Menstrual Problems Flashcards
What is the normal ages for menarche to menopause
13-51
What Is the normal cycle pattern of a period?
4-5/21-35
What is menstruation triggered by?
A fall in progesterone 2 weeks after ovulation if not pregnant
Mean blood loss of a normal period
30-40ml
Blood loss per cycle in menorrhagia
> 80ml/cycle
Types of dysmenorrhoea
Primary = on first or second day of menstruation Secondary = Most commonly seen in pathology e.g. endometriosis - may last the whole time of the period
When is intermenstrual bleeding (IMB) normal?
when related to ovulation ONLY
Definition of intermenstrual bleeding (IMB)
Bleeding between periods
Definition of post coital bleeding (PCB)
Bleeding after intercourse
Causes of post coital bleeding (PCB)
chlamydia (esp. < 25 y/o)
Cervical cancer
cervical polyps
Oligomenorrhoea meaning
infrequent periods e.g. /45-90 days
Questions to ask in a history about menstrual problems
Subjective - patients perspective Clots/flooding/pads/tampons Pain (with heavy flow or premenstrual) Effect of symptoms on life and QoL Associated symptoms e.g. vomiting
Investigations of heavy periods
FBC (anaemic)
TFTs and coagulation if suggestive
Endometrial biopsy (if >45/persistent IMB/obesity)
Key Investigation of intermenstrual bleeding and post coital bleeding in the <25s
Chlamydia test
Possible investigations of menstrual problems (depending on patient and symptoms)
FBC (anaemic)
TFTs and coagulation if suggested
Endometrial biopsy (if >45/persistent IMB/obesity)
Chlamydia test
Pregnancy test/contraceptive history
Transvaginal USS
Hysteroscopy (persistent IMB/endometrial pathology suspected on USS)
Likely causes of menstrual problems in early teens
Anovulatory cycles
- PHA not established yet so girls dont have a regular cycle
- Tend to be heavy, infrequent and generally not painful
Likely causes of menstrual problems in teens –> 40
Chlamydia Contraception related side effects Endometriosis/adenomyosis (heavy + painful) Fibroids (heavy, no pain usually) endometrial/cervical polyps (IMB/PCB) Dysfunctional bleeding
How much of the menstrual problems due to contraceptive related side effects settle?
80% settle
20% can continue to have irregular bleeding
Likely causes of menstrual problems from 40 –> menopause
Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction
What should always be considered in menstrual problems as a cause?
Pregnancy
FIGO classification for the causes of abnormal uterine bleeding - PALM-COEIN
Polyp Adenomyosis Leiomyoma (fibroids) Malignancy/hyperplasia Coagulation e.g. VW disease, haemophilia Ovarian e.g. PCO/anovulatory cycles Endocrine e.g. Thyroid dysfunction Iatrogenic e.g. warfarin Not yet classified - haven't found a cause
Definition of dysfunctional uterine bleeding (DUB)
Abnormal bleeding but NO structural/endocrine/neoplastic/infectious cause found(yet)
Hormonal and ovarian activity in dysfunctional uterine bleeding can be described as….
erratic
Treatment of dysfunctional uterine bleeding (DUB)
Reassure no sinister pathology
Non-hormonal
- tranexamic acid (antifibrinolytic) reduces blood loss by 60%
- mefenamic acid (prostaglandin inhibitor) reduces blood loss by 30% and reduces pain
Hormonal
- progesterone only tablets e.g. provera
- injections e.g. depo provera
- levonogestrel intrauterine system (reduces bleeding, may become amenorrhoeic or irregular)
- COCP
Surgical treatment (if family complete)
- Endometrial ablation
- hysterectomy
- Salpingo-oophrectomy
When treating dysfunctional uterine bleeding, who would use non-hormonal treatments?
For those trying to conceive
When are non-hormonal treatments for DUB taken?
At the time of the periods and continued through the period but for no longer than 7 days
Why would hormonal treatments for Dysfunctional uterine bleeding not be suitable for those trying to conceive?
As the treatments are contraceptive in nature
Types of hysterectomy
Total hysterectomy = cervix and uterus removed
Subtotal hysterectomy = uterus removed, cervix left
Total hysterectomy with bilateral salpingo-oophrectomy
Wetheims hysterectomy = through abdomen, removal of uterus, lymphatics and surrounding tissues
Risks of hysterectomy
Infection DVT Bladder Bowel Vessel injury Altered bladder function Adhesions
What does a hysterectomy guarantee?
Amenorrhoea
When would ovaries be removed along with the uterus?
Endometriosis
Presence of an ovarian pathology
What does an oophorectomy immediately cause?
Immediate menopause
What is used to treat immediate menopause caused by an oophrectomy?
HRT until 50
What does an oophorectomy reduce the risk of?
Subsequent ovarian cancer
Common sites for endometriosis
Ovary
Pouch of douglas
Pelvic peritoneum
Presentation of endometriosis
Asymptomatic and may be no signs Premenstrual pelvic pain Can sometimes then develop non-cyclic pelvic pain Dysmenorrhoea Deep dyspareunia Subfertility Tender nodules in rectovaginal septum Limited uterine mobility Adnexal mass
Theories of pathogenesis of endometriosis
Sampsons theory of retrograde menstruation
Coelomic metaplasia (common embryonic precursor)
Haematogenous spread
Direct transplantation
Investigations for endometriosis
Laparoscopy (superficial)
MRI (deep i.e. stage IV)
USS (Endometrioma - chocolate cysts)
Sites possible for endometriosis
Umbilicus Small bowel Fallopian tube Ureter Ovary (then formation of chocolate cyst) Sigmoid colon Rectovaginal septum and uterosacral ligaments Utereovesical fold Uterine serosa Bladder Appendix Peritoneum Caecum
Treatment for endometriosis
Hormonal treatment and analgesics - Progesterone oral/injection/LNG-IUS - COCP - GnRH analogues (e.g. leuporelin) Surgical - excisions of deposits from peritoneum/ovary - diathermy/laser ablation of deposits - removal of ovaries +/- hysterectomy
In the treatment of endometriosis, what do GnRH analogues do?
Induce a medical menopause
Can disease recur after treatment for endometriosis?
Yes
Definition of endometriosis
Endometrial type tissue outside of the uterine cavity
Definition of adenomyosis
The presence of endometrial tissue in the myometrium (muscle wall of the uterus)
Why can adenomyosis be mistaken for fibroids?
Due to the thickened wall of the uterus
At what age does adenomyosis present?
Late 30s/40s
Age of presentation of adenomyosis vs endometriosis
Adenomyosis tends to present much later than endometriosis
Presentation of adenomyosis
Heavy painful periods
Bulky tender uterus
Painful intercourse
May co-exist with endometriosis
Is adenomyosis usually found in non-parous women or parous women?
Parous women
Investigations for adenomyosis
MRI
Hysterectomy (histology)
Treatment of adenomyosis
No symptoms = No treatment
Treat symptoms of heavy and painful periods with hormonal contraception (mirena (LNG IUS), progesterones, COCP)
Another name for fibroids
Leiomyoma
Which race have a higher incidence for fibroids?
Afro-carribean women
How many 40 y/os have fibroids of varying size?
60%
Investigations for fibroids
Abdominal palpation - irregularly enlarged uterus up to 12 weeks
USS - transvaginal or if > 16 weeks abdominal
Hysteroscopy - if inside uterine cavity
Types of fibroids
Submucous
Intramural
Subserous
Where are submucous fibroids?
Protrude into the uterine cavity
Where are intramural fibroids?
Within the uterine wall
Where are subserous fibroids?
Project out of the uterus into the peritoneal cavity
Presentation of fibroids
Usually asymptomatic
Large fibroids may present with pressure symptoms depending on their location
- pressing bladder - increased frequency
- pressing bowel - constipation
menorrhagia (enlarge uterine cavity surface area)
Inter menstrual bleeding
In pregnancy
- pain
- malpresentation
- obstruction of labour (cervical fibroid)
What type of fibroid tends to cause heavy bleeding?
Intramural
What type of fibroid may cause intermenstrual bleeding?
Submucous or fibroid polyps
Treatment of fibroids
No symptoms = No treatment
Standard menorrhagia treatment if cavity not too distorted
GnRH analogues or ulipristal acetate (to shrink fibroids, usually preoperatively)
Submucous fibroids - transcervical resection hysteroscopically
Myomectomy
Uterine artery embolization
Hysterectomy
In the treatment of fibroids, in what situation is a myomectomy carried out?
Women who wish to conceive as this preserves the uterus
What does the passage of clots represent?
Heavy flow
Treatment of menorrhagia
FIRST LINE = LNG-IUS mirena coil (if not trying to conceive)
SECOND LINE = tranexamic acid/ COCP
THIRD LINE = progesterones e.g. deprovera
surgery may be indicated if underlying pathology such as polyps
Most common cause of post-coital bleeding in pre-menopausel women
Cervical ectropion
Who is cervical ectropion more common in?
Women on the COCP
Causes of post coital bleeding in pre-menopausal women
Cervical ectropion Infection e.g. cervicitis secondary to chlamydia Cervical or endometrial polyps vaginal cancer cervical cancer Trauma
When is tranexamic acid used vs mefenamic acid?
Tranexamic acid - heavy menstrual bleeding
Mefenamic acid - dysmenorrhoea
Pathology of cervical ectropion
Elevated oestrogen levels result in a larger area of columnar epithelium being present on the ectocervix
Causes of cervical ectropion
Ovulatory phase
Pregnancy
COCP
Presentation of cervical ectropion
Vaginal discharge
PCB
Treatment of cervical ectropion
Ablative treatment ONLY for troublesome symptoms
What long acting method of contraception be used as emergency contraception?
Copper IUD
What is pre menstrual syndrome?
The emotional and physical symptoms that women may experience prior to menstruation
Presentation of pre menstrual syndrome
Depression Bloating Anxiety / stress Mastalgia Mood swings
Treatment of pre menstrual syndrome
COCP
Conservative
What is supportive of PMS?
Abscence of PMS in puberty, pregnancy and after menopause
How does the contraceptive patch work?
Wear one patch for a week, then change and wear for 3 weeks in a row
1 week break after 3 weeks
Gold standard investigation for endometriosis
Laparoscopy
Explain fibroid degeneration
Fibroids are sensitive to oestrogen and so can grow during pregnancy
If their growth outstrips their blood supply, they can undergo red or Carneous degeneration
Presentation of fibroid degeneration
Low grade fever
Pain
Vomiting
Treatment of fibroid degeneration and how long does it take to resolve?
Rest and analgesia
4-7 days
First line treatment for menorrhagia (if not trying to conceive)
IUS Mirena
