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Y3 repro > menstrual problems > Flashcards

menstrual problems Flashcards

1
Q

what is the menstrual cycle

A

time from the first day of a woman’s period to the day before her next period

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2
Q

blood loss in a normal menstrual period

A

normal loss - <80ml over 7 days (16tsp)

avg loss 30-40ml (6-8tsp)

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3
Q

length of normal menstrual cycle

A

avg duration of bleeding 2-7 days

length 28 days (avg 24-35)

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4
Q

when does menarche usually occur

A

10-16yrs

avg 12yrs

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5
Q

when does menopause occur

A

50-55yrs

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6
Q

disturbances of menstruation

A

disturbance of menstrual frequency - infrequent or frequent
irregular menstrual bleeding - absent or irregular
abnormal duration of flow - prolonged or shortened
abnormal menstrual volume - heavy or light

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7
Q

menstrual frequency limits

A

frequent <24 days
normal 24-38 days
infrequent >38 days

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8
Q

menstrual regularity limits

A

absent/amenorrhoea - no bleeding
regular <20 days variation in 12mths
irregular >20 days variation in 12mths

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9
Q

menstrual duration limits

A

prolonged >8 days
normal 2-7 days
shortened <2 days

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10
Q

menstrual volume limits

A

heavy >80ml
normal 5-80ml
light <5ml

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11
Q

heavy menstrual bleeding

A

difficult to measure
bleeding >80ml over 7 days, regular cycle
AND/OR the need to change menstrual products every 1-2hrs
AND/OR passage of clots >2.5cm
bleeding through clothes
AND/OR very heavy periods as reported by the woman/affecting QOL

can occur alone or in combination w/ symptoms like dysmenorrhoea

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12
Q

how common is heavy menstrual bleeding

A

5% of women aged 30-49 in UK consult GP each year

20% of women in UK have hysterectomy <60 due to HMB

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13
Q

what is a health implication of heavy menstrual bleeding

A

anaemia

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14
Q

causes of HMB

A

uterine and ovarian pathology
systemic diseases and disorders
iatrogenic

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15
Q

causes of HMB - uterine and ovarian

A 
uterine fibroids
endometrial polyps
endometriosis and adenomyosis 
PID and infection
endometrial hyperplasia or carcinoma 
PCOS
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16
Q

presentation of uterine fibroids

A

HMB
dysmenorrhoea
pelvic pain

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16
Q

presentation of uterine fibroids

A

HMB
dysmenorrhoea
pelvic pain

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17
Q

presentation of uterine fibroids

A

HMB
dysmenorrhoea
pelvic pain

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18
Q

presentation of uterine fibroids

A

HMB
dysmenorrhoea
pelvic pain

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19
Q

presentation of endometrial polyps

A

HMB

intermenstrual bleeding

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20
Q

presentation of endometriosis and adenomyosis

A 
HMB 
dysmenorrhoea
dyspareunia 
pelvic pain 
difficulty conceiving
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21
Q

presentation of PID and pelvic infection

A

vaginal discharge
pelvic pain
intermenstrual and post-coital bleeding
fever

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22
Q

presentation of endometrial hyperplasia or carcinoma

A

post-coital bleeding
intermenstrual bleeding
pelvic pain

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23
Q

presentation of PCOS

A

anovulatory menorrhagia

irregular bleeding

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24
Q

causes of HMB - systemic diseases and disorders

A

coagulation disorders e.g. Von Wilebrand
hypothyroidism
liver/renal disease

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25
Q

causes of HMB - iatrogenic

A

anti coagulation
herbal supplements e.g. ginseng, ginkgo, soya - alter oestrogen levels or coagulation parameters
IUCD

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26
Q

mnemonic for causes of HMB

A

PALM
COEIN

polyp
adenomyosis
leiomyoma/fibroid
malignancy

coagulopathy 
ovulation dysfunction
endometrium/hyperplasia 
iatrogenic 
not classified
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27
Q

what are fibroids

A

non cancerous growths made of muscle and fibrous tissue

also called myoma or lieomyoma

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28
Q

symptoms of fibroids

A 
may be asymptomatic 
HMB 
pelvic pain 
urinary symptoms 
pressure symptoms 
backache
infertility 
miscarriage
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29
Q

diagnosis of fibroids

A

USS

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30
Q

management of fibroids

A

symptom based

HMB +/- small fibroids - COCP, POP, mirena
large fibroids and fertility preservation desired - fibroid embolisation, myomectomy
submucosal fibroids - hysteroscopid fibroid resection

declined or failed medical treatment and fertility preservation not required - hysterectomy

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31
Q

what is endometriosis

A

endometrial tissue present outside the lining of the uterus

during menstruation this ectopic tissue behaves the same as endometrium and bleeds

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32
Q

how common is endometriosis

A

affects women of reproductive age

1.5mln in UK

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33
Q

presentation of endometriosis

A

may present w/ HMB
most often pelvic pain
multi-system involvement
severe impact on QOL

can also cause infertility, fatigue, systemic symptoms

severity of deposits may not correspond with symptoms

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34
Q

symptoms of endometriosis

A

painful menstrual cramps, get worse over time
lower back pain
abnormal bleeding/spotting between periods
pain during and after sex
painful bowel movements or urination
diarrhoea, nausea and blotting

35
Q

why is endometriosis difficult to diagnose

A

many symptoms are overlapping with other diseases

often misdiagnosed

36
Q

endometriosis sites

A 
colon 
small intestine 
rectum 
ovary 
fallopian tube 
uterus 
bladder 
pouch of douglas
37
Q

endometriosis stages

A
  1. minimal - small patches, surface lesions or inflammation on/around organs in the pelvic cavity
  2. mild - more widespread and starting to infiltrate pelvic organs
  3. moderate - peritoneum or other structures, scarring and adhesions
  4. severe - infiltrative and affecting many pelvic organs and ovaries, often with distortions of anatomy and adhesions
38
Q

diagnosis of endometriosis

A

pelvic examination
USS
diagnostic laparoscopy

39
Q

management of endometriosis

A

analgesia
medical
surgical

40
Q

medical management of endometriosis

A 
COCP
pop
mirena 
depot provera
GnRH anaelogues
41
Q

surgical management of endometriosis

A 
ablation
hysterectomy
endometrioma excision
pelvic clearance
hysterectomy

surgical management may be required as part of fertility treatment

42
Q

what is adenomyosis

A

endometrium becomes embedded in myometrium

43
Q

presentation of adenomyosis

A

HMB

may also have significant dysmenorrhoea

44
Q

management of adenomyosis

A

may respond to hormones partially

definitive treatment is hysterectomy

45
Q

what are endometrial polyps

A

overgrowth of endometrial lining can lead to formulation of pediculated structures (polyps) which extend into the endometrium

mostly benign

46
Q

diagnosis of endometrial polyps

A

US

hysteroscopy

47
Q

management of endometrial polyps

A

polypectomy

48
Q

management of endometrial polyps

A

polypectomy

49
Q

management of HMB

A

hx
pelvic examination - speculum, bimanual, remember to check cervix
clotting profile, TFT
Pelvic USS
laparoscopy if suspected endometriosis
endometrial biopsy from all women ≥44 w/ HMB, refractory to medical treatment

50
Q

what do management options for HMB depend on

A

impact on QOL
underlying pathology
desire for further fertility
women’s preference

51
Q

treatment options for menstrual disorders

A 
observation and monitoring 
hormones
hormone containing IUD - mirena 
endomyometrial resection (EMR)
endometrial ablation (NovaSure)
removal of fibroids or polyps 
hysterectomy
52
Q

deciding on treatment for menstrual disorders

A

does the patient want treatment?
are hormonal treatments CI/failed/declined?

hormonal: mirena IUS, COCP, POP, Depot provera

non hormonal: mefenamic acid, tranexamic acid, GnRH analogues
endometrial ablation, fibroid embolisation, hysterectomy

53
Q

what is tranexamic acid

benefits

A

antifibrinolytic

reduces blood loss 60%

54
Q

what is mefenamic acid

benefits

A

prostaglandin inhibitor

reduces blood loss 60% and pain

55
Q

when are tranexamic acid and mefenamic acid used

A

both are taken at the time of periods
do not regulate cycles
suitable for those trying to conceive or avoiding hormones

56
Q

hormonal options for menstrual disorders and effects

A

COCP - lighter periods, regular, less painful
LNG IUS and depo-provera - reduces bleeding, may cause irregular bleeding, some women will be amenorrhoeic

oral progestogens (e.g. provera) - day 5-25 cycle reduce bleeding and regulate, day 15-25 may regulate cycle but does not reduce amount of bleeding

57
Q

what is endometrial ablation

A

permanent destruction of endometrium using different energy sources

58
Q

how can endometrial ablation be carried out

A

1st generation - hysteroscopic vision, uses diathermy

2nd gen - thermal balloon, radio frequency

59
Q

pre-requisits for endometrial ablation

A

uterine cavity length <11cm
sub mucous fibroids <3cm
previous normal endometrial biopsy

60
Q

results of endometrial ablation

A

60% no periods
85% satisfied
15% subsequent hysterectomy

61
Q

what is a hysterectomy

A

surgical removal of uterus

62
Q

how can hysterectomy be carried out

A

vaginal
laparoscopic:
laparoscopically assisted vaginal hysterectomy (LAVH)
total laparoscopic hysterectomy (TLH)
laparoscopically assisted subtotal hysterectomy

63
Q

types of hysterectomy

A

total - cervix and uterus removed

subtotal - uterus removed, cervix left

64
Q

hysterectomy recovery

A

major surgery
3-5 days in hospital - open/vaginal
1-2 days in hospital - laparoscopic
2-3mths full recovery

65
Q

risks of hysterectomy

A 
infection 
DVT 
bladder/bowel/vessel injury 
altered bladder function
adhesions
66
Q

what is guaranteed following hysterectomy

A

amenorrhoea

67
Q

what is a salpingo-oophorectomy

A

removal of tubes and ovaries

68
Q

when would ovaries be removed as well as uterus

A

women with endometriosis

presence of ovarian pathology

69
Q

disadvantages of oopherectomy

A

immediate menopause

recommended HRT until 50y/o

70
Q

advantages of oophorectomy

A

reduces risk of subsequent ovarian cancer

71
Q

why is there still a high risk of menopause even if the ovaries are conserved following surgery

A

compromised blood supply

high risk of menopause in next 2yrs

72
Q

what is oligo/amenorrhoea

A

infrequent, absent or abnormally light menstruation

73
Q

what is important to check re. oligo/amenorrhoea

A

is this normal for the person

74
Q

causes of oligo/amenorrhoea

A 
life changes - stress, ED/malnourished, obesity, intense exercise
hormones - POP, mirena, depot injection
1y ovarian insufficiency 
PCOS
hyperprolactinaemia 
prolactinoma
thyroid disorders
obstructions of uterus/cervix/vagina

investigate and treat cause

75
Q

what is PCOS

A

polycystic ovarian syndrome
metabolic syndrome
diagnosis confirmed if 2/3 criteria met

76
Q

diagnosing PCOS

A

US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity

77
Q

diagnosing PCOS

A

US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity

78
Q

management of PCOS

A

lifestyle changes - aim to achieve normal BMI

symptom based treatment

79
Q

what is required in PCOS to prevent hyperplasia

A

at least 3 withdrawal bleeds per year to prevent hyperplasia or endometrial protection

achieved w/ COCP, POP, mirena IUS or norethisterone

80
Q

what is DUB

A

dysfunctional uterine bleeding
common disorder of XS uterine bleeding affecting premenopausal women that isn’t due to pregnancy or any unrecognisable uterine/systemic disease

81
Q

underlying pathophysiology of DUB

A

ovarian hormonal dysfunction

82
Q

what is important to exclude in DUB

A

common causes - PALM COEIN

83
Q

management of DUB

A

conservative/medical/surgical based on severity of symptoms and pts wishes

GnRH analogues could be good for bridging pts who are nearly menopausal and have failed/declined other medical treatment and surgical management isn;t desirable

84
Q

how do GnRH analogues work

A

ant oestrogen and produce psuedo menopause

85
Q

GnRH analogues for DUB

A

could be good for bridging pts who are nearly menopausal and have failed/declined other medical treatment and surgical management isn’t desirable

up to 6mth therapy
if further desired by pt and no CI - should be given add back HRT till pt confirmed menopausal

Y3 repro (47 decks)

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