Menstrual Dysfunction Flashcards
How do you assess menstrual dysfunction in a woman?
Heavy menstrual bleeding effects 20-30% of women during their reproductive life. It is more important to assess by the impact that it is having on a woman’s life rather than trying to measure exact blood loss. However, the passage of blood clots is an indicator of excessive loss.
What questions do you ask in a woman with abnormal vaginal bleeding?
- Woman’s age - >/= 45yrs considered at higher risk for serious underlying pathology
- Is bleeding regular - irregular bleeding is more likely to be pathological so is a worrying feature and malignancy must be excluded
- Does she complain of other symptoms associated with fibroids - heaviness in the pelvis, urinary symptoms or fibroids seen on previous scan
- Any previous hx - any bleeding disorders like vW disease, symptoms of thyroid dysfunction?
- FH of coagulation disorders
- Any medications - any contraception e.g. copper coil can make periods heavier; any anticoagulants?
- Consider whether the woman wants to have more children in future (affects treatment choice)
What examination do you do on a woman who has abnormal vaginal bleeding?
- Speculum exam to look at vulva, vagina and cervix (to exclude an obvious vaginal or cervical lesion) - although cervical pathology does not cause menorrhagia, it may cause irregular bleeding
- Bimanual exam (pressing the fingers through the vagina to feel the cervix and palpating the stomach (where the uterus would be - can be enlarged in fibroids) to feel for any abnormalities e.g. fibroids
- Also check if the woman is anaemic and confirm the woman’s smear history
What does the endometrial thickness indicate?
A normal endometrial thickness largely depends on the timing of the scan in relation to the menstrual cycle.
- The endometrial thickness would be thickest in the secretory phase up to 16mm.
- On your period it would be around 2-4mm
What are red flag symptoms/signs for immediate 2 week wait referral?
- Age >45yrs refer for a hysteroscopy if presenting with abnormal uterine bleeding
- Intermenstrual bleeding
- Postcoital bleeding
- Postmenopausal bleeding
- Abnormal exam findings e.g. pelvic mass or lesion on cervix
- Treatment failure after 3 months
What is a hysteroscopy?
- A hysteroscope is a narrow lumen camera which is passed through the cervical os to enable visualisation of the uterine cavity. It is also used to take biopsies of the endometrium and any suspicious areas.
- A hysteroscopy is usually performed in the outpatient’s department without the need for anaesthetic however in cases where cervical dilatation is needed, injections of cervical LA can be used.
- Fibroids, polyps and adhesions within the endometrial cavity can also be treated via hysteroscopy.
What are indications for a hysteroscopy?
- Sterility
- Infertility
- Menstrual disorders
- Suspicious ultrasonic endometrial findings
- Check-ups after intrauterine interventions
- Check-ups after endometrial hyperplasia with medication
- Lost IUD
What are the medical treatment options for heavy menstrual bleeding?
- Mirena intrauterine system (IUS) - 1st line treatment, unless patient wishes to conceive or there are other contraindications
- Non-hormonal medical treatment such as tranexamic acid and mefanamic acid (NSAIDs) which can be useful for patients still wishing to conceive
- COCP or oral progestogens (can suppress menstruation)
- Levonorgestrel IUD are often good
- It is strongly advised that women try these interventions for 3 months (6 months for Mirena) before pursuing other options
What are the surgical treatment options for heavy menstrual bleeding?
Examples are endometrial ablation, hysterectomy, removal of anatomic source e.g. fibroid, polyp. These options need to be discussed with the patient thoroughly as they are considered permanent and all options for fertility would be removed. They may be preferable for women who prefer to have no periods at all.
Describe the Mirena coil
- 1st line for menorrhagia
- Small intra-uterine device containing progestogen - greatly reduces endometrial proliferation - reduces blood loss
- Can be inserted easily in clinic without need for anaesthetic
- GP check up 6 weeks after implantation to check it’s stayed in place (speculum exam to check threads are present)
- Side effects: risk of ovarian cysts, acne, mood changes, breast soreness. Some women report weight gain but that is not proven. Very rarely there is a risk that the Mirena will expel and a small risk it will be imbedded into the myometrium
What are the main causes of abnormal uterine bleeding?
PALM COEIN
- Polyps
- Adenomyosis (cells of uterus lining grow into uterus muscle)
- Leiomyoma (fibroids)
- Malignancy
- Coagulopathy (liver decreases coag factors) e.g. VW disease
- Ovulatory dysfunction
- Endometrial process (effected by oestrogen)
- Iatrogenic
- Not yet classified
What is the most common cause for abnormal uterine bleeding in adolescent women?
Ovulatory dysfunction due to anovulatory bleeding due to disorder of HPO axis (e.g. PCOS). The regular periods are usually sorted out by 2-3 years of menarche.
What are other causes of abnormal uterine bleeding?
- Dysfunctional uterine bleeding (bleeding of unknown cause)
- Pregnancy and complications
- STIs e.g. chlamydia and gonorrhoea
- Ask about herbal remedies and contraception (hormonal contraception can cause breakthrough bleeding within 3 months of starting)
What are peri-menopausal women more at risk of?
Polpys, adenomyosis, leiomyomas and malignancies, ovulatory dysfunction secondary to declining ovarian function.
What should be looked for in an examination for abnormal uterine bleeding?
- Excessive weight gain
- Signs of PCOS e.g. hirsutism and acne
- Signs of thyroid disease
- Evidence of insulin resistance (PCOS can cause this)
- Signs of bleeding disorder: petechiae, ecchymosis, skin pallor or swollen joints
- Pelvic exam: bimanual exam to assess size and contour of uterus
