Menstrual problems Flashcards
What is the normal age range for menstruation?
13-51yrs
Menarche-menopauce
How is menstruation triggered?
Fall in progesterone 2wks after ovulation if not pregnant
What is the mean volume of blood lost during menstruation?
30-40ml
What is menorrhagia and typically what volume?
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
What do you ask in history of menstrual problems?
PAtient’s perception
Clots/flooding/pads/tampons
Pain
Effect on lifestyle
What do you exam in history of menstrual problems?
General
Abdo
Speculum
Bimanual
What are the investigations for those with menstrual problems?
Heavy periods: FBC, thyroid function, coag, endometrial biopsy
IMB and PCB: chlamydia
Pregnancy test
TV US
Hysteroscopy
When would you do hysteroscopy?
Persistent IMB
Suspected endometrial pathology on US
If early teens, what are likely menstrual problem?
Anovulatory cycles
Coagulation problems
If teens-40, what are likely menstrual problems?
Chlamydia Contraception related Endometriosis/adenomyosis Fibroids Endometrial/cervical polps Dysfunctional bleeding
If 40-menopause, what are likely menstrual problems?
Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction
What is the mneumonic for the FIGO classification of abnormal uterine bleeding?
PALM-COEIN
What is PALM-COEIN (FIGO classification of abnormal uterine bleeding)?
P - polyp A - adenomyosis L - leiomyoma M - malignancy/hyperplasia C - coagulation O - ovarian (PCOS/anovulatory) E - endocrine (thyroid) I - iatrogenic (warfarin) N - not yet classified
What is DUB?
Dysfunctional uterine bleeding
What is dysfunctional uterine bleeding (DUB)?
Abnormal bleeding but no structural/endocrine/neoplastic/infectious cause found
What is endometriosis?
Endometrial type tissue outside the uterine cavity
What is endometriosis dependent on?
Oestrogen
Where does endometriosis usually affect?
Ovary, pouch of Douglas, pelvic peritoneum
What are the signs/symptoms of endometriosis?
Premenstrual pelvic pain
Dysmenorrhoea
Deep dyspareunia
Subfertility
May be no signs
Tender nodules in rectovaginal septum
Limited uterine mobility
Adnexal mass
What is the gold standard for diagnosing endometriosis?
Laparoscopy
What can be seen on laparoscopy for endometriosis?
Clear, red, bluish black or white lesions
What is the diagnostic technique for deep endometriosis?
MRI
What can be used to diagnose endometrioma?
US
What are the investigations for endometriosis?
Laparoscopy
MRI
What are chocolate cysts?
Noncancerous, fluid-filled cysts that typically form deep within the ovaries
What are the treatment options for endometriosis?
Medical
Surgical
What are the medical treatments for endometriosis?
Progesterone: oral/injection/Levonorgesterel IUD
CHC pill
GnFH analogues (e.g. leuprorelin)
What are the surgical treatments for endometriosis?
Excision of deposits from peritoneum/ovary
Diathermy/laser ablation of deposits
Removal of ovaries with/without hysterectomy
What is adenomyosis?
Presence of endometrial tissue in the myometrium
What are the symptoms/signs of adenomyosis?
Heavy painful periods
Bulky tender uterus
Usually parous women
May co-exist with endometriosis
How is adenomyosis diagnosed?
MRI
Histology (post-hysterectomy)
What is the treatment for adenomyosis?
Hormonal contraception for painful/heavy periods: LNHIUS (Mirena), progestogens, combined OCP
What are fibroids?
Smooth muscle growths (leiomyoma)
What are the symptoms of fibroids?
Usually asymptomatic Large = pressure symptoms Menorrhagia IMB In pregnancy: pain, malpresentation, obstruction in labour
What group have a higher incidence of fibroids?
Afro-Caribbean women
What are the investigations for fibroids?
Clinical exam = irregularly enlarged uterus
US
Hysteroscopy
What are the 3 types of fibroids?
Submucous = protrude into uterine cavity Intramural = within uterine wall Subserous = project out of uterus into peritoneal cavity
What is the treatment for fibroids?
Only symptomatic GnRH analogues or Ulipristal acetate - shrink fibroids Transcervical resection Myomectomy Uterine artery embolisation Hysterectomy
What is the treatment for submucous fibroids?
Transcervical resection hysteroscopically
What are treatments options for DUB?
Reassurance not sinister
Medical
Surgical
What are the medical treatments for DUB?
Non-hormonal: tranexamic acid or mefanamic acid
Hormonal: POP, injection (Depo Provera), LNG IUS, CHC pill
What are the surgical treatments for DUB?
Endometrial ablation
Hysterectomy
What does tranexamic acid do in DUB?
Reduces blood loss
What does Mefenamic acid do in DUB?
Reduces blood loss and pain
When are tranexamic acid and Mefenamic acid taken for DUB?
At time of periods
What approaches are there to hysterectomy?
Abdominal
Vaginal
Laparoscopic
What is removed in a total hysterectomy?
Cervix and uterus
What is removed in subtotal hysterectomy?
Uterus removed
Cervix left
What are the risks for hysterectomy?
Infection, DVT, bladder/bowel/vessel injury, altered bladder function, adhesions
What does hysterectomy guarantee?
Amenorrhoea
What is removal of the ovaries with uterus called?
Total hysterectomy with bilateral salpingo-oophrorectomy
What are disadvantages of oophroectomy?
Immediate menopause, recommended HRT till age 50
What are advantages of oophorectomy?
Reduces risk of ovarian cancer
Why is there a high risk of menopause 2yrs post-hysterectomy?
Compromised blood supply
