Menstrual Disorders (HMB, AUB) Flashcards
What is the definition of Chronic AUB?
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
What is the definition of Acute AUB?
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
What is the FIGO definition of normal frequency of menstrual periods
24-38 days (inclusive)
Therefore
> 38 days is infrequent
< 24 days is frequent
What is the FIGO definition of normal duration of a menstrual period?
≤8 days inclusive
Therefore, prolonged > 8 days
What is the FIGO definition of normal regularity of menstrual cycle?
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
What are the FIGO definitions for flow volume
Light, normal or heavy
PATIENT DEFINED
NICE definition of HMB: bleeding volume sufficient to interfere with the woman’s quality of life
What is the FIGO AUB System 2?
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
FIGO suggests endometrial sampling for all women with AUB over what age?
45 years
What are screening questions you can ask a woman with HMB to detect coagulopathies?
- HMB since menarche
- One of PPH, surgical related bleeding, or bleeding with dental work
- Two or more of: bruising 1-2x /month, epistaxis 1-2x / month, frequent fum bleeding, fam hx of bleeding symptoms
What are the contra-indications to endometrial ablation? (7)
- Large uterus > 12 week size or large uterine cavity > 12cm length
- Large submucous fibroid > 2cm
- Non-benign endometrial pathology
- Cervical cancer
- Current pelvic infection
- Hysterectomy is required for another condition
- Desire to preserve fertility
How much levonorgestrel does the Mirena release daily?
20micrograms / 24 hours
What were the findings of the Cochrane review looking at first generation vs second generation endometrial ablation?
Second generation
- shorter operating times
- more likely to be performed under LA (rather than GA)
No difference in
- amenorrhoea
- patient satisfaction
When organising a Pelvic USS to investigate HMB, at what point in the cycle should it be requested for?
Early follicular phase of cycle
Red herring if thickened endometrium in lateral phase of cycle (as it is physiologically thickened at this stage)
What are five complications of endometrial ablation?
Uterine perforation Haemorrhage Infection Haematometra PATTS: Post-ablation tubal sterilisation syndrome (6-8%) 2-3 years post op
Endometrial polyps larger than _____ are unlikely to regress
1cm
What % of women age 18 to 50 have AUB?
5%
Regarding Mirena:
What is the efficacy?
Does Mirena reduce the risk of cervical malignancy?
Efficacy 70-95%
Reduces cervical malignancy by 30%
Regarding cyclical oral progestogens
What is the efficacy?
Efficacy 87%
Regarding COCP:
What is the efficacy?
What additional benefits does it have apart from lighter bleeding and reducing dysmenorrhoea?
Efficacy 35-70%
Benefits:
- Contraceptive
- Reduces acne
- Can avoid bleeding
What is the efficacy of TXA in reducing HMB?
25-55%
What is the efficacy of NSAIDs in reducing HMB?
10-50%
What are disadvantages of endometrial ablation?
- 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
What are the disadvantages of uterine artery embolisation?
- 25% risk of hysterectomy
- Loss of fertility; not for women desiring fertility
- Risk of ovarian failure
- Fibroid expulsion and associated complications
What are the disadvantages of hysterectomy?
- Surgical (bleeding, intrabdominal injury) and anaesthetic complications
- Loss of fertility.
- Possible impact on bladder function, sexual function
- Possible loss of ovarian function
- Earlier menopause
What is the pathophysiology behind fibroids causing HMB?
- Abnormalities of uterine vasculature
- Abnormal contractility leading to impaired endometrial haemostasis
- Molecular dysregulation of angiogenic factors
What are the effects of fibroids on:
Fertility
Obstetric outcomes
Fertility:
- Reduced fertility especially if submucous.
Obstetric:
- Miscarriage
- Placental abruption
- FGR
- Malpresentation
- Preterm labour
- Obstructed labour
What rare complications can occur with fibroids?
- Ectopic secretion of hormones e.g. EPO, parathyroid hormone-related protein, prolactin
- IVC compression and VTE
- Complete urinary obstruction
What operations may you need to perform for complications following uterine artery embolisation for uterine fibroids?
- Submucous: hysteroscopic retrieval
- Pedunculated or subserosal: laparoscopic retrieval
Mechanism of AUB in fibroids
Abnormal uterine vasculature Impaired endometrial haemostasis Dysregulation of angiogenic factors Increased surface area Altered uterine contractility
What percentage of women with AUB will have:
- Coagulation disorder?
- vWF deficiency?
- 20%
- 13%
What screening q should be asked to determine if there’s a chance of underlying coagulation disorder?
- 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
How much may TXA reduce bleeding by?
Mechanism of action?
30-55%
Prevents fibrin degradation
Early complications of UAE
Embolisation syndrome: fever, nausea, pain, malaise
Vaginal discharge,
pelvic infection,
expulsion of necrotic submucous fibroid
According to the RANZCOG guideline, what are the 3 most common complications from UAE?
- Discharge and fever – 4%
- Bilateral UAE failure (4%)
- Postembolisation failure (2.86%)
A rare, though concerning, complication is VTE (0.286%)
What effect can UAE have on ovarian reserve?
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.
What is the prevalence of HMB?
1/4 -1/6 women reproductive age
Define HMB.
> 80ml blood loss during menses (only for research)
Excessive menstrual blood loss that interferes with physical, psychological, social or material well being (NICE 2018)
How should PCB be managed?
Speculum examination Cervical smear (cytology and HrHPV in Aus) STI screen (chlamydia)
If persistent PCB despite the above - warrant gynaecology referral.
How should IMB be managed?
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
