menstrual problems Flashcards
what is the menstrual cycle
time from the first day of a woman’s period to the day before her next period
blood loss in a normal menstrual period
normal loss - <80ml over 7 days (16tsp)
avg loss 30-40ml (6-8tsp)
length of normal menstrual cycle
avg duration of bleeding 2-7 days
length 28 days (avg 24-35)
when does menarche usually occur
10-16yrs
avg 12yrs
when does menopause occur
50-55yrs
disturbances of menstruation
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
menstrual frequency limits
frequent <24 days
normal 24-38 days
infrequent >38 days
menstrual regularity limits
absent/amenorrhoea - no bleeding
regular <20 days variation in 12mths
irregular >20 days variation in 12mths
menstrual duration limits
prolonged >8 days
normal 2-7 days
shortened <2 days
menstrual volume limits
heavy >80ml
normal 5-80ml
light <5ml
heavy menstrual bleeding
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
how common is heavy menstrual bleeding
5% of women aged 30-49 in UK consult GP each year
20% of women in UK have hysterectomy <60 due to HMB
what is a health implication of heavy menstrual bleeding
anaemia
causes of HMB
uterine and ovarian pathology
systemic diseases and disorders
iatrogenic
causes of HMB - uterine and ovarian
uterine fibroids endometrial polyps endometriosis and adenomyosis PID and infection endometrial hyperplasia or carcinoma PCOS
presentation of uterine fibroids
HMB
dysmenorrhoea
pelvic pain
presentation of uterine fibroids
HMB
dysmenorrhoea
pelvic pain
presentation of uterine fibroids
HMB
dysmenorrhoea
pelvic pain
presentation of uterine fibroids
HMB
dysmenorrhoea
pelvic pain
presentation of endometrial polyps
HMB
intermenstrual bleeding
presentation of endometriosis and adenomyosis
HMB dysmenorrhoea dyspareunia pelvic pain difficulty conceiving
presentation of PID and pelvic infection
vaginal discharge
pelvic pain
intermenstrual and post-coital bleeding
fever
presentation of endometrial hyperplasia or carcinoma
post-coital bleeding
intermenstrual bleeding
pelvic pain
presentation of PCOS
anovulatory menorrhagia
irregular bleeding
causes of HMB - systemic diseases and disorders
coagulation disorders e.g. Von Wilebrand
hypothyroidism
liver/renal disease
causes of HMB - iatrogenic
anti coagulation
herbal supplements e.g. ginseng, ginkgo, soya - alter oestrogen levels or coagulation parameters
IUCD
mnemonic for causes of HMB
PALM
COEIN
polyp
adenomyosis
leiomyoma/fibroid
malignancy
coagulopathy ovulation dysfunction endometrium/hyperplasia iatrogenic not classified
what are fibroids
non cancerous growths made of muscle and fibrous tissue
also called myoma or lieomyoma
symptoms of fibroids
may be asymptomatic HMB pelvic pain urinary symptoms pressure symptoms backache infertility miscarriage
diagnosis of fibroids
USS
management of fibroids
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
what is endometriosis
endometrial tissue present outside the lining of the uterus
during menstruation this ectopic tissue behaves the same as endometrium and bleeds
how common is endometriosis
affects women of reproductive age
1.5mln in UK
presentation of endometriosis
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
symptoms of endometriosis
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
why is endometriosis difficult to diagnose
many symptoms are overlapping with other diseases
often misdiagnosed
endometriosis sites
colon small intestine rectum ovary fallopian tube uterus bladder pouch of douglas
endometriosis stages
- minimal - small patches, surface lesions or inflammation on/around organs in the pelvic cavity
- mild - more widespread and starting to infiltrate pelvic organs
- moderate - peritoneum or other structures, scarring and adhesions
- severe - infiltrative and affecting many pelvic organs and ovaries, often with distortions of anatomy and adhesions
diagnosis of endometriosis
pelvic examination
USS
diagnostic laparoscopy
management of endometriosis
analgesia
medical
surgical
medical management of endometriosis
COCP pop mirena depot provera GnRH anaelogues
surgical management of endometriosis
ablation hysterectomy endometrioma excision pelvic clearance hysterectomy
surgical management may be required as part of fertility treatment
what is adenomyosis
endometrium becomes embedded in myometrium
presentation of adenomyosis
HMB
may also have significant dysmenorrhoea
management of adenomyosis
may respond to hormones partially
definitive treatment is hysterectomy
what are endometrial polyps
overgrowth of endometrial lining can lead to formulation of pediculated structures (polyps) which extend into the endometrium
mostly benign
diagnosis of endometrial polyps
US
hysteroscopy
management of endometrial polyps
polypectomy
management of endometrial polyps
polypectomy
management of HMB
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
what do management options for HMB depend on
impact on QOL
underlying pathology
desire for further fertility
women’s preference
treatment options for menstrual disorders
observation and monitoring hormones hormone containing IUD - mirena endomyometrial resection (EMR) endometrial ablation (NovaSure) removal of fibroids or polyps hysterectomy
deciding on treatment for menstrual disorders
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
what is tranexamic acid
benefits
antifibrinolytic
reduces blood loss 60%
what is mefenamic acid
benefits
prostaglandin inhibitor
reduces blood loss 60% and pain
when are tranexamic acid and mefenamic acid used
both are taken at the time of periods
do not regulate cycles
suitable for those trying to conceive or avoiding hormones
hormonal options for menstrual disorders and effects
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
what is endometrial ablation
permanent destruction of endometrium using different energy sources
how can endometrial ablation be carried out
1st generation - hysteroscopic vision, uses diathermy
2nd gen - thermal balloon, radio frequency
pre-requisits for endometrial ablation
uterine cavity length <11cm
sub mucous fibroids <3cm
previous normal endometrial biopsy
results of endometrial ablation
60% no periods
85% satisfied
15% subsequent hysterectomy
what is a hysterectomy
surgical removal of uterus
how can hysterectomy be carried out
vaginal
laparoscopic:
laparoscopically assisted vaginal hysterectomy (LAVH)
total laparoscopic hysterectomy (TLH)
laparoscopically assisted subtotal hysterectomy
types of hysterectomy
total - cervix and uterus removed
subtotal - uterus removed, cervix left
hysterectomy recovery
major surgery
3-5 days in hospital - open/vaginal
1-2 days in hospital - laparoscopic
2-3mths full recovery
risks of hysterectomy
infection DVT bladder/bowel/vessel injury altered bladder function adhesions
what is guaranteed following hysterectomy
amenorrhoea
what is a salpingo-oophorectomy
removal of tubes and ovaries
when would ovaries be removed as well as uterus
women with endometriosis
presence of ovarian pathology
disadvantages of oopherectomy
immediate menopause
recommended HRT until 50y/o
advantages of oophorectomy
reduces risk of subsequent ovarian cancer
why is there still a high risk of menopause even if the ovaries are conserved following surgery
compromised blood supply
high risk of menopause in next 2yrs
what is oligo/amenorrhoea
infrequent, absent or abnormally light menstruation
what is important to check re. oligo/amenorrhoea
is this normal for the person
causes of oligo/amenorrhoea
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
what is PCOS
polycystic ovarian syndrome
metabolic syndrome
diagnosis confirmed if 2/3 criteria met
diagnosing PCOS
US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity
diagnosing PCOS
US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity
management of PCOS
lifestyle changes - aim to achieve normal BMI
symptom based treatment
what is required in PCOS to prevent hyperplasia
at least 3 withdrawal bleeds per year to prevent hyperplasia or endometrial protection
achieved w/ COCP, POP, mirena IUS or norethisterone
what is DUB
dysfunctional uterine bleeding
common disorder of XS uterine bleeding affecting premenopausal women that isn’t due to pregnancy or any unrecognisable uterine/systemic disease
underlying pathophysiology of DUB
ovarian hormonal dysfunction
what is important to exclude in DUB
common causes - PALM COEIN
management of DUB
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
how do GnRH analogues work
ant oestrogen and produce psuedo menopause
GnRH analogues for DUB
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
