Menstrual Problems Flashcards
What is normal with menstruation?
- 28 day cycle
- Ovulation occurs at 14 days roughly
- First 2-7 days is shedding of the lining of the endometrium
- Mean blood loss is 30-40ml
- Age 13-51 yrs menarche-menopause
What does oligomenorrhea mean? Dysmenorrhoea?
Infrequent periods
Painful periods
What needs to be questioned when taking a period history?
- Patients perception of how it differs from normal
- Clots/bleeding/how many pads needed/bleed through clothes
- Pain (with heavy flow or premenstrual)
- Ask about effect of symptoms on lifestyle and quality of life
What needs examined when there is issues with menstruation?
- General / abdominal / speculum / bimanual
Why do we investigate FBC in someone who has menorrhagia?
- To check if they are becoming anaemic
What clinical indications would cause you to check there thyroid function? (women having period problems)
Consider thyroid if very tired and gaining weight
What other investigations may be necessary in menstrual problems and why?
- Pregnancy test
- Transvaginal ultrasound scan
- Hysteroscopy: Persistent IMB, suspected endometrial pathology on ultrasound
What is an anovulatory cycle?
When ovulation is skipped/period missed.
What menstrual problems are early teens likely to come across?
- Anovulatory cycles
- Coagulation problems
What problems are likely to occur to teens-40?
- Chlamydia
- Contraception related
- Endometriosis
- Fibroids
- Endometrial/cervical polyps
- Dysfunctional bleeding
What menstrual problems are likely to occur to age 40-menopause?
- Perimenopausal anovulation
- Endometrial cancer
- Warfarin
- Thyroid dysfunction
What is the FIGO classification of abnormal uterine bleeding?
PALM-COEIN
P- polyp
A- adenomyosis
L- leiomyoma
M- malignancy
C- coagulation
O-ovarian, PCOS
E- endocrine
I- iatrogenic
N- not yet classified
What is dysfunctional uterine bleeding? (DUB)
- Abnormal bleeding but no structural/endocrine/neoplastic/infectious cause found
- 50% of hystorectomies for menorrhagia are for DUB
What is endometriosis? Where does it normally present?
- Endometrial type tissue found outwith the uterine cavity
- An oestrogen dependent chronic condition
- Usually presents in the pouch of douglas (because blood gravitates there), ovary and pelvic perineum
What is the cause of endometriosis?
Retrograde menstruation is the most suspected cause
Symptoms of endometriosis?
- Premenstrual pelvic pain
- Dysmenorrhoea
- Deep dyspareunia
- Subfertility
Signs of endometriosis?
- Potentially none
- Tender nodules in the rectovaginal septum
- Limited uterine mobility
- Adnexal mass
How to diagnose endometriosis?
- Gold Standard: laparoscopy - clear, red, bluish black or white lesions
- MRI for deep endometriosis
- Ultrasound can diagnose endometrioma (chocolate cyst)
What is the treatment of endometriosis?
Medical
- Progesterone: oral/injected
- Combined oral contraceptive pill
- GnRH analogues
Surgical
- Excision of deposits from peritoneum/ovary
- Diathermy/laser ablation of deposits
- Removal of ovaries with or without hystorectomy
What is adenomyosis?
‘Cousin of endometriosis’
- Endometrium cells migrate to the muscle cell wall of the uterus (presence of endometrial cells in te myometrium)
Signs and Symptoms of adenomysis?
- Heavy painful periods
- Bulky tender uterus
- Usually in parous women
- May co-exist with endometriosis
How do we diagnose adenomyosis?
- MRI may suggest diagnosis but limited availability
- histology of uterine muscle – generally post hysterectomy
Management of adenomyosis?
Treat symptoms of heavy and painful periods with hormonal contraception
What are fibroids? Features?
Smooth muscle growths also known as leiomyoma.
Common and usually asymptomatic: Up to 60% of 40 year olds have fibroids of varying size
How is a diagnosis of fibroids made?
- clinical exam – irregularly enlarged uterus
- ultrasound
- Hysteroscopy (if inside uterine cavity)
What are the three types of fibroids?
- Sub-mucous: Protrude into uterine cavity
- Intramural: within uterine wall
- Sub-serous: project out of uterus into peritoneal cavity
Symptoms of fibroids?
- Large fibroids may cause pressure symptoms
- Menorrhagia: enlarge the uterine cavity surface area
- Submucous or fibroid polyps may cause intermenstrual bleeding
- May be asymptomatic
Management of fibroids?
[only if symptomatic]
- Standard menorrhagia treatment if cavity not too distorted
- GnRH analogues or Ulipristal acetate may be used temporarily to shrink the fibroids – usually preoperatively
- Submucous fibroids: Transcervical resection hysteroscopically
- Myomectomy
- Uterine artery embolisation
- Hysterectomy
Management of DUB?
- May just need reassurance that there is no sinister pathology
Medical
- Non hormonal: Tranexamic acid or Mefanamic acid
- Hormonal: Progestogen only tablets, injections (Depo Provera), Levonorgesterel Intrauterine System, Combined pill
Surgical
- Endometrial ablation
- Hysterectomy
What is tranexamic acid and how does it function?
- Antifibrinolytic
- Reduces blood loss by 60%
What is Mefenamic acid and how does it work?
- Prostaglandin inhibitor
- Reduces blood loss by 30% and pain
What is salpingo-oophorectomy?
Removal tubes + ovaries
