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
