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General Gynaecology > Menstrual Disorders (HMB, AUB) > Flashcards

Menstrual Disorders (HMB, AUB) Flashcards

1
Q

What is the definition of Chronic AUB?

A

Bleeding from the uterine corpus that is abnormal in duration, volume, frequency and/or regularity
And has been present for the preceding SIX Months

FIGO

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2
Q

What is the definition of Acute AUB?

A

An episode of HMB that in the opinion of the clinician, is of sufficient quantity to require immediate intervention to minimise or prevent further blood loss

FIGO

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3
Q

What is the FIGO definition of normal frequency of menstrual periods

A

24-38 days (inclusive)

Therefore
> 38 days is infrequent
< 24 days is frequent

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4
Q

What is the FIGO definition of normal duration of a menstrual period?

A

≤8 days inclusive

Therefore, prolonged > 8 days

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5
Q

What is the FIGO definition of normal regularity of menstrual cycle?

A

Cycle variation =≤7 days (26-41 yo) or ≤ 9 days (<26 or >41 yo)

Therefore Irregular if variation >/= 8-10 days

Cycle regularity changes significantly after 45yo

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6
Q

What are the FIGO definitions for flow volume

A

Light, normal or heavy
PATIENT DEFINED

NICE definition of HMB: bleeding volume sufficient to interfere with the woman’s quality of life

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7
Q

What is the FIGO AUB System 2?

A

Classification of Causes of AUB in the reproductive years
Structural (PALM) and Non-structural (COEIN)

P - Polyp
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia

C - Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Iatrogenic 
N - Not otherwise classified
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8
Q

FIGO suggests endometrial sampling for all women with AUB over what age?

A

45 years

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9
Q

What are screening questions you can ask a woman with HMB to detect coagulopathies?

A
  1. HMB since menarche
  2. One of PPH, surgical related bleeding, or bleeding with dental work
  3. Two or more of: bruising 1-2x /month, epistaxis 1-2x / month, frequent fum bleeding, fam hx of bleeding symptoms
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10
Q

What are the contra-indications to endometrial ablation? (7)

A
  1. Large uterus > 12 week size or large uterine cavity > 12cm length
  2. Large submucous fibroid > 2cm
  3. Non-benign endometrial pathology
  4. Cervical cancer
  5. Current pelvic infection
  6. Hysterectomy is required for another condition
  7. Desire to preserve fertility
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11
Q

How much levonorgestrel does the Mirena release daily?

A

20micrograms / 24 hours

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12
Q

What were the findings of the Cochrane review looking at first generation vs second generation endometrial ablation?

A

Second generation

  • shorter operating times
  • more likely to be performed under LA (rather than GA)

No difference in

  • amenorrhoea
  • patient satisfaction
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13
Q

When organising a Pelvic USS to investigate HMB, at what point in the cycle should it be requested for?

A

Early follicular phase of cycle

Red herring if thickened endometrium in lateral phase of cycle (as it is physiologically thickened at this stage)

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14
Q

What are five complications of endometrial ablation?

A 
Uterine perforation
Haemorrhage
Infection
Haematometra
PATTS: Post-ablation tubal sterilisation syndrome (6-8%) 2-3 years post op
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15
Q

Endometrial polyps larger than _____ are unlikely to regress

A

1cm

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16
Q

What % of women age 18 to 50 have AUB?

A

5%

17
Q

Regarding Mirena:

What is the efficacy?
Does Mirena reduce the risk of cervical malignancy?

A

Efficacy 70-95%

Reduces cervical malignancy by 30%

18
Q

Regarding cyclical oral progestogens

What is the efficacy?

A

Efficacy 87%

19
Q

Regarding COCP:

What is the efficacy?
What additional benefits does it have apart from lighter bleeding and reducing dysmenorrhoea?

A

Efficacy 35-70%

Benefits:

  • Contraceptive
  • Reduces acne
  • Can avoid bleeding
20
Q

What is the efficacy of TXA in reducing HMB?

A

25-55%

21
Q

What is the efficacy of NSAIDs in reducing HMB?

A

10-50%

22
Q

What are disadvantages of endometrial ablation?

A
  • Incomplete destruction of endometrium and haematometra
  • Post ablation tubal sterilisation syndrome
  • Needs additional contraception
  • Cannot and should not get pregnant; risk of morbidly adherent placenta
  • Thermal injury
  • Infection
  • Uterine perforation
23
Q

What are the disadvantages of uterine artery embolisation?

A
  • 25% risk of hysterectomy
  • Loss of fertility; not for women desiring fertility
  • Risk of ovarian failure
  • Fibroid expulsion and associated complications
24
Q

What are the disadvantages of hysterectomy?

A
  • Surgical (bleeding, intrabdominal injury) and anaesthetic complications
  • Loss of fertility.
  • Possible impact on bladder function, sexual function
  • Possible loss of ovarian function
  • Earlier menopause
25
Q

What is the pathophysiology behind fibroids causing HMB?

A
  • Abnormalities of uterine vasculature
  • Abnormal contractility leading to impaired endometrial haemostasis
  • Molecular dysregulation of angiogenic factors
26
Q

What are the effects of fibroids on:
Fertility
Obstetric outcomes

A

Fertility:
- Reduced fertility especially if submucous.

Obstetric:

  • Miscarriage
  • Placental abruption
  • FGR
  • Malpresentation
  • Preterm labour
  • Obstructed labour
27
Q

What rare complications can occur with fibroids?

A
  • Ectopic secretion of hormones e.g. EPO, parathyroid hormone-related protein, prolactin
  • IVC compression and VTE
  • Complete urinary obstruction
28
Q

What operations may you need to perform for complications following uterine artery embolisation for uterine fibroids?

A
  • Submucous: hysteroscopic retrieval

- Pedunculated or subserosal: laparoscopic retrieval

29
Q

Mechanism of AUB in fibroids

A 
Abnormal uterine vasculature 
Impaired endometrial haemostasis
Dysregulation of angiogenic factors
Increased surface area 
Altered uterine contractility
30
Q

What percentage of women with AUB will have:

  • Coagulation disorder?
  • vWF deficiency?
A
  • 20%

- 13%

31
Q

What screening q should be asked to determine if there’s a chance of underlying coagulation disorder?

A
  • HMB since menarche?
  • 1 of the following:
  • PPH
  • Surgery related bleeding
  • bleeding after dental work
  • 2 or more of the following:
  • Bruising 1-2x a month
  • Epistaxis 1-2x a month
  • Frequent gum bleeding
  • Fhx of bleeding sx
32
Q

How much may TXA reduce bleeding by?

Mechanism of action?

A

30-55%

Prevents fibrin degradation

33
Q

Early complications of UAE

A

Embolisation syndrome: fever, nausea, pain, malaise

Vaginal discharge,
pelvic infection,
expulsion of necrotic submucous fibroid

34
Q

According to the RANZCOG guideline, what are the 3 most common complications from UAE?

A
  • Discharge and fever – 4%
  • Bilateral UAE failure (4%)
  • Postembolisation failure (2.86%)

A rare, though concerning, complication is VTE (0.286%)

35
Q

What effect can UAE have on ovarian reserve?

A

A retrospective study (with temp not permanent embolic agents) of ovarian reserve noted a significant reduction in AMH 3 months after
UAE.

Women under the age of 40 showed a partial recovery of AMH by 12 months, but women over 40 did not.

36
Q

What is the prevalence of HMB?

A

1/4 -1/6 women reproductive age

37
Q

Define HMB.

A

> 80ml blood loss during menses (only for research)

Excessive menstrual blood loss that interferes with physical, psychological, social or material well being (NICE 2018)

38
Q

How should PCB be managed?

A 
Speculum examination
Cervical smear (cytology and HrHPV in Aus)
STI screen (chlamydia)

If persistent PCB despite the above - warrant gynaecology referral.

39
Q

How should IMB be managed?

A

Single episode - no management required, especially if on hormonal medication.

Recurrent IMB:

  • Speculum examination
  • Cervical smear (cytology and HrHPV in Aus)
  • STI screen (chlamydia)
  • Pelvic USS
  • Referral to gynaecologist

General Gynaecology (16 decks)

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