Menstrual dysfunction Flashcards
What are considered ‘red flag’ situations in GP requring urgent referral to secondary care?
Age >40 years
Age >35 years plus:
- Unopposed oestrogen use
- Nulliparity
- PCOS
- Weight >90kg
- Familial uterine cancer syndrome
Association with high grade Pap smear
What are the important questions to focus on in the history of a patient with menstrual disturbance?
LMP, LMP, always LMP
Length of symptoms, days bleeding, presence of clots
Contraception
Menstrual diary
Symptoms of anaemia
Reproductive history
Med/Surg history, FHx, drugs, etc.
Fertility wishes
What are you looking for on examination?
General: ?anaemia, thyroid status
Abdominal: masses, e.g. fibroid uterus
Speculum: cervical lesion, e.g. cancer, ectropion, fibroid polyp
Bimanual: size, a/v or r/v, mobile or fixed, uterine masses, adnexal masses
Which investigations are relevant for menstrual disorders?
Haemoglobin
Iron studies
TFTs if indicated
Serum testosterone if PCOS suspected
Transvaginal scan of the pelvis - ?fibroids, endometrial thickness
How can you stop the bleeding for someone with a dysunctional beed?
High dose continuous progestogens
Medroxyprogesterone acetate (Provera) 30mg daily - continue for a month
If cycles anovulatory, may need subsequently need cyclical progestogens to control menses if COC contraindicated
What are non-hormonal approaches to managing menorrhagia?
Tranexamic acid (antifibrinolytic): 500mg - 1.5g TDS to QID. Start on the first day of the period (or the day before if immediate premenstrual symptoms reliable). Take only while menstruating
NSAIDs
What are the hormonal options for treating menorrhagia?
Combined oral contraceptive pill - consider tri-cycle
Mirena
Cyclical progestogens
What if the endometrium is abnormal on ultrasound - e.g. >15mm
Repeat scan early follicular phase, when it should be thinnest
Pipelle in select cases
Hysteroscopy if polyp suspected or high risk for endometrial hyperplasia/cancer
Hysteroscopy can be outpatient or under GA
What are the surgical options for the management of menorrhagia?
Endometrial ablation - most successful in >45y, may need repeat in younger women after 5-7 years. Aim is eumenorrhea not amenorrhoea
Myomectomy if fertility desired:
- submucous - hysteroscopic
- intramural/subserosal - open/laparoscopic
Hysterectomy - abdominal, vaginal, laparoscopic
Define the types of dysmenorrhoea
Primary: menstrual pain without an underlying pathology
Secondary: menstrual pain with an underlying pathology
Give four differential diagnoses of secondary dysmenorrhoea.
- Endometriosis
- Adenomyosis
- Uterine polyps
- Uterine anomalies (e.g. non-communicating uterine horn)
- Fibroids/leiomyoma
- Intrauterine synechiae
- Ovarian cysts
What is the commonest cause of secondary dysmenorrhoea?
Endometriosis
Give four differential diagnoses of menorrhagia
Fibroids/Leiomyoma
Adenomyosis
Anovulation
Idiopathic
Endometrial hyperplasia
Give four non-gynaecological differential diagnoses of menorrhagia
Endocrine: hyper/hypothyroidism, hyperprolactinaemia
Haematological: coagulopaties (vWD), PLT abnormalities (ITP)
Renal failure: impairs oestrogen excretion
Liver disease: ↓ clotting factors
Drugs
Give and justify 5 blood tests that may be done when working up menorrhagia.
FBC: ?anaemia, ?quantitative PLT abnormality
Iron studies: ?iron deficient from bleeding
TFTs: ?hyper/hypothyroidism
Prolactin: ?hyperprolactinaemia
PCOS bloods: testosterone
Coagulation profile: e.g. vWF activity assay if primary menorrhagia
Give three medical treatment options for menorrhagia.
Tranexamic acid: antifibrinolytic
NSAIDs: anti-prostaglandin
Hormonal (COCP, DepoProvera): cycle control
What is the red flag condition to consider in a post-menopausal woman with PV bleeding?
Endometrial cancer
Give two hypothalamic, two pituitary and two ovarian causes of anovulation.
Hypothalamus: excessive exercise, ↓ BMI
Pituitary: Hypopituitarism, SOL e.g pituitary adenoma + hyperprolactinaemia
Ovarian: PCOS, premature ovarian failure
Give two hormonal blood tests that may aid in diagnosing anovulation.
Day 3 FSH: FSH should be low in the early follicular phase of the cycle. A high FSH at this time could mean premature ovarian failure (premature menopause)
Progesterone 7 days before expected menses (e.g. day 21 in 28 day cycle): corpus luteum should have formed and be producing progesterone
Define the types of amenorrhoea.
Primary: lack of menstruation by the age of 16 in the presence of secondary sexual characteristic or 14 in their absence.
Secondary: absence of menstruation for 6 months
Name two physiological causes of amenorrhoea.
Lactation
Menopause
Pregnancy
Name three pathological causes of amenorrhoea.
- Stress
- Anorexia
- Excessive exercise
- SOL
- Micro or macroadenoma
- Sheehan’s syndrome
- PCOS
- Premature ovarian failure
- Asherman’s syndrome
- Hyperprolactinaemia
- Cushing’s syndrome
- Congenital adrenal hyperplasia
Give four blood tests you would consider in patients with amenorrhoea.
- Pregnancy test
- FSH/LH
- in premature ovarian failure
- in hypothalamic causes
- Testosterone ?diagnosis of PCOS
- Prolactin
- TFTs
What is oligomenorrhoea?
Infrequent menstrual periods
- Cycles are longer than 32 days
- Usually represent anovulation or intermittent ovulation
Name three causes of oligomenorrhoea.
- PCOS - most common cause
- Borderline or low BMI
- Obesity (without PCOS)
- Ovarian resistance / premature ovarian failure
- Mild hyperprolactinaemia
- Mild thyroid disease
What can be used to regulate cycles in patients with oligomenorrhoea?
- COCP
- Cyclical progestagens
Name three causes of intermenstrual bleeding.
- Uterine fibroids - submucosal
- Uterine polyps
- Cervicitis
- IUD
- Ectopic pregnancy or miscarriage
- Hypothyroidism
- Cervical or uterine cancer
Name three investigations you would perform on a patient with intermenstrual bleeding.
- PAP smear
- vaginal swabs for chlamydia and gonorrhoea
- FBC - may be anaemic
- TFTs - may have hypothyroidism
- ßhCG to exclude ectopic/miscarriage
- USS - assess endometrium/investigate for masses
When does menarche typically occur?
- Mean age is 12.5 years
- Puberty onset can be anywhere from 8 - 13y
