Menstrual dysfunction Flashcards
Normal endometrial thickness
- 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.
Vaginal Bleeding: Red flag signs + symptoms
- 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.
Hysteroscopy: DEFINITION
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.
Treatment for heavy menstrual bleeding:
- Invasive
- Non-invasive
Adenomyosis:
- Definition
- Features
- Management
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
Abnormal Uterine Bleeding (AUB): Definition
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.
Abnormal Uterine Bleeding (AUB): Causes
PALM COEIN
- P - polyp
- A - adenomyosis
- L - Leiomyoma (fibroids)
- M - Malignancy
- C - Coagulopathy
- O - Ovarian dysfunction (PCOS)
- E - Endometrial dysfunction
- I - Iatrogenic
- N - Not yet classified
Endometrial ablation: Definition
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
Mirena
- Definition
- Side effects
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
Benign neoplasms of the uterus: Types (2)
- Uterine fibroids
- Endometrial polyps
Benign neoplasms of the uterus: Uterine fibroids
- Definition
- Symptoms
- Types
- Diagnosis
- Treatment
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
Benign neoplasms of the uterus: Endometrial polyps (adenoma)
- 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.
Menstrual cycle: Overview
- 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.
Menstrual cycle:
- Ovarian cycle (3)
- Uterine cycle (4)
Ovarian cycle:
- Follicular phase
- Ovulation
- Luteal phase
Uterine cycle:
- Period
- Proliferative phase
- Ovulation
- Secretory phase
Menstrual cycle: Normal or pathological?
- 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.
