Menstrual problems Flashcards
What is the normal age of menarche to menopause?
13-51 years old
What is the normal length of a menstrual cycle?
Between 21-35 days
What triggers menstruation?
Menstruation is triggered by fall in progesterone 2 weeks after ovulation if not pregnant
Mean blood loos in menstruation?
30-40ml
What is menorrhagia?
Heavy periods (>80ml/cycle)
What is dysmenorrhoea?
Painful periods
What is inter-menstrual bleeding (IMB)?
Bleeding between periods
What is postcoital bleeding (PCB)?
Bleeding after intercourse
What is oligomenorrhoea?
Infrequent periods eg /45-90
20% of gynaecology outpatient referrals
Menstrual problems - history?
> Subjective – patient’s perception
> Clots / flooding / pads+ tampons
> Pain (with heavy flow or premenstrual)
> Ask about effect of symptoms on lifestyle and quality of life
Menstrual problems - Examination?
> General
Abdominal
Speculum
Bimanual
If a patient presented with heavy periods what would you want to investigate?
> Full blood count
Thyroid function
Coagulation
Endometrial biopsy (Over 45/persistant IMB/ Obesity)
If a patient presented with intermenstrual (IMB) bleeding what would you want to investigate?
> Test for chlamydia
Persistant endometrial biopsy
Hysteroscopy
If a patient presented with Post coital bleeding (PCB) what would you want to investigate?
Test for chlamydia
Investigations when issues with menstruation?
> Full blood count > Thyroid function > Coagulation > Endometrial biopsy > STD testing (Chlamydia) > Pregnancy test > Transvaginal US > Hysteroscopy
In terms on menstruation when would you want to perform hysterocopy?
> Persistant IMB
> Suspected endometrial pathology on US
Within early teens if there are issues with menstruation what are the most likely causes?
> Anovulatory cycles
Coagulation problems
Always consider pregnancy and look at the cervix
Within teens-40 if there are issues with menstruation what are the most likely causes?
> Chlamydia > Contraception related > Endometriosis / adenomyosis > Fibroids > Endometrial or cervical polyps > Dysfunctional bleeding
Always consider pregnancy and look at the cervix
Within 40-menopause if there are issues with menstruation what are the most likely causes?
> Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction
Always consider pregnancy and look at the cervix
What is the FIGO classification of abnormal uterine bleeding?
PALM-COEIN: P- polyp A- adenomyosis L- leiomyoma M- malignancy/hyperplasia C- coagulation eg von willebrand’s disease O- ovarian eg polycystic ovaries / anovulatory cycles E – endocrine eg thyroid I- iatrogenic eg warfarin N- not yet classified
What is Dysfunctional uterine bleeding (DUB)?
Abnormal bleeding but no structural / endocrine /neoplastic / infectious cause found for (yet)
What are 50% of hysterectomies for menorrhagia for?
Dysfunctional uterine bleeding (DUB)
What is endometriosis?
Endometrial type tissue outside the uterine cavity
What makes endometriosis?
Oestrogen
What is the most likely locations of endometriosis?
Usually ovary, pouch of Douglas, pelvic peritoneum
Theories of pathogenesis of endometriosis?
> Retrograde menstruation
Coelomic metaplasia
Haematogenous spread
Direct transplantation
Symptoms of endometriosis?
> Can be asymptomatic > Premenstrual pelvic pain, > Dysmenorrhoea, > Deep dyspareunia, > Sub-fertility
Signs of endometriosis?
> May be none
> Tender nodules in rectovaginal septum
> Limited uterine mobility
> Adnexal mass
Diagnosis of endometriosis?
> Gold standard - laparoscopy - clear, red (Red-flame), bluish black or white lesions, powder burn nodule
> MRI for deep endometriosis
> Ultrasound can diagnose endometriosis (chocolate cyst)
What commonly happens in ovarian endometriosis and helps with diagnosis?
“Chocolate cysts” which can be seen laparoscopically and on US
How do we treat endometriosis?
> Medical (hormonal treatment and analgesics)
> Surgical
Disease may reoccur after treatment
How do we treat endometriosis - medically?
Medical (hormonal treatment and analgesics):
1) Progestogen - oral/injection/ Levonorgesterel Intrauterine system (LNG-IUS)
2) Combined oral contraceptive pill
3) GnRH analogues (eg leuprorelin)
4) (danazol/gestrinone no longer used)
Disease may recur after treatment
How do we treat endometriosis - Surgically?
Surgical:
1) Excision of deposits from peritoneum/ovary
2) Diathermy / laser ablation of deposits
3) Removal of ovaries with or without hysterectomy
Disease may recur after treatment
What is adenomyosis?
Characterised by the presence of endometrial tissue in the myometrium
Symptoms and signs of adenomyosis?
1) Heavy painful periods
2) Bulky tender uterus
3) Usually in parous women
4) May co-exist with endometriosis
Diagnosis of adenomyosis?
Diagnosis:
> MRI may suggest diagnosis but limited availability
> Histology of uterine muscle – generally post hysterectomy
Treatment of adenomyosis?
1) Treat symptoms of heavy and painful periods with hormonal contraception:
> LNG IUS (Mirena)
> Progestogens
> Combined oral contraceptive pill
2) Often failed medical treatment/ endometrial ablation and diagnosed on pathology at hysterectomy
What are fibroids?
Smooth muscle growths also known as leiomyoma
How common are fibroids?
> Very common and usually asymptomatic
> Up to 60% of 40 year olds have fibroids of varying size
> Higher incidence in Afro-caribbean women
How are fibroids diagnosed?
Diagnosis:
> Clinical exam – irregularly enlarged uterus
> Ultrasound
> Hysteroscopy (if inside uterine cavity)
Types of fibroids?
1) Sub mucous = Protrude into uterine cavity
2) Intramural = Within uterine wall
3) Sub serous = Project out of uterus into peritoneal cavity
Types of fibroids - Sub-mucous?
Sub-mucous = Protrude into uterine cavity
Types of fibroids - ?
Intramural = Within uterine wall
Types of fibroids - Sub-serous?
Sub-serous = Project out of uterus into peritoneal cavity
Diagnosis of fibroids?
> Ultrasound
Hysteroscopy
Laproscopy
Symptoms of fibroids?
> May be asymptomatic
> Large fibroids may cause pressure symptoms (depends on location)
> Menorrhagia: enlarge the uterine cavity surface area
> Submucous or fibroid polyps may cause intermenstrual bleeding
> Can rapidly increase in size in pregnancy causing pain, malpresentation or obstruction in labour (cervical fibroid)
Treatment of fibroids?
1) Standard menorrhagia treatment if cavity not too distorted
2) GnRH analogues or Ulipristal acetate may be used temporarily to shrink the fibroids – usually preoperatively
3) Submucous fibroids: Transcervical resection
4) Hysteroscopically
5) Myomectomy
6) Uterine artery embolisation
7) Hysterectomy
Treatments for Dysfunctional Uterine Bleeding?
Medical treatment:
1) Non hormonal:
> Tranexamic acid
> Mefanamic acid
2) Hormonal:
> Progestogen only tablets, injections (Depo Provera)
> Levonorgesterel Intrauterine System
> Combined pill
Surgical treatment (if family complete): > Endometrial ablation > Hysterectomy
Treatments for Dysfunctional Uterine Bleeding - Medical treatment?
Medical treatment:
1) Non hormonal:
> Tranexamic acid
> Mefanamic acid
2) Hormonal:
> Progestogen only tablets, injections (Depo Provera)
> Levonorgesterel Intrauterine System
> Combined pill
Treatments for Dysfunctional Uterine Bleeding - Surgical treatment?
Surgical treatment (if family complete): > Endometrial ablation > Hysterectomy
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Non-hormonal?
1) Tranexamic acid (antifibrinolytic) reduces blood loss 60%
2) Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain
> Both of them are taken at the time of periods
> Suitable for those trying to conceive
> Do not regulate cycles
Treatments for Dysfunctional Uterine Bleeding - Medical treatment -Tranexamic acid?
Tranexamic acid (antifibrinolytic) reduces blood loss 60%
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Mefenamic acid?
Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Hormonal?
1) Combined contraceptive pill makes periods lighter, regular and less painful
2) LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
3) Oral progestogens eg Provera10mg od:
- Day 5-25 cycle reduce bleeding +regulate
- Day 15-25 may regulate cycle but does not reduce amount of bleeding
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Combined contraceptive pill?
Combined contraceptive pill makes periods lighter, regular and less painful
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - LNG IUS and Depo-Provera?
LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Oral progestogens eg Provera10mg od?
- Day 5-25 cycle reduce bleeding +regulate
- Day 15-25 may regulate cycle but does not reduce amount of bleeding
Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation?
Permanent destruction of endometrium using different energy sources
60% will have no periods, 85% are satisfied, 15% will have subsequent hysterectomy
Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation - first generation?
First generation ablation: under hysteroscopic vision – uses diathermy
Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation - second generation?
Second generation ablation: thermal balloon, radiofrequency
Pre-requisites for endometrial ablation?
> Uterine cavity length <11 cm
> Submucous fibroids < 3cm
> Previous normal endometrial biopsy
What is a hysterectomy?
Surgical removal of uterus
Types of hysterectomy approach?
1) Abdominal
2) Vaginal
3) Laparoscopic:
> Laporoscopically assisted vaginal hysterectomy (LAVH)
> Laparoscopic hysterectomy
> Total laparoscopic hysterectomy TLH
> Laparoscopically assisted subtotal hysterectomy
What is a total hysterectomy?
Total hysterectomy: cervix and uterus removed
What is a subtotal hysterectomy?
Subtotal hysterectomy: uterus removed, cervix left
Types of hysterectomy?
1) Subtotal
2) Total
3) Total with bilateral sapling-oophorectomy
4) Wartheim’s hysterectomy
How many days in hospital are required for hysterectomy?
> 3-5 days in hospital
1-2 days laparoscopic approach
> 2-3 months recovery
What are the risk of a hysterectomy?
1) Infection
2) DVT
3) Bladder, bowel, vessel injury
4) Altered bowel functions
5) Adhesion
Guarantees amenorrhoea
What is the removal of the ovaries with uterus called?
Salpingo-oophorectomy
When may sapling-oophprectomy be performed?
1) Endometriosis
2) Ovarian pathology
What is the major disadvantage of oophorectomy?
Immediate menopause
What is the major advantage of oophorectomy?
Reduced risk of subsequent ovarian cancer
