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Menstrual Problems Flashcards

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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
types of endocervical resection/ablation?
transcervical endometrial resection rollerball endometrial ablation thermal balloon ablation thermal hydro-ablation
26
types of hysterectomy?
sub-total total abdominal vaginal laparoscopic assisted subtotal
27
advantages of surgical DUB management?
effective | definitive treatment
28
disadvantages of surgical DUB management?
fertility lost complications anaesthetic risk waiting list
29
what can cause intermenstrual bleeding?
``` cervical ectropion PID and STDs endometrial or cervical polyps cervical cancer endometrial cancer undiagnosed pregnancy/pregnancy complications molar pregnancy ```
30
when do premenstrual symptoms occur?
luteal phase
31
contributing factors to physical manifestations of premenstrual symptoms?
``` decreased progesterone synthesis increased prolactin increased oestrogen increased aldosterone increased prostaglandins ```
32
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
33
what can cause post-coital bleeding?
``` cervical ectropion cervical carcinoma trauma atrophic vaginitis cervitis due to STD polyps idiopathic ```
34
what can cause cervical ectropion?
usually hormonal (high oestrogen in pregnancy, hormonal contraceptives - esp COCP)
35
post-menopausal bleeding (PMB) definition?
bleeding after periods have stopped for 12 months
36
when might cyclical post menopausal bleeding be normal?
if patient is taking combined cyclical HRT | should still investigate
37
NICE guidelines for investigation in post-menopausal bleeding in women >55?
should be seen within 2 weeks
38
causes of PMB?
``` atrophic vaginitis (most common) endometrial polyps endometrial hyperplasia endometrial carcinoma cervical carcinoma ovarian cancer vaginal cancer (rare) ```
39
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
40
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
41
how is atrophic vaginitis managed?
topical oestrogen and vaginal lubricants for symptomatic relief can consider HRT
42
how is endometrial hyperplasia managed?
``` dilation and curettage progesterone treatment (mirena coil = first line, then oral) ```
43
most common cause of menstrual irregularity?
PCOS
44
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
45
features of PCOS?
``` obesity hypertension acanthosis nigricans acne and hirsutism alopecia insulin resistance and lipid abnormalities irregular periods ```
46
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
47
hormonal changes in PCOS?
increase in LH:FSH ratio | LH high and FSH low/normal
48
how is PCOS managed generally?
optimise BMI and protect endometrium with hormonal contraception
49
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
50
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
51
side effects of clomifene?
hot flushes and sweating | increased risk of multiple pregnancy and ovarian cancer
52
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
53
how can the acne associated with PCOS be managed?
co-cyrprindol (dianette) - manages acne and hirsutism COCP can improve symptoms of hyperandrogenism including acne
54
how is amenorrhoea associated with PCOS managed?
COCP | cyclical medroxyprogesterone or mirena coil can be helpful as an alternative
55
what is dysmenorrhoea?
excessive pain during menstrual period
56
types of dysmenorrhoea?
primary | secondary
57
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
58
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
59
what is secondary dysmenorrhoea?
result of underlying pathology | typically begins many years after menarche
60
features of secondary dysmenorrhoea?
pain starts 3-4 days before onset of period
61
what can cause secondary dysmenorrhoea?
``` endometriosis adenomyosis PID copper IUD (mirena can treat it, doesnt cause) fibroids ```
62
how does the uterus appear in adenomyosis?
large and globular
63
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)
64
features of endometriosis?
heavy bleeding and dysmenorrhoea uterosacral nodularity and/or tenderness fixed retroverted uterus
65
features of adenomyosis?
prolonged heavy periods and pain | bulky uterus
66
features of fibroids?
pain can cause pressure effects on adjacent organs or fibroid red degeneration during pregnancy palpable pelvic mass
67
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
68
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) ```
69
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 ```

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