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Year 3 - Reproduction > Menstrual problems > Flashcards

Menstrual problems Flashcards

1
Q

What is the normal age of menarche to menopause?

A

13-51 years old

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2
Q

What is the normal length of a menstrual cycle?

A

Between 21-35 days

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3
Q

What triggers menstruation?

A

Menstruation is triggered by fall in progesterone 2 weeks after ovulation if not pregnant

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4
Q

Mean blood loos in menstruation?

A

30-40ml

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5
Q

What is menorrhagia?

A

Heavy periods (>80ml/cycle)

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6
Q

What is dysmenorrhoea?

A

Painful periods

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7
Q

What is inter-menstrual bleeding (IMB)?

A

Bleeding between periods

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8
Q

What is postcoital bleeding (PCB)?

A

Bleeding after intercourse

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9
Q

What is oligomenorrhoea?

A

Infrequent periods eg /45-90

20% of gynaecology outpatient referrals

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10
Q

Menstrual problems - history?

A

> 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

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11
Q

Menstrual problems - Examination?

A

> General
Abdominal
Speculum
Bimanual

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12
Q

If a patient presented with heavy periods what would you want to investigate?

A

> Full blood count
Thyroid function
Coagulation
Endometrial biopsy (Over 45/persistant IMB/ Obesity)

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13
Q

If a patient presented with intermenstrual (IMB) bleeding what would you want to investigate?

A

> Test for chlamydia
Persistant endometrial biopsy
Hysteroscopy

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14
Q

If a patient presented with Post coital bleeding (PCB) what would you want to investigate?

A

Test for chlamydia

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15
Q

Investigations when issues with menstruation?

A 
> Full blood count 
> Thyroid function
> Coagulation 
> Endometrial biopsy 
> STD testing (Chlamydia)
> Pregnancy test
> Transvaginal US
> Hysteroscopy
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16
Q

In terms on menstruation when would you want to perform hysterocopy?

A

> Persistant IMB

> Suspected endometrial pathology on US

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17
Q

Within early teens if there are issues with menstruation what are the most likely causes?

A

> Anovulatory cycles
Coagulation problems

Always consider pregnancy and look at the cervix

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18
Q

Within teens-40 if there are issues with menstruation what are the most likely causes?

A 
> Chlamydia
> Contraception related
> Endometriosis / adenomyosis
> Fibroids 
 > Endometrial or cervical polyps
> Dysfunctional bleeding

Always consider pregnancy and look at the cervix

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19
Q

Within 40-menopause if there are issues with menstruation what are the most likely causes?

A

> Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction

Always consider pregnancy and look at the cervix

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20
Q

What is the FIGO classification of abnormal uterine bleeding?

A 
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
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21
Q

What is Dysfunctional uterine bleeding (DUB)?

A

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

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22
Q

What are 50% of hysterectomies for menorrhagia for?

A

Dysfunctional uterine bleeding (DUB)

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23
Q

What is endometriosis?

A

Endometrial type tissue outside the uterine cavity

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24
Q

What makes endometriosis?

A

Oestrogen

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25
Q

What is the most likely locations of endometriosis?

A

Usually ovary, pouch of Douglas, pelvic peritoneum

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26
Q

Theories of pathogenesis of endometriosis?

A

> Retrograde menstruation
Coelomic metaplasia
Haematogenous spread
Direct transplantation

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27
Q

Symptoms of endometriosis?

A 
> Can be asymptomatic
> Premenstrual pelvic pain, 
> Dysmenorrhoea,
> Deep dyspareunia, 
> Sub-fertility
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28
Q

Signs of endometriosis?

A

> May be none

> Tender nodules in rectovaginal septum

> Limited uterine mobility

> Adnexal mass

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29
Q

Diagnosis of endometriosis?

A

> 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)

30
Q

What commonly happens in ovarian endometriosis and helps with diagnosis?

A

“Chocolate cysts” which can be seen laparoscopically and on US

31
Q

How do we treat endometriosis?

A

> Medical (hormonal treatment and analgesics)

> Surgical

Disease may reoccur after treatment

32
Q

How do we treat endometriosis - medically?

A

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

33
Q

How do we treat endometriosis - Surgically?

A

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

34
Q

What is adenomyosis?

A

Characterised by the presence of endometrial tissue in the myometrium

35
Q

Symptoms and signs of adenomyosis?

A

1) Heavy painful periods
2) Bulky tender uterus
3) Usually in parous women
4) May co-exist with endometriosis

36
Q

Diagnosis of adenomyosis?

A

Diagnosis:
> MRI may suggest diagnosis but limited availability

> Histology of uterine muscle – generally post hysterectomy

37
Q

Treatment of adenomyosis?

A

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

38
Q

What are fibroids?

A

Smooth muscle growths also known as leiomyoma

39
Q

How common are fibroids?

A

> Very common and usually asymptomatic

> Up to 60% of 40 year olds have fibroids of varying size

> Higher incidence in Afro-caribbean women

40
Q

How are fibroids diagnosed?

A

Diagnosis:
> Clinical exam – irregularly enlarged uterus

> Ultrasound

> Hysteroscopy (if inside uterine cavity)

41
Q

Types of fibroids?

A

1) Sub mucous = Protrude into uterine cavity
2) Intramural = Within uterine wall
3) Sub serous = Project out of uterus into peritoneal cavity

42
Q

Types of fibroids - Sub-mucous?

A

Sub-mucous = Protrude into uterine cavity

43
Q

Types of fibroids - ?

A

Intramural = Within uterine wall

44
Q

Types of fibroids - Sub-serous?

A

Sub-serous = Project out of uterus into peritoneal cavity

45
Q

Diagnosis of fibroids?

A

> Ultrasound
Hysteroscopy
Laproscopy

46
Q

Symptoms of fibroids?

A

> 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)

47
Q

Treatment of fibroids?

A

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

48
Q

Treatments for Dysfunctional Uterine Bleeding?

A

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
49
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment?

A

Medical treatment:
1) Non hormonal:
> Tranexamic acid
> Mefanamic acid

2) Hormonal:
> Progestogen only tablets, injections (Depo Provera)
> Levonorgesterel Intrauterine System
> Combined pill

50
Q

Treatments for Dysfunctional Uterine Bleeding - Surgical treatment?

A 
Surgical treatment (if family complete):
> Endometrial ablation
> Hysterectomy
51
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Non-hormonal?

A

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

52
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment -Tranexamic acid?

A

Tranexamic acid (antifibrinolytic) reduces blood loss 60%

53
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Mefenamic acid?

A

Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain

54
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Hormonal?

A

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

55
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Combined contraceptive pill?

A

Combined contraceptive pill makes periods lighter, regular and less painful

56
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - LNG IUS and Depo-Provera?

A

LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic

57
Q

Treatments for Dysfunctional Uterine Bleeding - Medical treatment - Oral progestogens eg Provera10mg od?

A
  • Day 5-25 cycle reduce bleeding +regulate

- Day 15-25 may regulate cycle but does not reduce amount of bleeding

58
Q

Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation?

A

Permanent destruction of endometrium using different energy sources

60% will have no periods, 85% are satisfied, 15% will have subsequent hysterectomy

59
Q

Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation - first generation?

A

First generation ablation: under hysteroscopic vision – uses diathermy

60
Q

Treatments for Dysfunctional Uterine Bleeding - Surgical treatment - Endometrial ablation - second generation?

A

Second generation ablation: thermal balloon, radiofrequency

61
Q

Pre-requisites for endometrial ablation?

A

> Uterine cavity length <11 cm

> Submucous fibroids < 3cm

> Previous normal endometrial biopsy

62
Q

What is a hysterectomy?

A

Surgical removal of uterus

63
Q

Types of hysterectomy approach?

A

1) Abdominal
2) Vaginal

3) Laparoscopic:
> Laporoscopically assisted vaginal hysterectomy (LAVH)
> Laparoscopic hysterectomy
> Total laparoscopic hysterectomy TLH
> Laparoscopically assisted subtotal hysterectomy

64
Q

What is a total hysterectomy?

A

Total hysterectomy: cervix and uterus removed

65
Q

What is a subtotal hysterectomy?

A

Subtotal hysterectomy: uterus removed, cervix left

66
Q

Types of hysterectomy?

A

1) Subtotal
2) Total
3) Total with bilateral sapling-oophorectomy
4) Wartheim’s hysterectomy

67
Q

How many days in hospital are required for hysterectomy?

A

> 3-5 days in hospital
1-2 days laparoscopic approach

> 2-3 months recovery

68
Q

What are the risk of a hysterectomy?

A

1) Infection
2) DVT
3) Bladder, bowel, vessel injury
4) Altered bowel functions
5) Adhesion

Guarantees amenorrhoea

69
Q

What is the removal of the ovaries with uterus called?

A

Salpingo-oophorectomy

70
Q

When may sapling-oophprectomy be performed?

A

1) Endometriosis

2) Ovarian pathology

71
Q

What is the major disadvantage of oophorectomy?

A

Immediate menopause

72
Q

What is the major advantage of oophorectomy?

A

Reduced risk of subsequent ovarian cancer

Year 3 - Reproduction (25 decks)

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