Menstrual disorders Flashcards
What is a menstrual cycle?
the time from the first day of a woman’s period to the day before her next period
normal blood loss in a period?
80ml over 7 days (16 tsp)
average duration of a period?
2-7 days
length of a cycle?
28 days ( average 24-35)
disturbances of menstruation - what are the 4 categories?
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.
when is a cycle considered frequent/ infrequent
< 24 days
> 38 days
when is a cycle considered regular/irregular
< 20 days variation in 12 months
>20 days variation in 12 months
what volume of blood loss in one menstrual cycle is considered heavy, normal and light?
> 80 ml
5-80ml
<5ml
- when is it considered heavy?
- Bleeding>8dysmenorrhea0 ml over 7 days, regular cycle
AND/OR the need to change menstrual products every one to two hours
Features of heavy menstrual bleeding?
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
Can occur alone or in combination with symptoms like dysmenorrhea.
Health Implications e.g. anaemia
20%women in UK have hysterectomy aged <60 due to HMB
Common causes of HMB - 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).
Sytemic diseases and disorders causing HMB? (4)
- Coagulation disorders (for example von Willebrand disease).
- history of dental bleeding or prolonged injury should be sorted, especially in those with younger age
- Hypothyroidism (which may also present with fatigue, constipation, intolerance of cold, and hair and skin changes)
- Liver or renal disease.
Iatrogenic causes of HMB? (3)
- 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).
MNEMONIC to remember HMB?
P - polyp
A - adenomyosis
L - leiomyoma/fibroid
M - malignancy
C - coagulopathy O - ovulation E - Endometrium/ hyperplaia L - latrogenic N - not yet classified
What are fibroids?
Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma
What can fibroids cause symptom wise? (9)
HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage
diagnosis of fibroids?
ultrasound
For HMB +/- small fibroids- what can they be controlled by? (3)
COCP
POP
Mirena
options for large fibroids?
desired Fibroid embolisation myomectomy
submucosal fibroids - what can be carried out?
Hysteroscopic fibroid resection
Declined or failed medical treatment & fertility preservation not required - what is the next step?
-Hysterectomy
what is endometriosis?
tissue present outside the lining of uterus
what does the tissue do during menstruation if you have endometriosis?
ectopic tissue behaves the same as endometrium and bleeds
who does endometriosis effect ?
women of reproductive age. 1.5 million women in UK affected.
how may endometriosis present?
- what involvement does it have?
- what can it cause?
with HMB
- pelvic pain
- multi system
- infertility, fatigue and systemic symptoms
symptoms of endometriosis?
Lowe back pain
painful cramps that get worse - dysmenorrhoea
- abnormal bleeding or spotting doing period
- painful urination/ pooing
- pain during/ after intercourse
endometriosis is often misdiagnosed as it is hard to diagnose with the vague symptoms - what may it be mistaken for?
- IBS
- anxiety/depression
- stress
- fatigue
Endometriosis stages - briefly describe them
stage 1 - minimal, may be small patches of surface lesions on or around organs in pelvic cavity
stage 2 - mild , begins to infiltrate pelvic organs
stage 3 - moderate - peritoneum pelvic side walls and other structures are involved
stage 4 - severe - infiltrated and affecting pelvic organs and ovaries - adhesions present
diagnosis of endometriosis
- Pelvic examination
- Ultrasound scan, Diagnostic laparoscopy
management of endometriosis - medical and surgical
Management Options: Analgesia, Medical, Surgical
Medical — COCP, POP, Mirena IUS , Depot provera, GnRH Analogues
Surgical- Ablation,Hysterectomy endometrioma excision, pelvic clearance, Hysterectomy
Surgical management may be required as part of fe
What is Adenomyosis?
condition where endometrium becomes embedded in myometrium .
what does Adenomyosis cause?
HMB
You may have significant ….? with Adenomyosis
dysmenorrhea.
treatment and definitive treatment for adenomyosis?
May respond to hormones partially
- Definitive treatment is hysterectomy
Endometrial polyps - overgrowth of endometrial lining can lead to?
- polyps are mostly ?
- to formation of pediculated structures called polyps which extend into endometrium
- benign
mamagement for Endometrial polyps?
polypectomy
Management of Heavy menstrual bleeding (lots)
- what profile needs to be done
- Thorough history Pelvic examination (Speculum,Bimanual) remember to look at cervix - Clotting profile, thyroid function Pelvic Ultrasound scan Laparoscopy if endometriosis 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
with endometrial polyps - what is it always important to look at?
the cervix
non hormonal treatment for polyps? (3)
mefenamic acid
transexemic acid
GnRH analogues
what does transexemic acid do?
reduces blood loss 60%
antifibrinolytic)
what does mefenamic acid do?
(prostaglandin inhibitor) reduces blood loss 30% and pain
when are transexemic acid and mefenamic acid taken?
who are they suitable for?
- at the time of periods , Do not regulate cycles
Suitable for those trying to conceive or avoiding hormones
What does LNG IUS (Mirena) and depo-provera do?
reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
oral progestogens eg provera 10mg - when can it be given?
day 5-25 cycle reduce bleeding +regulate
- day 15-25 may regulate cycle but does not reduce amount of bleeding
Surgical Treatments - endometrial ablation
Permanent destruction of endometrium using different energy sources
what does first generation ablation under hysteroscopic vision use?
diathermy
what does second generation ablation use?
thermal balloon, radio frequency
cervix removed or reserved in hysterectomy - what are they called?
Total hysterectomy: cervix and uterus removed
Subtotal hysterectomy: uterus removed, cervix left
ovaries and tubes removed called?
sapling-oophorectomy
risks of hysterectomy?
infection, DVT BLADDER/BOWEL/ VESSEL INJURY
- altered bladder function / adhesions
Ovaries may be removed with uterus in women with?
endometriosis or presence of ovarian pathology
Disadvantages of oophorectomy?
immediate menopause – recommended HRT till age 50
Advantages of oophorectomy?
Reduces risk of subsequent ovarian cancer
Oligo/amennorhea?
infrequent, absent or abnormally light menstruation
causes of amennorhea?
Life changes:stress, eating disorders/malnourishment, obesity, Intense exercise
hormones that may cause amennorhoea
- what may they have?
POP, mirena , depot injection
prim ovarian insufficiency
what to look for with amennorhoea - underlying causes (4)
- 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
Polycystic Ovary Syndrome is a ?
Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met
criteria for Polycystic Ovary Syndrome? (3)
- Ultrasound appearance of ovary
- Biochemical hyperandrogenism
- Clinical hyperandrogenism with oligomenorrhoea ,hirsuitism, acne, infertility and obesity
Polycystic Ovary Syndrome? can result in?
oligo menorrhea /amenorrhea
management of Polycystic Ovary Syndrome?
includes lifestyle adjustment with aim to achieve normal BMI
Polycystic Ovary Syndrome? - how man withdrawal bleeds do they need and why?
- how is this achieved ?
3
- to prevent hyperplasia or endometrial protection
COCP,POP, mirena IUS or norethisterone
What is Dysfunctional Uterine bleeding?
excessive uterine bleeding
- affects premenopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases.
Dysfunctional Uterine bleeding - the underlying pathophysiology is believed to be due to?
ovarian hormonal dysfunction
Dysfunctional Uterine bleeding - GnRh analogues are good for?
bridging for patients who are nearly menopausal - the have declined other options
How do GnRh analogues work?
ant estrogen and produce a pseudo menopause .
6 month therapy is needed for?
dysfunctional uterine bleeding
- should get add back HRT until they are confirmed menopausal
