menstrual disorders Flashcards
what is the normal cycle
24-32 days
what is regularity
best between 20-40y longer after menarche
okay to have a fluctuation
shorter in pre-menopause
mean blood loss
37-43ml/ per period mostly in first 48h
top 10% lose more than 80ml blood per period
3/4 are anaemic
factors affecting mean blood loss
age - as you get older you bleed more 40s ealy 50s have heavy periods
genetics - monozygotic twins heavy periods
parity - more children you have the heavier your period
Heavy irregular bleeding (metrorrhagia)
no pattern can bleed anytume anyday
define absent periods - amenorrhoea
no period 6 months or more
what is dysfunctional uterine bleeding
DUB (60%) = primary menorrhagia
Heavy menstrual bleeding with no recognizable pelvic pathology, pregnancy or general bleeding disorders
have to exclude other causes
pathology for abnormal uterine bleed (AUB)/ heavy menstrual bleed (HMB)
- Fibroids
- Adenomyosis / endometriosis
dysfucntional uterine bleeding - hypothyroidism
- IUCD - copper coils the copper toxicity cause inflammation
- endometrial carcinoma
- clotting abnormalities - von Willebrand’s, thrombocytopenia, platelet disorders, coagulation disorders
- leukaemia.
- polyps
- cervical cancer
what qs to ask during clinical assessment for heavy bleeding
the nature of the bleeding
related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids
impact on her quality of life
other factors that may affect treatment options (such as comorbidities or previous treatment for heavy menstrual bleeding).
Impact on work/social life - do they miss work
bleeding through clothing - how many pads they change
bed soiling or disrupted
sleep due to heavy bleeding
low risk patient wi heavy period
Age <45 No IMB No risk factors for endometrial cancer normal BMI may jave contraceptional needs
low risk clinical assessment
history
examination
1st Ix - FBC
who is high risk patient w heavy period
Age >45IMB
Suspected pathology - ie fibroids
Risk factors for endometrial
- diabetes
- obesity
- PCOS
- strong FH of breast cancer or breast syndromes
cancer
high risk pt assessment for heavy periods w suspected submucosal fibroids, polyps or endometrial pathology
History
Examination
FBC
High risk
hysteroscopy - biopsy
1) they have symptoms such as persistent intermenstrual bleeding or
2) they have risk factors for endometrial pathology (see below).
if hysteroscopy rejected suggest under anaesthaseia if still rejected suggest pelvic US
symptomatic treatment for regular heavy periods not hormonal
the treatment for no identified pathology, fibroids less than 3cm or suspected or diagnosed adenomyosis
tranexamic acid - procoagulant - only take it when period is heavy
plus mefenamic acid - non steroidal inhibits PG synthesis, analgesic, anitimflammatory agent
GIVE BOTH
hormonal treatment for heavy periods
the treatment for no identified pathology, fibroids less than 3cm or suspected or diagnosed adenomyosis
FIRST LINE Mirena system (progestogen laden IUS) - BEST ONE
Progestogen Only Pill (POP)
LARC (long acting reversible contraceptives) such as:
Implant
Depo-Provera - 3 monthly injection
If they want regular bleeding but treat the heavy bleeding
COCP
if fribroids are diagnosed what medical treatment can u suggest
GnRH analogues - downregulate the ovaries put women in temp medical menopause
if polyps are diagnosed causing the heavy bleed Mx
Hysteroscopic removal of polyps (MYOSURE) - endometrium and uterine cavity intact
if fibroids are diagnosed causing the heavy bleed more than 3cm
Myomectomy for fibroids - can still have children BUT depends on clincial circumstances
fibroid/Uterine artery embolization - not suitable for women who wants to have children
heavy bleeding but family complete CONSERVATIVE SURGERY
endometrial ablation (NOVASURE)
family complete definitiv surgery heavy bleed
Hysterectomy (laparoscopic or open)
Excessively heavy menstrual bleeding may be controlled in the short term using the following medications:
tranxemaic acid - bridge
Norethisterone: 5mg po tds for up to 7 days. Can be used in a 3-weeks-on, 1-week-off pattern for 3-4 months to temporise, for example where patient is on waiting list for treatment.
GnRH analogues: Monthly (or quarterly, depending on preparation) injection to downregulate the cycle and induce temporary ‘medical menopause’. Often used to stop very heavy periods in the presence of fibroids, to allow for correction of anaemia and iron stores in preparation for another intervention.
role of tranexamic acid
Inhibit plasminogen activation (inhibit tPA, and uPA), thus reduce fibrinolysis
Reduces MBL by 50%
SEs of tranexamic acid
Nausea, dizziness, tinnitus, rash, abdominal cramp
NSAID role
Inhibit the production of PG and inhibit the binding of PGE2 to its receptor
Reduces MBL by 20-44.5%
SEs of NSAID
gastrointestinal (50%) usually mild. Dizziness and headaches 20%, deranged liver function, asthma, renal disease.
when should testing for coagulation disorders in HMB women should be considered
have had heavy menstrual bleeding since their periods started and
have a personal or family history suggesting a coagulation disorder.
when to consider endometrial biopsy at the time of hysteroscopy
women with persistent intermenstrual or persistent irregular bleeding, and women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome
women taking tamoxifen
women for whom treatment for heavy menstrual bleeding has been unsuccessful.
when to offer pelvic US w heavy menstrual bleeding
their uterus is palpable abdominally
history or examination suggests a pelvic mass
examination is inconclusive or difficult, for example in women who are obese.
when to offer transvaginal US w heavy bleeding
significant dysmenorrhoea (period pain) or
a bulky, tender uterus on examination that suggests adenomyosis.
what do u do if a woman declines transvaginal US
transabdominal US or MRI
pharmacological
hormonal
non-hormonal
surgical treatment
IF FIBROIDS ARE MORE THAN 3 CM
pharmacological:
non-hormonal:
tranexamic acid
NSAIDs
hormonal: LNG-IUS combined hormonal contraception cyclical oral progestogens uterine artery embolisation
surgical:
uterine artery embolisation
myomectomy ONLY MX TO IMPROVE FERTILTY
hysterectomy.
signs of anaemia
pale conjunctiva glossitis - inflammation of the tongue koilonychia pale mucous membranes sores in the corner of the mouth
role of oestrogen during the follicular phase
thins the cervical mucus
thickens the endometrium
during menstruation which layer is shed
only the functional layer the basal layer stays intact
role of progestrone
what produces before implanatation
where is it produced in the later stages of pregnancy
progestrone
allow endometrium to become receptive to implantation of a balstocyst and prevents menstruation occuring
- inhibits LH and FSH production
- initiation of the secretory phase of the endometrium
- increase in basal body temperature
placenta
which Sx are present in a woman whos about to ovulate
increase in basal body temperature
thinning of cervical mucous
what is the proliferative phase and when does it occur
days 1 - 5
increased levels of oestrogen driving repair and growth of the functional endometrial layer
what is the secretory phase and when does it occur
begins after ovulation when the ruptured graafian follicle develops into the corpus luteum.
days 14-28
Role of LH
formation and maintenance of the corpus luteum
thinning of the Graafian follicles membrane
what is endometriosis
chronic oestrogen-dependent condition
growth of ectopic endometrial tissue outside of the uterine cavity
clinical features of endometriosis
- chronic pelvic pain - worse at the time if menstruation or just prior to it
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be see
Ix for endometriosis
GOLD STANDARD - laparoscopy
Mx for endometriosis
FIRST LINE - NASIDs and/or paracetamol
COCP or POP tried
if analgesia/hormonal Mx fails or fertility is a priority do SURGERY
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
routes of administration for HRT
oral - low dose oestrogen
transdermal - gel (oestrogen only) - patch (oestrogen/combined oestrogen and progestrone - spray orestrogen only
- injected beneath the skin
Sequential HRT- starting within 12 months of the last period to minimise the risk of irregular bleeding patterns.
Continuous Combined HRT (cc-HRT)- not had a period for 12 months. women can experience some irregular bleeding in the first 3 months of treatment.
Tibolone - is its own class of HRT. It’s risk profile is broadly the same as ccHRT.
Vaginal Oestrogen – Vaginal pessaries or creams can help with vaginal and urinary symptoms
types of regimen for combined HRT
- Monthly cyclical regimen — oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days.
- Three-monthly cyclical regimen — oestrogen is taken daily and progestogen is given for 14 days every 13 weeks.
- Continuous combined regimen — oestrogen and progestogen are taken daily.
oestrogen related adverse effects
Fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, and dyspepsia.
progestrone related adverse effects
Fluid retention, breast tenderness, headaches or migraine, mood swings, premenstrual syndrome-like symptoms, depression, acne vulgaris, lower abdominal pain, and back pain. They tend to occur in a cyclical pattern during the progestogen phase of cyclical HRT.
2 main hormones used in HRT
oestrogen – types used include estradiol, estrone and estriol
progestogen – a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel
define menopause
Menopause is defined when a woman aged 45 or over has amenorrhoea for at least 12 months.
Her last period naturally.
Ovaries are removed at surgery
Radiotherapy
Chemotherapy
sx of menopause
- menstrual irregularity
- hot flushes
- sweats
- vaginal dryness
- dyspareunia, recurrent UTIs
mood changes - - irritable - loss of concentration
- anxiety
- low mood
- depression
- sleep disturbance, - loss of libido
- joint and muscle ache pain
diagnosis of menopause
clinical
- No blood test is needed after 45 years of age but just treat symptoms only
- Could be done between 40 and 45 years of age - if have irregular periods or considering preg-nancy
- The test should be done for anyone before the age of 40 with perimenopausal symptoms
- This is confirmed when serum FSH levels are more than 40 MIU/ML at least twice 4-6 weeks apart - then can say woman has menopause
FSH levels - high
FBC
TFT
Glucose
what conditions may be associated with menopause
CVS disease osteoporosis urogenital atrophy redistribution of body fat alzheimers
Mx of vasomotor symptoms short term
HRT upto 5 years
what does the oestrogen do in the HRT and in who can we use it
- relieves hot flushes
- prevents vaginal Sx
- maintains bone strength
what does combined HRT do and in who do we use it
women who have nod had a hysterectomy
oestrogen can stimulate the endometrium leading to cancer maybe
progesterone counteract the effects of oestrogen by shedding the endometrium and protect the endometrium
which HRT may result in a bit of bleed
sequential HRT - monthly bleeds
14 days every 13 weeks - bleeds every 3 months
continuous - no bleeds
what is tibolone
oestrogen progestrone testosterone
- relieves menopausal symptoms, prevents bone loss and may improve interest in sex
SEs ass w HRT
breast tenderness leg cramps nausea bloatedness irritability depression irregular bleeding/spotting
diagnosis of premature ovarian insuffieciency
- no periods or infrequent ones
AND
elevated FSH levels on 2 blood samples take 4-6 weeks apart
Mx of premature ovarian insufficiency
hormonal treatment w HRT or a combine hormonal contraceptive
what are endometrial polyps
made of
- benign lesions of surface endometrium
- appear at any age
- subfertility
fibrous tissue covered by columnar epithelium glands
Sx
Ix
Mx of endometrial polyps
asymptomatic
- abnormal uterine bleeding - intermenstrual/HMB/PMB
- US scan -> best detected in the secretory phase of the menstrual cycle
Mx - dilatation and curretage
Types of fibroids and ass sx
Ix
submucosal - distort the pelvic organs/ HMB/infertility
subserosal - pressure on adjacent organs and cause bowel and bladder symptoms
intramural
US of abdomen
hysteroscopy
laparoscopy
fibroids are more common in who
most common in 30-50 afro carribean ethnicity obesity nulliparous (PCOS) diabetes hypertension FH of fibroids. Pregnancy causes enlargement and the menopause is associated with involution. age
what is ‘red degeneration’ fibroids
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
> 5cm fibroids
occur in pregnancy, after mx with embolisation
severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
Sx and signs of fibroids
abnormal uterine bleeding
pelvic pain -> acute - torsion or prolapse
dysparaeunia
abdominal pain worse during mens
bloating/feeling full in the abdomen
pressure - palpable in abdomen, bladder, rectum - increased urinary frequency, tenesmus - change in bowel habit
complciations of pregnancy -> recurrent miscarriage SUBMUCOUS fibroids, obstruct
PPH
preterm labour
perinatal morbidity
infertility
what is adenomyosis
characterized by the invasion
of endometrial glands and stroma into myometrium with
surrounding smooth muscle hyperplasia.
pelvic pain and heavy bleeding during menstruation
presence of endometrial tissue in the myometrium
Ix for adenomyosis
transvaginal US even if pelvis looks normal if contradicted do transabdominal US
histological assessment from hysterctomy
clinical presentation of endometriosis/adenomyosis
parous women
- dysmenorrhea
- HMB
- Painful intercourse (dyspareunia),
- Painful defecation (dyschezia) and
- Painful urination (dysuria)
- Heavy periods
- Lower abdominal pain persistent
- IMB and PCB
- Epistaxes , rectal bleeding
- Little correlation between symptom severity and disease severity
microscopic appearance of adenomyosis
whorl-like trabeculated appearance -> dark haemorrhagic spots
PMDD
very severe form of premenstrual syndrome (PMS), which can cause many emotional and physical symptoms every month during the week or two before you start your period. It is sometimes referred to as ‘severe PMS’.
make it difficult to work, socialise and have healthy relationships. In some cases, it can also lead to suicidal thoughts.
mood swings feeling upset or tearful feeling angry or irritable feelings of anxiety feeling hopeless feelings of tension or being on edge difficulty concentrating feeling overwhelmed lack of energy less interest in activities you normally enjoy suicidal feelings
Complications of fibroids
Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare
what is primary dysmenorrhoea
no underlying pelvic pathology
Excessive endometrial prostaglandin production is thought to be partially responsible.
Features
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
Management
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
secondary dysmenorrhoea
underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include: endometriosis adenomyosis pelvic inflammatory disease intrauterine devices* fibroids
what is premenstrual syndrome
describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
presence of ovulatory menstrual cycles
Emotional symptoms include: anxiety stress fatigue mood swings
Physical symptoms
bloating
breast pain
Mx of Premenstrual syndrome
- mild symptoms can be managed with lifestyle advice
- apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates - moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg) - severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
conservative Mx of menopause
- Exercises
- Running, Swimming and Yoga are highly recommended
- Smoking cessation
- Reduced alcohol and coffee intake also helps with symptoms of hot flushes and night sweats.
Mediterranean style diet
Bio-identical hormones
herbal meds
vaginal lubricants
acupuncture/homeopathy
psych Mx - CBT has been proven to elevate the low mood or anxiety
Benefits of HRT
when is it CI in a pt
most effective Mx for hot flushes and low mood
- increase libido
- reduce vaginal dryness
- prevents osteoporosis
- reduce urinary sx
oestrogen only increases risk of endometrial
combined increases risk of breast
Hx of thromboembolism
Hx of breast cancer
Hx of migraines
