Menstruation

Question 1

Causes of menorrhagia?

Answer 1

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Question 2

What is Menorrhagia?

Answer 2

excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life’

Question 3

Investigations for Menorragia?

Answer 3

Question 4

Management of menorragia?

Answer 4

Non-hormonal therapy – tranexamic acid (anti-fibrinolytic), NSAID

Hormonal therapy – Mirena IUS, the COCP, GnRH agonists

Surgery – endometrial ablation (EA), thermal balloon (Thermachoice)

Uterine artery embolization - carried out by interventional radiology (for fibroid disease)

Myomectomy and Hysterectomy - should be considered if fibroids causing large/distorted uterus

Question 5

Clinical Features of Fibroids?

Answer 5

Symptoms – dysmenorrhoea, menorrhagia, pressure symptoms (especially urinary frequency), pelvic pain; fibroids are associated with subfertility

During pregnancy, fibroids may cause pain due to degeneration, abnormal lie, obstruction, and difficulty with delivery (either vaginal or Caesarean birth)

Signs – examination may be normal; a hard, irregular uterine mass or masses may be palpable

Question 6

Investigation for Fibroids?

Answer 6

Transvaginal or abdominal US

MRI may be needed if US is inconclusive

Question 7

Medical/Surgical Treatment of Fibroids?

Answer 7

GnRH analogues
* shrink fibroids temporarily
* Usually only indicated prior to surgery to temporarily shrink the fibroids

Uterine artery embolization:
* The uterine artery is catheterised, and the vessel supplying the fibroid is embolised
* Family should be complete

Myomectomy
* Surgical excision of the fibroid
* Open, laparoscopic, or hysteroscopic
* Fibroids may recur after myomectomy

Hysterectomy
* Curative
* Women who have a completed family or are >45 years of age

Question 7

Causes of Secondary Dysmenorrhoea?

Answer 7

Endometriosis

Adenomyosis

Pelvic inflammatory disease

Pelvic adhesions

Fibroids (may be present though they are not always causal)

Cervical stenosis (iatrogenic, post-LLETZ or instrumentation)

Question 8

Investigations for Dysmennorrhoea?

Answer 8

STI screen (including Chlamydia & Gonorrhoea)

USS – endometriomas, PID sequelae, fibroids, congenital abnormalities

Question 9

Management of Dysmennorrhoea

Answer 9

Analgesia – mefenamic acid 500mg TDS during period

Hormonal therapy – COCP, the Mirena IUS, or GnRH analogues

Treat the underlying cause
* Endometriosis – COCP, progestogens, GnRH analogues
* PID – antibiotics
* Obstruction – surgery

Question 10

Primary vs Secondary amenorrhoea

Answer 10

Primary amenorrhoea:
* A lack of menstruation by the age of 16 in the presence of secondary sexual characteristics
OR
* A lack of menstruation by the age of 14 in the absence of secondary sexual characteristics

Secondary amenorrhoea: Refers to the cessation of menstruation for >6 months

Question 11

Causes of Amennorrhoea?

Answer 11

Most common causes
* Pregnancy (Always exclude pregnancy in cases of amenorrhoea)
* Lactation
* Stress
* Menopause
* Hormonal agents
* Polycystic ovarian syndrome (PCOS)
* Pituitary (Prolactinoma, Sheehans)
* Premature ovarian failure (POF)

Question 12

Examination/Investigations for Amennorhea?

Answer 12