Menstrual Disorders Flashcards
1
Q
What is the menstrual cycle?
A
The time from the first day of a woman’s period to the day before her next period
2
Q
How much blood is lost in menstruation?
A
- Normal loss:less than 80 ml over 7 days
* Average loss: 30-40 ml
3
Q
How long does a period last?
A
2-7 days
4
Q
What is the length of a menstrual cycle?
A
28 days (average 24-35 days)
5
Q
When is menarche?
A
- 10-16 years
* Average - 12 years
6
Q
When is menopause?
A
50-55 years
7
Q
How may menstruation be disturbed?
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
8
Q
How may menstruation be disturbed?
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
MENSTRUAL PARAMETERS
9
Q
What defines heavy menstrual bleeding?
A
•Difficult to measure quantity
•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
•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
10
Q
What are the uterine and ovarian pathologies that can cause HMB?
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)
11
Q
What are the systemic diseases and disorders that can cause HMB?
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
12
Q
What are the iatrogenic causes of HMB?
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)
13
Q
What is PALM COEIN?
A
•Pneumonic to remember the causes of HMB
P - polyp
A - adenomyosis
L - leiomyoma/fibroid
M - malignancy
C - coagulopathy O - ovulation dysfunction E - endometrium/hyperplasia I - iatrogenic N - not yet classified
14
Q
What are fibroids?
A
- Non cancerous growths made of muscle and fibrous tissue
* Also called myoma or lieomyoma
15
Q
What are the signs and symptoms of fibroids?
A
- May be asymptomatic
* Can cause HMB, pelvic pain, urinary symptoms, pressure symptoms, backache, infertility, miscarriage
16
Q
How are fibroids managed?
A
- Management: Symptom based
- For HMB +/- small fibroids -COCP, POP, Mirena
- Large fibroids & fertility preservation desired - Fibroid embolisation, myomectomy
- Submucosal fibroids - Hysteroscopic fibroid resection (still myomectomy)
- Declined or failed medical treatment & fertility preservation not required -Hysterectomy
Fibroid embolisation - blocks off arteries to fibroid making them shrink
BASICALLLY: Hormones, fibroid embolisation, myomectomy or hysterectomy
17
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
18
Q
How does endometriosis present?
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
- Painful menstrual cramps - worsening
- Lower back pain
- Abnormal bleeding/spotting between period
- Pain during and after sexual intercourse
- Painful bowel movements or urination
- Diarrhoea, nausea and bloating
19
Q
What are the stages of endometriosis?
A
•Stage 1 (minimal)
- few superficial implants
- surface lesions or inflammation on or around organs in the pelvic cavity
•Stage 2 (mild)
-more widespread and starting to infiltrate pelvic organs
•Stage 3 (moderate)
- peritoneum or other structures
- sometimes also scarring and adhesion
•Stage 4 (severe)
- infiltrative and affecting many pelvic organs inc. ovaries
- often with distortion of the anatomy and adhesions
20
Q
How is endometriosis diagnosed?
A
- Pelvic examination
- Ultrasound scan
- Diagnostic laparoscopy
21
Q
How is endometriosis managed?
A
- Analgesia
- Medical
- Surgical
22
Q
How is endometriosis managed medically?
A
- COCP
- POP
- Mirena IUS
- Depot provera - contraception injection
- GnRH Analogues
23
Q
How is endometriosis managed surgically?
A
- Ablation - only if no intent for children
- Hysterectomy endometrioma excision - only affected tissue
- Pelvic clearance
- Hysterectomy
•Surgical management may be required as part of fertility treatment
24
Q
What is adenomyosis?
A
A condition where endometrium becomes embedded in myometrium
25
How does adenomyosis present?
* Heavy menstrual bleed
| * May have significant dysmenorrhea
26
How is adenomyosis treated?
* May respond to hormones partially
| * Definitive treatment is hysterectomy
27
What are endometrial polyps?
* Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium
* Mostly benign
28
How are endometrial polyps diagnosed?
* USS
| * Hysteroscopy
29
How are are endometrial polyps managed?
Polypectomy
30
How is general HMB investigated?
* Thorough history
* Pelvic examination (Speculum,Bimanual) - remember to look at cervix
* Clotting profile, thyroid function
* Pelvic Ultrasound scan
* Laparoscopy if endometriosis suspected
31
How is general HMB managed?
```
•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
32
What are non-hormonal medical treatments for HMB?
* 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
33
What are hormonal medical treatments for HMB?
* 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 e.g. Provera10mg
- day 5-25 cycle reduce bleeding +regulate
- day 15-25 may regulate cycle but does not reduce amount of bleeding
34
What are hormonal medical treatments for HMB?
* 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 e.g. Provera10mg
- day 5-25 cycle reduce bleeding +regulate
- day 15-25 may regulate cycle but does not reduce amount of bleeding
35
What are the surgical treatments for HMB?
* Endometrial ablation
* Hysterectomy
* Removal of ovaries with the uterus
36
What 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
37
What are the prerequisites for endometrial ablation?
* Uterine cavity length <11 cm
* Sub mucous fibroids < 3cm
* Previous normal endometrial biopsy
Mainly used for endometriosis but may be used to treat small fibroids (otherwise embolisation).
38
What is a hysterectomy?
•Surgical removal of uterus
- Abdominal
- Vaginal
- Laparoscopic
•Guarantees amenorrhoea
1. Subtotal (cervix left)
2. Total (cervix and uterus)
3. Total with bilateral sapling-oophorectomy
4. Wertheim's hysterectomy
39
What are the types of laparoscopic hysterectomy?
* Laporoscopically assisted vaginal hysterectomy (LAVH)
* Total laparoscopic hysterectomy (TLH)
* Laparoscopically assisted subtotal hysterectomy
40
Is a hysterectomy a major surgery?
* Yes
* 3-5 days in hospital (open/vaginal)
* 1-2 days laparoscopic approach
* 2-3 months full recovery
41
What are the risks associated with a hysterectomy?
* Infection
* DVT
* Bladder, bowel or vessel injury
* Altered bladder function
* Adhesions
42
What is the removal of the ovaries with the uterus?
* Salpingo-oophorectomy
| * Ovaries may be removed with uterus in women with endometriosis or presence of ovarian pathology
43
What are the disadvantages of oophorectomy?
Immediate menopause – recommended HRT till age 50
44
What are the advantages of oophorectomy?
Reduces risk of subsequent ovarian cancer
45
What are the causes of oligo/amenorrhoea?
* 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
What is dysfunctional uterine bleeding?
•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
47
What is the pathophysiology of dysfunctional uterine bleeding?
Underlying pathophysiology is believed to be due to ovarian hormonal dysfunction
48
How is dysfunctional uterine bleeding managed?
* 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
* Up to 6 month therapy
* If further desired by patient and no contraindication, should be given add back HRT till patient confirmed menopausal.
GnRH REDUCES OESTROGEN CAUSING PSEUDOMENOPAUSE
