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cOGTEXT > Menstrual Problems > Flashcards

Menstrual Problems Flashcards

1
Q

menorrhagia?

A

heavy bleeding

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2
Q

metorrhagia?

A

regular intermenstrual bleeding

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3
Q

polymenorrhoea?

A

menses occuring <21 day cycle

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4
Q

polymenorrhagia?

A

increased bleeding and frequent cycle

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5
Q

menometrorrhagia?

A

prolonged menses and intermenstrual bleeding

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6
Q

amenorrhoea?

A

absence of menstruation >6 months

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7
Q

oligomenorrhoea?

A

menses at intervals >35 days
or
presence of 5 or fewer menstrual cycles over a year

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8
Q

local causes of menorrhagia?

A 
fibroids
adenomyosis
endocervical/endometrial polyp
endometrial hyperplasia
IUD
pelvic inflammatory disease
endometriosis
malignancy of uterus/cervix
hormone producing ovarian tumours
AVM
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9
Q

systemic causes of menorrhagia?

A

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)

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10
Q

what other causes of heavy vaginal bleeding should be considered?

A

pregnancy complications

  • miscarriage
  • ectopic
  • molar
  • placenta praevia
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11
Q

investigations in menorrhagia?

A

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

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12
Q

what is non-organic menorrhagia?

A

occurs in absence of pathology
AKA dysfunctional uterine bleeding (DUB)
50% of abnormal uterine bleeding cases

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13
Q

types of DUB?

A

anovulatory: 85% of DUB cases, irregular cycles
ovulatory: regular heavy periods

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14
Q

who are anovulatory cycles most common in?

A

obese women

more common at extremes of repro life

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15
Q

who are ovulatory DUB most common in?

A

35-45 yrs

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16
Q

what causes ovulatory DUB?

A

inadequate progesterone production by corpus luteum

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17
Q

how is DUB investigated?

A

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)

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18
Q

options for medical management of DUB?

A 
progesterone IUD (mirena)
COCP
antifibrinolytics (tranexamic acid)
NSAIDs (mefenamic acid)
oral progesterone
GnRH analogue/agonists
danazol
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19
Q

when is mirena best used for DUB?

A

first line DUB treatment
good if there is compliance concerns
avoids drug interactions of COCP and POP

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20
Q

how is tranexamic acid used?

A

taken during menstruation only
decreases blood loss by 50%
good if woman is considering getting pregnant

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21
Q

how is mefenamic acid taken?

A

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

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22
Q

how do GnRH analoges work?

A

act on pituitary to stop oestrogen production resulting in amenorrhoea (-ve feedback)

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23
Q

how should GnRH analogies be taken and why?

A

short term use (<6 months) as they can cause osteoporosis long term unless combined with HRT

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24
Q

how can DUB be managed surgically?

A

usually only when medical management fails
endometrial resection/ablation
hysterectomy

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25
Q

types of endocervical resection/ablation?

A

transcervical endometrial resection
rollerball endometrial ablation
thermal balloon ablation
thermal hydro-ablation

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26
Q

types of hysterectomy?

A

sub-total
total abdominal
vaginal
laparoscopic assisted subtotal

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27
Q

advantages of surgical DUB management?

A

effective

definitive treatment

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28
Q

disadvantages of surgical DUB management?

A

fertility lost
complications
anaesthetic risk
waiting list

29
Q

what can cause intermenstrual bleeding?

A 
cervical ectropion
PID and STDs
endometrial or cervical polyps
cervical cancer
endometrial cancer
undiagnosed pregnancy/pregnancy complications
molar pregnancy
30
Q

when do premenstrual symptoms occur?

A

luteal phase

31
Q

contributing factors to physical manifestations of premenstrual symptoms?

A 
decreased progesterone synthesis
increased prolactin
increased oestrogen
increased aldosterone
increased prostaglandins
32
Q

management of premenstrual symptoms?

A

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

33
Q

what can cause post-coital bleeding?

A 
cervical ectropion
cervical carcinoma
trauma
atrophic vaginitis
cervitis due to STD
polyps
idiopathic
34
Q

what can cause cervical ectropion?

A

usually hormonal (high oestrogen in pregnancy, hormonal contraceptives - esp COCP)

35
Q

post-menopausal bleeding (PMB) definition?

A

bleeding after periods have stopped for 12 months

36
Q

when might cyclical post menopausal bleeding be normal?

A

if patient is taking combined cyclical HRT

should still investigate

37
Q

NICE guidelines for investigation in post-menopausal bleeding in women >55?

A

should be seen within 2 weeks

38
Q

causes of PMB?

A 
atrophic vaginitis (most common)
endometrial polyps
endometrial hyperplasia
endometrial carcinoma 
cervical carcinoma
ovarian cancer
vaginal cancer (rare)
39
Q

how is PMB investigated?

A

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

40
Q

when is TV US not used and what is done instead?

A

women taking tamoxifen as it makes endometrium thick, irregular and cystic
hysteroscopy and biopsy done instead

41
Q

how is atrophic vaginitis managed?

A

topical oestrogen and vaginal lubricants for symptomatic relief
can consider HRT

42
Q

how is endometrial hyperplasia managed?

A 
dilation and curettage 
progesterone treatment (mirena coil = first line, then oral)
43
Q

most common cause of menstrual irregularity?

A

PCOS

44
Q

criteria for diagnosing PCOS?

A

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

45
Q

features of PCOS?

A 
obesity
hypertension
acanthosis nigricans
acne and hirsutism
alopecia
insulin resistance and lipid abnormalities
irregular periods
46
Q

why does PCOS increase risk of endoemtrial hyperplasia and carcinoma?

A

causes no or reduced ovulation in presence of normal oestrogen levels so endometrium continues to proliferate without shedding

47
Q

hormonal changes in PCOS?

A

increase in LH:FSH ratio

LH high and FSH low/normal

48
Q

how is PCOS managed generally?

A

optimise BMI and protect endometrium with hormonal contraception

49
Q

how is the associated infertility managed in PCOS?

A

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

50
Q

how does clomifene work?

A

oestrogen blocker which blocks oestrogens negative feedback effect on hypothalamus resulting in more GnRH secretion and therefore more FSH and LH

51
Q

side effects of clomifene?

A

hot flushes and sweating

increased risk of multiple pregnancy and ovarian cancer

52
Q

what procedure can aid fertility in women who fail to conceive with comifene treatment?

A

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

53
Q

how can the acne associated with PCOS be managed?

A

co-cyrprindol (dianette)
- manages acne and hirsutism
COCP can improve symptoms of hyperandrogenism including acne

54
Q

how is amenorrhoea associated with PCOS managed?

A

COCP

cyclical medroxyprogesterone or mirena coil can be helpful as an alternative

55
Q

what is dysmenorrhoea?

A

excessive pain during menstrual period

56
Q

types of dysmenorrhoea?

A

primary

secondary

57
Q

what is primary dysmenorrhoea?

A

no underlying pelvic pathology
excessive prostaglandin production thought to be involved
in 50% of menstruating women and appears within 1-2 years of menarche

58
Q

features of primary dysmenorrhoea?

A

pain starts just before or within a few hours of period starting
suprapubic cramping pains which may radiate to back or down thigh

59
Q

what is secondary dysmenorrhoea?

A

result of underlying pathology

typically begins many years after menarche

60
Q

features of secondary dysmenorrhoea?

A

pain starts 3-4 days before onset of period

61
Q

what can cause secondary dysmenorrhoea?

A 
endometriosis
adenomyosis
PID
copper IUD (mirena can treat it, doesnt cause)
fibroids
62
Q

how does the uterus appear in adenomyosis?

A

large and globular

63
Q

types of fibroids depending on location?

A

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)

64
Q

features of endometriosis?

A

heavy bleeding and dysmenorrhoea
uterosacral nodularity and/or tenderness
fixed retroverted uterus

65
Q

features of adenomyosis?

A

prolonged heavy periods and pain

bulky uterus

66
Q

features of fibroids?

A

pain
can cause pressure effects on adjacent organs or fibroid red degeneration during pregnancy
palpable pelvic mass

67
Q

features of chronic PID?

A

STI history
pain not limited to just during menstruation
mucopurulent discharge
cervicitis
findings suggestive of Fitz curtis hugh syndrome on laparoscopy

68
Q

investigations in dysmenorrhoea?

A 
high vaginal and endocervical swabs (exclude STI)
pelvic US
diagnostic laparoscopy (often used when other tests are normal or if history suggests endometriosis)
69
Q

how is dysmenorrhoea managed?

A 
1st line = NSAIDs (e.g mefenamic acid/ibuprofen)
2nd line = COCP
dysmenorrhoea + menorrhagia = IUD
manage symptoms (esp fibroids) while awaiting hysterectomy = GnRH analogues

cOGTEXT (17 decks)

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