Menstrual Disorders Flashcards
what is normal menstruation?
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
picture showing menstrual cycle stages
changes in hormonal level, oravian level and laso the endometrial level
what happens at the different days of the menstrual cycle?
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
what are the different categories of disturbances of menstruation?
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
picture showing the parameters of mentsraul regularity and irregularity
what is heavy menstrual bleeding?
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
what may the effects of heavy menstrual bleeding be?
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
Heavy menstrual bleeding(HMB)-Causes:
Uterine and ovarian pathologies
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).
Heavy menstrual bleeding(HMB)-Causes:
Systemic diseases and disorders
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
Heavy menstrual bleeding(HMB)-Causes:
Iatrogenic causes
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)
Palm Coin can be a good way to remeber the causes of heavy menstrual bleeding
fibrois are a cause of heavy menstrual bleeding and other bleeding irregularities
what are fibroids and their effects?
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
how are fibroids diagnosed?
Ultrasound
what is the management of fibroids?
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)
what is endometriosis?
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
what are the effects of endometriosis?
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
what are some of the symptoms of endometriosis?
is the diagnosis of endometriosis challenging?
yes - common for women not to be diagnosed for several years
symptoms often vague and is often diagnosed as many things
whata re the different stages of endometriosis?
can the presentation of endometriosis change?
yes different depending on site and stage
how si the diagnosis of endometriosis made?
detialed history
Pelvic examination
Ultrasound scan, Diagnostic laparoscopy
what is the management of endometriosis?
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
what is adenomyosis?
A condition where endometrium becomes embedded in myometrium
what is the effects of adenomyosis?
Heavy menstrual bleed
May have significant dysmenorrhea
what is the treatment of adenomyosis?
May respond to hormones partially
Definitive treatment is hysterectomy
what are Endometrial polyps?
Overgrowth of endometrial lining can lead to formation of pediculated (having stalk) structures called polyps which extend into endometrium
mostly benign
how is a diagnosis of endometrial polyps made?
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)
what si the management of endometrial polyps?
polypectomy (removal)
what is the management of heavy menstrual bleeding?
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
patients _________ are paramount in what treatment method to use
preferences
when presenting the different optinos to a patient what categories may we put them in? and what options are avalible in each?
hormonal and non-hormonal
what medical treatment are avalible and what do they do?
- 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
one surgical ooption is endometrial ablation
- 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
what is a hysterectomy?
Surgical removal of uterus
what are the different methods of a hysterectomy?
- Abdominal
- Vaginal
- Laparoscopic:
- Laporoscopically assisted vaginal hysterectomy (LAVH)
- Total laparoscopic hysterectomy TLH
- Laparoscopically assisted subtotal hysterectomy
what is the difference between a total and a subtotal hysterectomy?
- Total hysterectomy: cervix and uterus removed
- Subtotal hysterectomy: uterus removed, cervix left
what is the recovery time of a hysterectomy?
- Major surgery
- 3-5 days in hospital (open / vaginal)
- 1-2 days laparoscopic approach
- 2-3 months full recovery
what are the risks of a hysterectomy?
infection/DVT/bladder/bowel/vessel injury/ altered bladder function / adhesions
hysterectomy is the only procedure to guarentee what?
Guarantees amenorrhoea
what is Salpingo-oophorectomy?
removal of tubes + ovaries
when would a salpingo-ooporectomy be done?
Ovaries may be removed with uterus in women with endometriosis or presence of ovarian pathology
what are the disadvantages of oophorectomy
immediate menopause – recommended HRT till age 50
high risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply
what are the advantages of oophorectomy
Reduces risk of subsequent ovarian cancer
what is Oligo/amennorhea?
Infrequent, absent or abnormally light menstruation
Important to check if its normal to a person
what are the causes of oligo/amennorhea?
➢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 ovarian syndrome?
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
what is the management of polycystic ovarian syndrome?
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
another cause of Heavy or irregular bleeding is dysfunctional uterine bleeeding, what is it?
- 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
what is the management of dysfunctional uterine bleeding?
- 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.
overall summary of how to manage menstraul problems
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
