Menstrual dysfunction Flashcards
1
Q
Normal endometrial thickness
A
- Determined by USS.
- 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.
2
Q
Vaginal Bleeding: Red flag signs + symptoms
A
- Age >45 years
- Intermenstrual bleeding
- Post-coital bleeding
- Post-menopausal bleeding
- Abnormal examination findings (e.g. pelvic mass/lesion on cervix)
- Treatment failure after 3 months
Any of these warrant immediate 2WW referral to secondary care.
3
Q
Hysteroscopy: DEFINITION
A
A hysteroscope is a narrow lumen camera which passes 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. Fibroids, polyps and adhesions within the endometrial cavity can also be treated via hysteroscopy.
4
Q
Treatment for heavy menstrual bleeding:
A
- Invasive
- Non-invasive
5
Q
Adenomyosis:
- Definition
- Features
- Management
A
Definition: Is characterised by the presence of endometrial tissue within the myometrium. It is more common in mutliparous women towards the end of their reproductive years.
Features:
- Dysmenorrhoea
- Menorrhagia
- Enlarged boggy uterus
Management:
- GnRH agonist
- Hysterectomy
6
Q
Abnormal Uterine Bleeding (AUB): Definition
A
Definition: Menstrual flow outside of normal regularity, frequency, volume or duration. It is a common medical problem. It has a medical, social, sexual and emotional impacts. The 5-10 years prior to menopause are the most common time for AUB to occur.
7
Q
Abnormal Uterine Bleeding (AUB): Causes
PALM COEIN
A
- P - polyp
- A - adenomyosis
- L - Leiomyoma (fibroids)
- M - Malignancy
- C - Coagulopathy
- O - Ovarian dysfunction (PCOS)
- E - Endometrial dysfunction
- I - Iatrogenic
- N - Not yet classified
8
Q
Endometrial ablation: Definition
A
Endometrial ablation is a procedure that surgically destroys (ablates) the lining of your uterus (endometrium).
Endometrial ablation reduces heavy periods in about 90% of patients and in about 50% it will stop them from having periods completely.
Main risks of ablation:
- Uterine perforation
- Infection
9
Q
Mirena
- Definition
- Side effects
A
Definition: The Mirena is a small intra-uterine device that contains progesterone. Its primary action is as a contraceptive, but the progesterone significantly reduces endometrial proliferation and hence reduces menstrual blood loss. It can be inserted easily in a clinic setting without the need for anaesthetic.
Side effects:
- Ovarian cysts
- Acne
- Weight gain
- Mood changes
- Breast soreness
Small risk of:
- Mirena being expelled
- Mirena becoming imbedded into the myometrium
10
Q
Benign neoplasms of the uterus: Types (2)
A
- Uterine fibroids
- Endometrial polyps
11
Q
Benign neoplasms of the uterus: Uterine fibroids
- Definition
- Symptoms
- Types
- Diagnosis
- Treatment
A
Definition: benign tumours arising from the myometrium of the uterus. Also called leiomyomata. Composed primarily of smooth muscle, but may also contain fibrous tissue.
Symptoms:
- Dysmenorrhoea
- Menorrhoea
- Pressure symptoms
- Pelvic pain
Types of uterine fibroids:
- Submucous
- Subserous
- Cervical
- Pedunculated
- Parasitic
- IV leiomyomatosis
Diagnosis:
- Clinical examination
- TVUS or abdo US
Treatment:
- Conservative: no treatment
- Medical: GnRH analogues (prior to surgery)
- Surgical: Myomectomy, hysterectomy, uterine artery embolization
12
Q
Benign neoplasms of the uterus: Endometrial polyps (adenoma)
A
- Focal overgrowth of the endometrium.
- They are malignant in <1%.
- More common in women <40 years.
- However can occur at any age.
- Treatment: resection during hysteroscopy.
- Polyp should be sent for histology.
N.B. A polyp can be a fibroid. Polyps are a growth on a stalk. Fibroid is a definition of tissue.
13
Q
Menstrual cycle: Overview
A
- Involves coordinated hormonal control of the endometrium.
- Allowing pregnancy or regular shedding (periods).
- Complex process, not fully understood.
- Involves HPO axis (Hypothalamus, Pituitary, Ovarian).
- Hypothalamus + pituitary: produce peptide hormones.
- Ovary: produces steroid hormones.
- Peptide hormones: GnRH, FSH, LH
- Steroid hormones: Progesterone, Oestrogen
- Average age of menarche: 12.8 (falling)
- Average age of menopause 51.
- Day 1 of a cycle is the first day of fresh bleeding - this should always be clarified when asking about LMP.
14
Q
Menstrual cycle:
- Ovarian cycle (3)
- Uterine cycle (4)
A
Ovarian cycle:
- Follicular phase
- Ovulation
- Luteal phase
Uterine cycle:
- Period
- Proliferative phase
- Ovulation
- Secretory phase
15
Q
Menstrual cycle: Normal or pathological?
A
- Ovulatory cycle vary - but normally 21-32 days.
- Ovulatory cycles that vary do so due to follicular phase.
- After menarche, cycles are often irregular for months or several years until maturation of the HPO axis reliably triggers ovulation.
- Peri-menopausal periods are commonly irregular.
- Do not blame erratic, chaotic or constant bleeding in women >45 years on ‘the menopausal change’ - it needs further investigation to exclude genital tract cancer.
- Nearly all women will experience some menstrual irregularity in timing or flow at some stage - many cases are transient.
16
Q
Bleeding + pain: What is normal?
A
- Bleeding can be for 1-7 days (average 3-5 days).
- Reported amount of blood loss = highly variable.
- Periods described as heavy should always be viewed as such.
- Pain is ‘normal’ (vasospasm + ischaemia), but is highly variable.
- Pain interfering with normal function needs to be addressed.
- Bleeding between period (IMB), after intercourse (PCB) or totally erratic/constant bleeding is always abnormal.
17
Q
Menstrual cycle: Follicular phase
A
- Hypothalamus releases GnRH (pulsatile)»_space; anterior pituitary produces FSH.
- FSH promotes ovarian follicular development»_space; recruitment of a dominant follicle containing a oocyte.
- Follicular granulosa cells produce oestrogen»_space; endometrial proliferation.
- ↑oestrogen levels»_space; -ve feedback on the hypothalamo-pituitary (HP) axis (via follicular inhibin) to stop further FSH production.
18
Q
Menstrual cycle: Ovulation
A
- Increasing dominant follicle oestrogen.
- (positive feedback via follicular activin)
- Altered hypothalamic GnrH pulsatility.
- Pituitary production of LH - LH surge 36h before ovulation.
19
Q
Menstrual cycle: Luteal phase
A
- Follice collapses down to become corpus luteum (CL) - (‘yellow body’).
- This produces oestrogen and progesterone (from theca cells).
- Progesterone + oestrogen act on an oestrogen-primed endometrium to induce secretory changes»_space; thickening and ↑ vascularity.
- Corpus luteum has a fixed lifespan of 14 days (programmed cell death) before undergoing involution»_space; corpus albicans (‘white body’).
- If implantation occurs, hCG (luteotrophic) ‘rescue’ of the CL allows continued production of progesterone to support the endometrium.
- In the absence of pregnancy, CL degeneration»_space; a rapid fall in progesterone + eostrogen, initiating menstruation.
20
Q
Menstrual cycle: Menstrual phase
A
- Rapid ↓ in steroids»_space; shedding of the unused endometrium.
- Inflammatory mediators (PGs, ILs and tumour necrosis factor (TNF))
- > > vasospasm (approx. 24hrs) in spiral end arteries»_space; hypoxia and endometrial devitalization.
- Vasodilation and spiral artery collapse»_space; loss of the layer and bleeding from vessels.
- Endometrium lost down to basalis layer.
- Complex vascular changes controlled by above secondary messengers, also»_space; natural haemostatic mechanisms including platelet plugs, coagulation cascade and fibrinolysis.
- All steroid hormones now at basal level, negative feedback is lifted, and GnRH-FSH production can begin a new cycle.
21
Q
Bleeding: Classification (11)
A
- Miscarriage
- Antepartum haemorrhage (APH)
- Intrapartum haemorrhage (IPH)
- Postpartum haemorrhage (PPH)
- Amenorrhoea
- Oligmenorrhoea
- Dysmenorrhoea
- Intermenstrual bleed (IMB)
- Post-coital bleed (PCB)
- Post-menpausal bleed (PMB)
- Dysfunctional uterine bleed (DUB)
22
Q
Menstrual disorders: AMENORRHOEA
- Definition
- Classification (2)
A
Definition: the absence (or cessation) of menstruation.
Classification:
- Primary: the lack of menstruation by age 16 in the presence of secondary sexual characteristics (or 14 in their absence)
- Secondary: is an absence of menstruation for 6 months
23
Q
Menstrual disorders: AMENORRHOEA: Diagnosis
- History
- Examination
- Investigations
A
History: (emphasis on)
- Sexual activity, risk of pregnancy, contraceptive use
- Galactorrhoea or androgenic symptoms (weight gain, acne, hirsutism)
- Menopausal symptoms (night sweats, hot flushes)
- Previous genital tract surgery (LLETZ)
- Issues with eating or excessive exercise
- Drug use
Examination:
- BMI <17/>30, hirsutism, secondary sexual characterisitics (Tanner staging)
- Stigmata of endocrinopathies (including Thyroid) or Turner’s syndrome.
- Evidence of virilization (deep voice, male pattern baldness, cliteromegaly)
- Abdominal: may show masses due to tumours or genital tract obstruction.
- Pelvic: imperforate hymen, blind ending vaginal septum, absence of cervix and uterus.
Investigations:
- Pregnancy test
- FSH/LH
- Testosterone + sex hormone-binding globulin (SHBG)
- Prolactin
- TFTs
- Pelvic ultrasound
- Karyotype
24
Q
Menstrual disorders: AMENORRHOEA: Causes
- Physiological (3)
- Iatrogenic (2)
- Pathological (7)
A
Physiological:
- Pregnancy
- Lactation
- Menopause
Iatrogenic:
- Progestagenic contraceptives (coil, POP, depo injection, implant)
- Others (COCP, GnRH analogues)
Pathological:
- Hypothalamic (functional/non-functional)
- Anterior pituitary
- Ovarian (PCOS, POF)
- Genital tract outflow obstruction
- Agenesis of uterus and müllerian duct structures
- Endocrinopathies
- Oestrogen -or androgen- secreting tumours.
25
Menstrual disorders: OLIGOMENORRHOEA
- Definition
- Causes
- Management
Definition: Infrequent periods. When cycles are longer than 32 days they usually represent anovulation or intermittent ovulation. Transient oligomenorrhoea is common ('stress' or emotionally related causes are often cited) and usually self-limiting.
Causes:
- PCOS
- Borderline low BMI
- Obesity without PCOS
- Ovarian resistance
- Mild degree of hyperprolactinaemia
- Mild thyroid disease
Management:
- Reassurance
- Treat underlying cause
- Not uncommon for no cause to be found.
- However serious pathology must be excluded.
- Attain normal BMI (via weight loss or weight gain)
- Provide regular cycles (COCP/cyclical progestagens)
- Full fertility screening
26
Menstrual disorders: DYSMENORRHOEA
- Definition
- Types
- Diagnosis
- Investigations
- Management
Definition: painful periods
- Primary: pain has no obvious organic cause
- Secondary: pain is due to underlying condition
Diagnosis:
- History (pain, hx of PID/STI, PSH)
- Examination (abdo + pelvic exam)
Investigations:
- STI screen
- USS
- Laparascopy
Management:
- Symptom control
- Treat any underlying disease
- Therapeutic laparoscopy
- Hysterectomy
- Laparascopic uterine nerve ablation (LUNA)
27
Menstrual disorders: DYSMENORRHOEA - Classification
- Primary
- Secondary
PRIMARY dysmenorrhoea: pain has no obvious organic cause
Pain in the menstrual cycle is due to:
- Uterine vasospasm
- Ischaemia
- Nervous sensitization due to PGs
- Other inflammatory mediators
- Uterine contractions
Theories for cause of primary dysmenorrhoea:
- Abnormal PG ratios/sensitivity
- Neuropathic dysregulation
- Venous pelvic congestion
- Psychological causes
SECONDARY dysmenorrhoea: pain that is due to an underlying condition. Causes include:
- Endometriosis
- Adenomyosis
- PID
- Pelvic adhesions
- Fibroids
- Cervical stenosis
- Asherman's syndrome
- Congenital abnormalities
28
Dysfunctioal Uterine Bleeding (DUB)
- Definition
- Aetiology
Definition: DUB is a diagnosis of exclusion and is defined as any abnormal uterine bleeding in the absence of pregnancy, genital tract pathology or systemic disease.
- Menorrhagia is the commonest symptom.
- If periods are reported as unacceptably heavy, then they are!
Aetiology: (exact causes are unknown)
- Abnormal PG ratios (+ other inflammatory mediators)
- Excessive fibrinolysis
- Defects in expression/function of matrix metalloproteinases (MMPs), vascular growth factors and endothelins
- Aberrant steroid receptor function
- Defects in the endomyometerial junctional zone
29
Dysfunctional Uterine Bleeding (DUB)
- Differentials
- Diagnosis (symptoms + signs)
- Investigations
Differentials:
- Submucous fibroids
- Adenomyosis
- Endometrial polyps, hyperplasia, or cancer
- Rarely: hypothyroidism or coagulation defects.
```
Diagnosis:
Symptoms:
- Heavy and/or prolonged vaginal bleeding
- Dysmenorrhoea
- Anaemia
- Smear hx + contraceptive hx = useful
```
Signs:
- Anaemia
- Abdo exam = usually normal
Investigations:
- FBC
- Ferritin
- TFTs
- Clotting screens
- Cervical smear
- STI screen
If >45 years, with RF for endometrial disease, or no clinical response:
- TVS USS
- Pipelle endometrial biopsy
- Hysteroscopy + biopsy
- Hysteroscopy
30
Dysfunctional Uterine Bleeding (DUB) - Management
- Medical
- Surgical
Medical management: Regular DUB
- Mirena coil
- Antifibrinolytics
- NSAIDs
- COCP
- Oral progestagens
```
Medical management: Irregular DUB
- Mirena coil
- Tranexmic acid + mefenamic acid
- COCP
- Cyclical Norethisterone or medroxyprogesterone
Severe cases:
- GnRH analogues
- High-dose progestagens: medoxyprogesterone acetate
```
Surgical
- Endometrial ablation
- Hysterectomy
N.B. Surgery is only for patients where medical management has failed - women must be certain they have completed their families before surgery.
31
Choice of management for DUB
Factors to consider:
- Treatment directed towards symptom relief + improved QoL.
- Women's wishes for treatment.
- Reproductive wishes + contraceptive methods.
- Whether periods are regular or irregular.
32
Premenstrual syndrome (PMS)
- Definition
- Diagnosis
Definition: Any definition of premenstrual syndrome should include:
- Distressing psychological, physical and/or behavioural symptoms.
- Occurrence in the luteal phase of the menstrual cycle
- Significant regression of symptoms with onset of or during the period.
Diagnosis:
- Self-diagnosis
- Detailed hx
- Symptom charts from National Associate of Premenstrual syndrome
Pre-menstrual dysphoric disorder (PMDD): Is a health problem that is similar to premenstrual syndrome (PMS), but it is more severe.
33
Premenstrual syndrome (PMS)Management
- Hormonal (4)
- Non-hormonal (2)
Hormonal: Ovulation suppression agents
- COCP
- Danazol
- Oestrogen
- GnRH analogues +/- addback HRT
Non-hormonal:
- SSRIs/SNRIs
- Antidepressants (e.g. tricyclics)
34
Premenstrual syndrome (PMS)
- Self-help techniques
- Complementary + alternative therapies
Self-help techniques:
- Dietary alteration
- Dietary supplements
- Exercise
- Stress reduction
- Cognitive behavioural therapy (CBT)
Complementary + alternative therapies:
- Acupuncture
- Homeopathy
- Progesterone + wild yam
- Phytoestrogens
- Herbal remedies
- Mind-body (aromatherapies, reflexology)
