Menstrual Problems Flashcards
menorrhagia?
heavy bleeding
metorrhagia?
regular intermenstrual bleeding
polymenorrhoea?
menses occuring <21 day cycle
polymenorrhagia?
increased bleeding and frequent cycle
menometrorrhagia?
prolonged menses and intermenstrual bleeding
amenorrhoea?
absence of menstruation >6 months
oligomenorrhoea?
menses at intervals >35 days
or
presence of 5 or fewer menstrual cycles over a year
local causes of menorrhagia?
fibroids adenomyosis endocervical/endometrial polyp endometrial hyperplasia IUD pelvic inflammatory disease endometriosis malignancy of uterus/cervix hormone producing ovarian tumours AVM
systemic causes of menorrhagia?
endocrine (hypo/hyperthyroid, diabetes, adrenal disease, prolactin disorder)
haematological disorder (vWF, immune thrombocytopaenic purpura with thrombosis-ITP, clotting factor deficiency)
liver disease
renal disease
drugs (anticoagulants etc)
what other causes of heavy vaginal bleeding should be considered?
pregnancy complications
- miscarriage
- ectopic
- molar
- placenta praevia
investigations in menorrhagia?
no real specific method to measure blood loss
need thorough history to determine blood loss (ask how many pads they go through a day etc)
then clinical examination (abdominal and pelvic exam)
look for signs of anaemia
cervical smear if due, swabs if infection suspected
what is non-organic menorrhagia?
occurs in absence of pathology
AKA dysfunctional uterine bleeding (DUB)
50% of abnormal uterine bleeding cases
types of DUB?
anovulatory: 85% of DUB cases, irregular cycles
ovulatory: regular heavy periods
who are anovulatory cycles most common in?
obese women
more common at extremes of repro life
who are ovulatory DUB most common in?
35-45 yrs
what causes ovulatory DUB?
inadequate progesterone production by corpus luteum
how is DUB investigated?
FBC
thyroid function
coagulation screen (if heavy bleeding)
renal/liver function tests
transvaginal US (look at endometrial thickness and presence of fibroids/pelvic masses)
endometrial sampling (pipelle/D&C)
cervical smear if due (not a test for DUB)
options for medical management of DUB?
progesterone IUD (mirena) COCP antifibrinolytics (tranexamic acid) NSAIDs (mefenamic acid) oral progesterone GnRH analogue/agonists danazol
when is mirena best used for DUB?
first line DUB treatment
good if there is compliance concerns
avoids drug interactions of COCP and POP
how is tranexamic acid used?
taken during menstruation only
decreases blood loss by 50%
good if woman is considering getting pregnant
how is mefenamic acid taken?
taken only during menstruation
decreases blood loss by 20-25%
good if there is also dysmenorrhoea (as also produces prostaglandins)
good if thinking of getting pregnant
how do GnRH analoges work?
act on pituitary to stop oestrogen production resulting in amenorrhoea (-ve feedback)
how should GnRH analogies be taken and why?
short term use (<6 months) as they can cause osteoporosis long term unless combined with HRT
how can DUB be managed surgically?
usually only when medical management fails
endometrial resection/ablation
hysterectomy
types of endocervical resection/ablation?
transcervical endometrial resection
rollerball endometrial ablation
thermal balloon ablation
thermal hydro-ablation
types of hysterectomy?
sub-total
total abdominal
vaginal
laparoscopic assisted subtotal
advantages of surgical DUB management?
effective
definitive treatment
disadvantages of surgical DUB management?
fertility lost
complications
anaesthetic risk
waiting list
what can cause intermenstrual bleeding?
cervical ectropion PID and STDs endometrial or cervical polyps cervical cancer endometrial cancer undiagnosed pregnancy/pregnancy complications molar pregnancy
when do premenstrual symptoms occur?
luteal phase
contributing factors to physical manifestations of premenstrual symptoms?
decreased progesterone synthesis increased prolactin increased oestrogen increased aldosterone increased prostaglandins
management of premenstrual symptoms?
keep diary for 2 cycles
symptom relief (pharmacological and non-pharmacological)
- SSRI if severe
- CBT
- lifestyle (alcohol, stress etc)
- COCP, transdermal oestrogen, GnRH analogues
- hysterectomy = last resort
what can cause post-coital bleeding?
cervical ectropion cervical carcinoma trauma atrophic vaginitis cervitis due to STD polyps idiopathic
what can cause cervical ectropion?
usually hormonal (high oestrogen in pregnancy, hormonal contraceptives - esp COCP)
post-menopausal bleeding (PMB) definition?
bleeding after periods have stopped for 12 months
when might cyclical post menopausal bleeding be normal?
if patient is taking combined cyclical HRT
should still investigate
NICE guidelines for investigation in post-menopausal bleeding in women >55?
should be seen within 2 weeks
causes of PMB?
atrophic vaginitis (most common) endometrial polyps endometrial hyperplasia endometrial carcinoma cervical carcinoma ovarian cancer vaginal cancer (rare)
how is PMB investigated?
TV US = first line
- endometrium <3mm = no further investigation
- >4mm = do biopsy (cut off = 5mm if taking HRT)
can also do CT, MRI of uterus, pelvis and abdomen
when is TV US not used and what is done instead?
women taking tamoxifen as it makes endometrium thick, irregular and cystic
hysteroscopy and biopsy done instead
how is atrophic vaginitis managed?
topical oestrogen and vaginal lubricants for symptomatic relief
can consider HRT
how is endometrial hyperplasia managed?
dilation and curettage progesterone treatment (mirena coil = first line, then oral)
most common cause of menstrual irregularity?
PCOS
criteria for diagnosing PCOS?
rotterdam criteria
must have 2 of the following
- biochemical or clinical hyperandrogenism
- polycystic ovaries on US scan (volume >10cm3 in at least 12 follicles in one ovary)
- oligo/amenorrhoea
features of PCOS?
obesity hypertension acanthosis nigricans acne and hirsutism alopecia insulin resistance and lipid abnormalities irregular periods
why does PCOS increase risk of endoemtrial hyperplasia and carcinoma?
causes no or reduced ovulation in presence of normal oestrogen levels so endometrium continues to proliferate without shedding
hormonal changes in PCOS?
increase in LH:FSH ratio
LH high and FSH low/normal
how is PCOS managed generally?
optimise BMI and protect endometrium with hormonal contraception
how is the associated infertility managed in PCOS?
5-10% weight loss if BMI >30
1st line = clomifene
adding metformin improves glucose tolerance and decreases androgen levels (improves ovulation rate)
2nd line = gonadotrophin injections if clomifene doesnt work
3rd line = IVF
how does clomifene work?
oestrogen blocker which blocks oestrogens negative feedback effect on hypothalamus resulting in more GnRH secretion and therefore more FSH and LH
side effects of clomifene?
hot flushes and sweating
increased risk of multiple pregnancy and ovarian cancer
what procedure can aid fertility in women who fail to conceive with comifene treatment?
ovarian drilling
diathermy used to destroy ovarian stroma which reduces androgen-secreting tissue leading to a restoration of the normal LH:FSH ratio and a fall in androgens
how can the acne associated with PCOS be managed?
co-cyrprindol (dianette)
- manages acne and hirsutism
COCP can improve symptoms of hyperandrogenism including acne
how is amenorrhoea associated with PCOS managed?
COCP
cyclical medroxyprogesterone or mirena coil can be helpful as an alternative
what is dysmenorrhoea?
excessive pain during menstrual period
types of dysmenorrhoea?
primary
secondary
what is primary dysmenorrhoea?
no underlying pelvic pathology
excessive prostaglandin production thought to be involved
in 50% of menstruating women and appears within 1-2 years of menarche
features of primary dysmenorrhoea?
pain starts just before or within a few hours of period starting
suprapubic cramping pains which may radiate to back or down thigh
what is secondary dysmenorrhoea?
result of underlying pathology
typically begins many years after menarche
features of secondary dysmenorrhoea?
pain starts 3-4 days before onset of period
what can cause secondary dysmenorrhoea?
endometriosis adenomyosis PID copper IUD (mirena can treat it, doesnt cause) fibroids
how does the uterus appear in adenomyosis?
large and globular
types of fibroids depending on location?
intramural (inside muscle wall)
submucosal (in mucosal layer)
pedunculated submucosal (under mucosal layer but dangling into uterus)
subserosal (just under outermost layer of uterus)
pedunculated subserosal (dangling outside uterus)
features of endometriosis?
heavy bleeding and dysmenorrhoea
uterosacral nodularity and/or tenderness
fixed retroverted uterus
features of adenomyosis?
prolonged heavy periods and pain
bulky uterus
features of fibroids?
pain
can cause pressure effects on adjacent organs or fibroid red degeneration during pregnancy
palpable pelvic mass
features of chronic PID?
STI history
pain not limited to just during menstruation
mucopurulent discharge
cervicitis
findings suggestive of Fitz curtis hugh syndrome on laparoscopy
investigations in dysmenorrhoea?
high vaginal and endocervical swabs (exclude STI) pelvic US diagnostic laparoscopy (often used when other tests are normal or if history suggests endometriosis)
how is dysmenorrhoea managed?
1st line = NSAIDs (e.g mefenamic acid/ibuprofen) 2nd line = COCP dysmenorrhoea + menorrhagia = IUD manage symptoms (esp fibroids) while awaiting hysterectomy = GnRH analogues
