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Reproduction Pathology > Menstrual Problems > Flashcards

Menstrual Problems Flashcards

1
Q

What is the normal ages for menarche to menopause

A

13-51

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2
Q

What Is the normal cycle pattern of a period?

A

4-5/21-35

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3
Q

What is menstruation triggered by?

A

A fall in progesterone 2 weeks after ovulation if not pregnant

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4
Q

Mean blood loss of a normal period

A

30-40ml

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5
Q

Blood loss per cycle in menorrhagia

A

> 80ml/cycle

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6
Q

Types of dysmenorrhoea

A 
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
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7
Q

When is intermenstrual bleeding (IMB) normal?

A

when related to ovulation ONLY

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8
Q

Definition of intermenstrual bleeding (IMB)

A

Bleeding between periods

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9
Q

Definition of post coital bleeding (PCB)

A

Bleeding after intercourse

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10
Q

Causes of post coital bleeding (PCB)

A

chlamydia (esp. < 25 y/o)
Cervical cancer
cervical polyps

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11
Q

Oligomenorrhoea meaning

A

infrequent periods e.g. /45-90 days

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12
Q

Questions to ask in a history about menstrual problems

A 
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
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13
Q

Investigations of heavy periods

A

FBC (anaemic)
TFTs and coagulation if suggestive
Endometrial biopsy (if >45/persistent IMB/obesity)

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14
Q

Key Investigation of intermenstrual bleeding and post coital bleeding in the <25s

A

Chlamydia test

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15
Q

Possible investigations of menstrual problems (depending on patient and symptoms)

A

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)

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16
Q

Likely causes of menstrual problems in early teens

A

Anovulatory cycles

  • PHA not established yet so girls dont have a regular cycle
  • Tend to be heavy, infrequent and generally not painful
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17
Q

Likely causes of menstrual problems in teens –> 40

A 
Chlamydia 
Contraception related side effects
Endometriosis/adenomyosis (heavy + painful)
Fibroids (heavy, no pain usually)
endometrial/cervical polyps (IMB/PCB)
Dysfunctional bleeding
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18
Q

How much of the menstrual problems due to contraceptive related side effects settle?

A

80% settle

20% can continue to have irregular bleeding

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19
Q

Likely causes of menstrual problems from 40 –> menopause

A

Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction

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20
Q

What should always be considered in menstrual problems as a cause?

A

Pregnancy

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21
Q

FIGO classification for the causes of abnormal uterine bleeding - PALM-COEIN

A 
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
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22
Q

Definition of dysfunctional uterine bleeding (DUB)

A

Abnormal bleeding but NO structural/endocrine/neoplastic/infectious cause found(yet)

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23
Q

Hormonal and ovarian activity in dysfunctional uterine bleeding can be described as….

A

erratic

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24
Q

Treatment of dysfunctional uterine bleeding (DUB)

A

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

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25
Q

When treating dysfunctional uterine bleeding, who would use non-hormonal treatments?

A

For those trying to conceive

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26
Q

When are non-hormonal treatments for DUB taken?

A

At the time of the periods and continued through the period but for no longer than 7 days

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27
Q

Why would hormonal treatments for Dysfunctional uterine bleeding not be suitable for those trying to conceive?

A

As the treatments are contraceptive in nature

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28
Q

Types of hysterectomy

A

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

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29
Q

Risks of hysterectomy

A 
Infection 
DVT
Bladder
Bowel 
Vessel injury 
Altered bladder function 
Adhesions
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30
Q

What does a hysterectomy guarantee?

A

Amenorrhoea

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31
Q

When would ovaries be removed along with the uterus?

A

Endometriosis

Presence of an ovarian pathology

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32
Q

What does an oophorectomy immediately cause?

A

Immediate menopause

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33
Q

What is used to treat immediate menopause caused by an oophrectomy?

A

HRT until 50

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34
Q

What does an oophorectomy reduce the risk of?

A

Subsequent ovarian cancer

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35
Q

Common sites for endometriosis

A

Ovary
Pouch of douglas
Pelvic peritoneum

36
Q

Presentation of endometriosis

A 
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
37
Q

Theories of pathogenesis of endometriosis

A

Sampsons theory of retrograde menstruation
Coelomic metaplasia (common embryonic precursor)
Haematogenous spread
Direct transplantation

38
Q

Investigations for endometriosis

A

Laparoscopy (superficial)
MRI (deep i.e. stage IV)
USS (Endometrioma - chocolate cysts)

39
Q

Sites possible for endometriosis

A 
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
40
Q

Treatment for endometriosis

A 
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
41
Q

In the treatment of endometriosis, what do GnRH analogues do?

A

Induce a medical menopause

42
Q

Can disease recur after treatment for endometriosis?

A

Yes

43
Q

Definition of endometriosis

A

Endometrial type tissue outside of the uterine cavity

44
Q

Definition of adenomyosis

A

The presence of endometrial tissue in the myometrium (muscle wall of the uterus)

45
Q

Why can adenomyosis be mistaken for fibroids?

A

Due to the thickened wall of the uterus

46
Q

At what age does adenomyosis present?

A

Late 30s/40s

47
Q

Age of presentation of adenomyosis vs endometriosis

A

Adenomyosis tends to present much later than endometriosis

48
Q

Presentation of adenomyosis

A

Heavy painful periods
Bulky tender uterus
Painful intercourse
May co-exist with endometriosis

49
Q

Is adenomyosis usually found in non-parous women or parous women?

A

Parous women

50
Q

Investigations for adenomyosis

A

MRI

Hysterectomy (histology)

51
Q

Treatment of adenomyosis

A

No symptoms = No treatment

Treat symptoms of heavy and painful periods with hormonal contraception (mirena (LNG IUS), progesterones, COCP)

52
Q

Another name for fibroids

A

Leiomyoma

53
Q

Which race have a higher incidence for fibroids?

A

Afro-carribean women

54
Q

How many 40 y/os have fibroids of varying size?

A

60%

55
Q

Investigations for fibroids

A

Abdominal palpation - irregularly enlarged uterus up to 12 weeks
USS - transvaginal or if > 16 weeks abdominal
Hysteroscopy - if inside uterine cavity

56
Q

Types of fibroids

A

Submucous
Intramural
Subserous

57
Q

Where are submucous fibroids?

A

Protrude into the uterine cavity

58
Q

Where are intramural fibroids?

A

Within the uterine wall

59
Q

Where are subserous fibroids?

A

Project out of the uterus into the peritoneal cavity

60
Q

Presentation of fibroids

A

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)

61
Q

What type of fibroid tends to cause heavy bleeding?

A

Intramural

62
Q

What type of fibroid may cause intermenstrual bleeding?

A

Submucous or fibroid polyps

63
Q

Treatment of fibroids

A

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

64
Q

In the treatment of fibroids, in what situation is a myomectomy carried out?

A

Women who wish to conceive as this preserves the uterus

65
Q

What does the passage of clots represent?

A

Heavy flow

66
Q

Treatment of menorrhagia

A

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

67
Q

Most common cause of post-coital bleeding in pre-menopausel women

A

Cervical ectropion

68
Q

Who is cervical ectropion more common in?

A

Women on the COCP

69
Q

Causes of post coital bleeding in pre-menopausal women

A 
Cervical ectropion 
Infection e.g. cervicitis secondary to chlamydia 
Cervical or endometrial polyps
vaginal cancer
cervical cancer
Trauma
70
Q

When is tranexamic acid used vs mefenamic acid?

A

Tranexamic acid - heavy menstrual bleeding

Mefenamic acid - dysmenorrhoea

71
Q

Pathology of cervical ectropion

A

Elevated oestrogen levels result in a larger area of columnar epithelium being present on the ectocervix

72
Q

Causes of cervical ectropion

A

Ovulatory phase
Pregnancy
COCP

73
Q

Presentation of cervical ectropion

A

Vaginal discharge

PCB

74
Q

Treatment of cervical ectropion

A

Ablative treatment ONLY for troublesome symptoms

75
Q

What long acting method of contraception be used as emergency contraception?

A

Copper IUD

76
Q

What is pre menstrual syndrome?

A

The emotional and physical symptoms that women may experience prior to menstruation

77
Q

Presentation of pre menstrual syndrome

A 
Depression
Bloating
Anxiety / stress 
Mastalgia 
Mood swings
78
Q

Treatment of pre menstrual syndrome

A

COCP

Conservative

79
Q

What is supportive of PMS?

A

Abscence of PMS in puberty, pregnancy and after menopause

80
Q

How does the contraceptive patch work?

A

Wear one patch for a week, then change and wear for 3 weeks in a row
1 week break after 3 weeks

81
Q

Gold standard investigation for endometriosis

A

Laparoscopy

82
Q

Explain fibroid degeneration

A

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

83
Q

Presentation of fibroid degeneration

A

Low grade fever
Pain
Vomiting

84
Q

Treatment of fibroid degeneration and how long does it take to resolve?

A

Rest and analgesia

4-7 days

85
Q

First line treatment for menorrhagia (if not trying to conceive)

A

IUS Mirena

Reproduction Pathology (28 decks)

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