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B2 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

Shortest to longest cycle variation =7-9 days

Irregular if variation >/= 8-10 days

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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

What is the FIGO Leiomyoma Subclassification System?

A

Submucous SM (0-2) vs Other O (4-8)

0 - Pedunculated intracavity
1 - <50% intramural
2 - >/=50% intramural
3 - Contacts endometrium, 100% intramura
4 - Intramural
5 - Subserous >/= 50% intramura
6 - Subserous < 50% intramural
7 - Subserous pedunculated
8 - Other (specify, e.g. cervical)
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9
Q

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

A

45 years

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10
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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11
Q

Which fibroids are associated with reduced fertility and increased miscarriage rate?

A

Submucosal ARE

Intramural MAY be

Subserosal are NOT

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12
Q

What are three indications for myomectomy in infertile women?

A
  1. Infertile women and those undergoing ART who have SM fibroids
  2. Infertile women with symptomatic fibroids
  3. Couple presenting with multiple failed cycles of ART where the female partner has IM fibroids
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13
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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14
Q

How is Uterine Artery embolisation done?

A

Placement of angiographic catheter into the uterine arteries
Via the common femoral artery
Injection of embolism particles until the flow becomes sluggish in both uterine arteries

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15
Q

What is the aim of uterine artery embolisation?

A

To reduce blood flow at the arteriolar levels
Producing ischaemia injury to the fibroids
Causing necrosis and shrinkage
Whilst allowing the surrounding normal myometrium to recover under supply of vaginal and ovarian collateral circulations

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16
Q

What were the Cochrane review findings, on UAE vs surgical management (myoemctomy / hysterectomy) for HMB? (6)

A
  1. No significant difference in patient satisfaction at 2 years and 5 years
  2. Similar intra-procedural complications
  3. No difference in short or long term complications
  4. No difference in long-term ovarian failure rates

With UAE

  1. Reduced length of procedure, hospitalisation and time to resumption of normal activities
  2. Increased rate of short and long-term minor complications, number of unplanned reviews and re-admissions after discharge, surgical re-intervention rate
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17
Q

What are procedural complications of UAE?

A

Groin haematoma
Arterial thrombosis
Pseudo-aneurysm

Embolisation syndrome: fever, nausea, pain, malaise
Vaginal discharge, pelvic infection, expulsion of necrotic submucous fibroid

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18
Q

What are the late complications of UAE?

A

Ovarian insufficiency
Failure of response
Need for re-intervention

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19
Q

What are the pregnancy outcomes after UAE?

A

No difference in PTB, IUGR, mal presentation

Significantly higher rates of CS, PPH, miscarriage

20
Q

What are contraindications to UAE?

A
  1. Current pregnancy
  2. Recent or current pelvic infection

Relative contra-indication

  1. Narrow-stalked, pedunculated and large intra-cavity submucosal fibroids
    - at risk of detaching and sloughing into the endometrial cavity, leaving to cervical obstruction and occasionally seps
21
Q

How much levonorgestrel does the Mirena release daily?

A

20micrograms / 24 hours

22
Q

What is the optimal imaging to evaluate uterine fibroids?

A

MRI
Sonohysterography
Hysteroscopy (this may under-represent SM lesions because of raised intra-uterine pressure)

HSG and TV USS are insufficiently sensitive or specific

RANZCOG Guideline

23
Q

Is medical management of fibroids in the context of infertility recommended?

A

No
It delays efforts to conceive
However, shorter term use of a GnRH analogue can be useful for pre-operative correction of anaemia or short term reduction in fibroid volume

RANZCOG Guideline

24
Q

For women that have umbilical artery embolisation for fibroids with HMBN, what % will go on to have a hysterectomy within 10 years?

A

35%

25
Q

What are fertility outcomes for women with fibroids, treated with UAE vs myomectomy?

A

UAED group, significantly

  • lower pregnancy rates
  • higher miscarriage rates
26
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
27
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)

28
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
29
Q

What is the incidence of fibroids

A

12-25% reproductive women

30
Q

What is MRgFUS?

What are the advantages and disadvantages of this therapy?

A

MRI guided focused Ultrasound
Management option for Uterine fibroids / HMB in PREmenopausal women who have completed their families

Thermoablative technique: uses ultrasound pulses to heat and destroy fibroid tissue

Advantages

  • Noninvasive
  • Uterus preserving, potentially could conceive
  • Short recovery time
  • MAY restore / preserve fertility but no long term data

Disadvantages

  • low rate of complications
  • nephrogenic systemic fibrosis from gadolinium contrast. Rare, usually in pre-existing CKD
  • skin burns
  • bowel injury, nerve injury and damage
31
Q

What % endometrial polyps are benign?

A

> 95%

32
Q

Endometrial polyps larger than _____ are unlikely to regress

A

1cm

33
Q

What % of women age 18 to 50 have AUB?

A

5%

34
Q

Regarding Mirena:

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

A

Efficacy 70-95%

Reduces cervical malignancy by 30%

35
Q

Regarding cyclical oral progestogens

What is the efficacy?

A

Efficacy 87%

36
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
37
Q

What is the efficacy of TXA in reducing HMB?

A

25-55%

38
Q

What is the efficacy of NSAIDs in reducing HMB?

A

10-50%

39
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
40
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
41
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
42
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
43
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
44
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
45
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

46
Q

Mechanism of AUB in fibroids

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

B2 Gynaecology (12 decks)

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