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
2
Q
blood loss in a normal menstrual period
A
normal loss - <80ml over 7 days (16tsp)
avg loss 30-40ml (6-8tsp)
3
Q
length of normal menstrual cycle
A
avg duration of bleeding 2-7 days
length 28 days (avg 24-35)
4
Q
when does menarche usually occur
A
10-16yrs
avg 12yrs
5
Q
when does menopause occur
A
50-55yrs
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
7
Q
menstrual frequency limits
A
frequent <24 days
normal 24-38 days
infrequent >38 days
8
Q
menstrual regularity limits
A
absent/amenorrhoea - no bleeding
regular <20 days variation in 12mths
irregular >20 days variation in 12mths
9
Q
menstrual duration limits
A
prolonged >8 days
normal 2-7 days
shortened <2 days
10
Q
menstrual volume limits
A
heavy >80ml
normal 5-80ml
light <5ml
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
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
13
Q
what is a health implication of heavy menstrual bleeding
A
anaemia
14
Q
causes of HMB
A
uterine and ovarian pathology
systemic diseases and disorders
iatrogenic
15
Q
causes of HMB - uterine and ovarian
A
uterine fibroids endometrial polyps endometriosis and adenomyosis PID and infection endometrial hyperplasia or carcinoma PCOS
16
Q
presentation of uterine fibroids
A
HMB
dysmenorrhoea
pelvic pain
16
Q
presentation of uterine fibroids
A
HMB
dysmenorrhoea
pelvic pain
17
Q
presentation of uterine fibroids
A
HMB
dysmenorrhoea
pelvic pain
18
Q
presentation of uterine fibroids
A
HMB
dysmenorrhoea
pelvic pain
19
Q
presentation of endometrial polyps
A
HMB
intermenstrual bleeding
20
Q
presentation of endometriosis and adenomyosis
A
HMB dysmenorrhoea dyspareunia pelvic pain difficulty conceiving
21
Q
presentation of PID and pelvic infection
A
vaginal discharge
pelvic pain
intermenstrual and post-coital bleeding
fever
22
Q
presentation of endometrial hyperplasia or carcinoma
A
post-coital bleeding
intermenstrual bleeding
pelvic pain
23
Q
presentation of PCOS
A
anovulatory menorrhagia
irregular bleeding
24
causes of HMB - systemic diseases and disorders
coagulation disorders e.g. Von Wilebrand
hypothyroidism
liver/renal disease
25
causes of HMB - iatrogenic
anti coagulation
herbal supplements e.g. ginseng, ginkgo, soya - alter oestrogen levels or coagulation parameters
IUCD
26
mnemonic for causes of HMB
PALM
COEIN
polyp
adenomyosis
leiomyoma/fibroid
malignancy
```
coagulopathy
ovulation dysfunction
endometrium/hyperplasia
iatrogenic
not classified
```
27
what are fibroids
non cancerous growths made of muscle and fibrous tissue
also called myoma or lieomyoma
28
symptoms of fibroids
```
may be asymptomatic
HMB
pelvic pain
urinary symptoms
pressure symptoms
backache
infertility
miscarriage
```
29
diagnosis of fibroids
USS
30
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
31
what is endometriosis
endometrial tissue present outside the lining of the uterus
during menstruation this ectopic tissue behaves the same as endometrium and bleeds
32
how common is endometriosis
affects women of reproductive age
| 1.5mln in UK
33
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
34
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
35
why is endometriosis difficult to diagnose
many symptoms are overlapping with other diseases
often misdiagnosed
36
endometriosis sites
```
colon
small intestine
rectum
ovary
fallopian tube
uterus
bladder
pouch of douglas
```
37
endometriosis stages
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
diagnosis of endometriosis
pelvic examination
USS
diagnostic laparoscopy
39
management of endometriosis
analgesia
medical
surgical
40
medical management of endometriosis
```
COCP
pop
mirena
depot provera
GnRH anaelogues
```
41
surgical management of endometriosis
```
ablation
hysterectomy
endometrioma excision
pelvic clearance
hysterectomy
```
surgical management may be required as part of fertility treatment
42
what is adenomyosis
endometrium becomes embedded in myometrium
43
presentation of adenomyosis
HMB
| may also have significant dysmenorrhoea
44
management of adenomyosis
may respond to hormones partially
| definitive treatment is hysterectomy
45
what are endometrial polyps
overgrowth of endometrial lining can lead to formulation of pediculated structures (polyps) which extend into the endometrium
mostly benign
46
diagnosis of endometrial polyps
US
| hysteroscopy
47
management of endometrial polyps
polypectomy
48
management of endometrial polyps
polypectomy
49
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
50
what do management options for HMB depend on
impact on QOL
underlying pathology
desire for further fertility
women's preference
51
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
```
52
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
53
what is tranexamic acid
| benefits
antifibrinolytic
| reduces blood loss 60%
54
what is mefenamic acid
| benefits
prostaglandin inhibitor
| reduces blood loss 60% and pain
55
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
56
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
57
what is endometrial ablation
permanent destruction of endometrium using different energy sources
58
how can endometrial ablation be carried out
1st generation - hysteroscopic vision, uses diathermy
2nd gen - thermal balloon, radio frequency
59
pre-requisits for endometrial ablation
uterine cavity length <11cm
sub mucous fibroids <3cm
previous normal endometrial biopsy
60
results of endometrial ablation
60% no periods
85% satisfied
15% subsequent hysterectomy
61
what is a hysterectomy
surgical removal of uterus
62
how can hysterectomy be carried out
vaginal
laparoscopic:
laparoscopically assisted vaginal hysterectomy (LAVH)
total laparoscopic hysterectomy (TLH)
laparoscopically assisted subtotal hysterectomy
63
types of hysterectomy
total - cervix and uterus removed
| subtotal - uterus removed, cervix left
64
hysterectomy recovery
major surgery
3-5 days in hospital - open/vaginal
1-2 days in hospital - laparoscopic
2-3mths full recovery
65
risks of hysterectomy
```
infection
DVT
bladder/bowel/vessel injury
altered bladder function
adhesions
```
66
what is guaranteed following hysterectomy
amenorrhoea
67
what is a salpingo-oophorectomy
removal of tubes and ovaries
68
when would ovaries be removed as well as uterus
women with endometriosis
| presence of ovarian pathology
69
disadvantages of oopherectomy
immediate menopause
| recommended HRT until 50y/o
70
advantages of oophorectomy
reduces risk of subsequent ovarian cancer
71
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
72
what is oligo/amenorrhoea
infrequent, absent or abnormally light menstruation
73
what is important to check re. oligo/amenorrhoea
is this normal for the person
74
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
75
what is PCOS
polycystic ovarian syndrome
metabolic syndrome
diagnosis confirmed if 2/3 criteria met
76
diagnosing PCOS
US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity
77
diagnosing PCOS
US appearance of ovary
biochemical hyperandrogenism
clinical hyperandrogenism - oligomenorrhoea, hirsuitism, acne, infertility, obseity
78
management of PCOS
lifestyle changes - aim to achieve normal BMI
| symptom based treatment
79
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
80
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
81
underlying pathophysiology of DUB
ovarian hormonal dysfunction
82
what is important to exclude in DUB
common causes - PALM COEIN
83
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
84
how do GnRH analogues work
ant oestrogen and produce psuedo menopause
85
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
