of endometriosis?

A
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18
Q

is the diagnosis of endometriosis challenging?

A

yes - common for women not to be diagnosed for several years

symptoms often vague and is often diagnosed as many things

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19
Q

whata re the different stages of endometriosis?

A
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20
Q

can the presentation of endometriosis change?

A

yes different depending on site and stage

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21
Q

how si the diagnosis of endometriosis made?

A

detialed history

Pelvic examination

Ultrasound scan, Diagnostic laparoscopy

22
Q

what is the management of endometriosis?

A

Management Options: Analgesia, Medical, Surgical

Medical - COCP, POP, Mirena IUS, Depot provera, GnRH Analogues (idea is to supress ovulation to sotp endometrium thickening)

Surgical - Ablation, Hysterectomy endometrioma excision, pelvic clearance, Hysterectomy

Surgical management may be required as part of fertility treatment

23
Q

what is adenomyosis?

A

A condition where endometrium becomes embedded in myometrium

24
Q

what is the effects of adenomyosis?

A

Heavy menstrual bleed

May have significant dysmenorrhea

25
Q

what is the treatment of adenomyosis?

A

May respond to hormones partially

Definitive treatment is hysterectomy

26
Q

what are Endometrial polyps?

A

Overgrowth of endometrial lining can lead to formation of pediculated (having stalk) structures called polyps which extend into endometrium

mostly benign

27
Q

how is a diagnosis of endometrial polyps made?

A

Diagnosis by Ultrasound or hysteroscopy (A hysteroscopy is a procedure used to examine the inside of the womb (uterus). It’s carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end)

28
Q

what si the management of endometrial polyps?

A

polypectomy (removal)

29
Q

what is the management of heavy menstrual bleeding?

A

Thorough history

Pelvic examination (Speculum,Bimanual) remember to look at cervix

Clotting profile, thyroid function

Pelvic Ultrasound scan (can pick up causes like fibroids and polyps)

Laparoscopy if endometriosis suspected (if endometrisosis is suspected)

Management options depend on:

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

Endometrial Biopsy from all women aged 44 or above with HMB, refractory to medical treatment

30
Q

patients _________ are paramount in what treatment method to use

A

preferences

31
Q

when presenting the different optinos to a patient what categories may we put them in? and what options are avalible in each?

A

hormonal and non-hormonal

32
Q

what medical treatment are avalible and what do they do?

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 , Do not regulate cycles
  • Suitable for those trying to conceive or avoiding hormones
  • Hormonal options: Combined contraceptive pill (COCP)makes periods lighter, regular and less painful
  • LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
  • Oral progestogens eg Provera10mg: day 5-25 cycle reduce bleeding + regulate, day 15-25 may regulate cycle but does not reduce amount of bleeding
33
Q

one surgical ooption is endometrial ablation

A
  • Permanent destruction of endometrium using different energy sources
  • First generation ablation: under hysteroscopic vision – uses diathermy
  • Second generation ablation: thermal balloon, radio frequency
  • Pre-requisites:
  • Uterine cavity length <11 cm
  • Sub mucous fibroids < 3cm
  • Previous normal endometrial biopsy

•60% will have no periods, 85% are satisfied, 15% will have subsequent hysterectomy

34
Q

what is a hysterectomy?

A

Surgical removal of uterus

35
Q

what are the different methods of a hysterectomy?

A
  • Abdominal
  • Vaginal
  • Laparoscopic:
  • Laporoscopically assisted vaginal hysterectomy (LAVH)
  • Total laparoscopic hysterectomy TLH
  • Laparoscopically assisted subtotal hysterectomy
36
Q

what is the difference between a total and a subtotal hysterectomy?

A
  • Total hysterectomy: cervix and uterus removed
  • Subtotal hysterectomy: uterus removed, cervix left
37
Q

what is the recovery time of a hysterectomy?

A
  • Major surgery
  • 3-5 days in hospital (open / vaginal)
  • 1-2 days laparoscopic approach
  • 2-3 months full recovery
38
Q

what are the risks of a hysterectomy?

A

infection/DVT/bladder/bowel/vessel injury/ altered bladder function / adhesions

39
Q

hysterectomy is the only procedure to guarentee what?

A

Guarantees amenorrhoea

40
Q

what is Salpingo-oophorectomy?

A

removal of tubes + ovaries

41
Q

when would a salpingo-ooporectomy be done?

A

Ovaries may be removed with uterus in women with endometriosis or presence of ovarian pathology

42
Q

what are the disadvantages of oophorectomy

A

immediate menopause – recommended HRT till age 50

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

43
Q

what are the advantages of oophorectomy

A

Reduces risk of subsequent ovarian cancer

44
Q

what is Oligo/amennorhea?

A

Infrequent, absent or abnormally light menstruation

Important to check if its normal to a person

45
Q

what are the causes of oligo/amennorhea?

A

➢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

46
Q

what is polycystic ovarian syndrome?

A

Polycystic ovary syndrome is a condition that affects how the ovaries work

Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met

Ultrasound appearance of ovary

Biochemical hyperandrogenism

Clinical hyperandrogenism with oligomenorrhoea, hirsuitism, acne, infertility and obesity

Results in oligo menorrhea /amenorrhea

47
Q

what is the management of polycystic ovarian syndrome?

A

management includes lifestyle adjustment with aim to achieve normal BMI

Symptom based treatment

At least 3 withdrawl bleeds required per year to prevent hyperplasia or endometrial protection

achieved with either COCP,POP, mirena IUS or norethisterone

48
Q

another cause of Heavy or irregular bleeding is dysfunctional uterine bleeeding, what is it?

A
  • Dysfunctional uterine bleeding (DUB) is a common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases.
  • underlying pathophysiology is believed to be due to ovarian hormonal dysfunction
  • Exclude common causes PALM COEIN
49
Q

what is the management of dysfunctional uterine bleeding?

A
  • Conservative /Medical Surgical treatment based on severity of symptoms and patient’s wishes
  • GnRh analogues could be good bridging for patients who are nearly menopausal and have not responded to or declined other medical treatment and surgical management not desirable. GnRH analogues work as ant estrogen and produce a pseudo menopause .
  • upto 6 month therapy. If further desired by patient and no contraindication, should be given add back HRT till patient confirmed menopausal.
50
Q

overall summary of how to manage menstraul problems

A

exclude pregnancy

good histroy

beta HcG shoudl laways be done

investigation for strucutral cause

endometril biopsy espceially in older owmen

management based on aetiology

if no indetifiable causes are regognised then consider abnormal uterine bleeding or dysfunctional uterine bleeding

Year 3 - Repro and Anaesthetics (50 decks)

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