Menstruation & Menopause Flashcards
What is the menstrual cycle?
Time from the first day of a woman’s period to the day before her next period
What is the normal blood loss for a period?
<80ml over 7 days (16tsp)
What is the average blood loss for a period?
30-40ml (7-8tsp)
What is the length of cycle?
28 days (average 24-35 days)
When is menarche?
10-16 years (average is 12 years)
At what age does menopause occur?
50-55 years
What are 4 examples of disturbances of menstruation?
- Disturbance of menstrual frequency – infrequent or frequent
- Irregular menstrual bleeding – absent or irregular
- Abnormal duration of flow – prolonged or shortened
- Abnormal menstrual volume – heavy or light.
How is HMB categorised (as is often difficult to measure/quantify)?
> 80ml over 7 days, regular cycle
AND/OR Need to change menstrual products every one to two hours
AND/OR passage of clots greater than 2.5 cm
‘Bleeding through the clothes’
AND/OR ‘very heavy’ periods as reported by the woman/affecting quality of life
Can occur alone or in combination with symptoms like dysmenorrhea.
…% of women in the UK have a hysterectomy aged <60 due to HMB
20%
What are some causes of HMB?
- Uterine & ovarian pathologies (Uterine fibroids, endometrial polyps)
- Systemic diseases & disorders (coagulation disorders)
- Iatrogenic causes (Anticoag treatment, IU contraceptive device (CU, IUD)
What are fibroids?
Non cancerous growths made of muscle & fibrous tissue (also called myoma or lieomyoma)
What can fibroids cause?
HMB, pelvic pain, urinary symptoms, pressure symptoms, backache, infertility, miscarriage
May be asymptomatic
How are fibroids diagnosed?
Ultrasound
What is the management for fibroids?
Symptom based management:
- For HMB +/- small fibroids- COCP, POP, Mirena
- Large fibroids & fertility preservation desired- Fibroid embolization, myomectomy
- Submucosal fibroids- Hysteroscopic fibroid resection
- Declined or failed medical treatment & fertility preservation not required-Hysterectomy
What is endometriosis?
Endometrial tissue present outside the lining of the uterus - During menstruation this ectopic tissue behaves the same as endometrium & bleeds
Affects women of reproductive age
How does endometriosis present?
- Most often Pelvic Pain
- May present with HMB
- Multisystem involvement
- Severely affects QoL
- Can cause infertility, fatigue & systemic symptoms too
In endometriosis: The severity of deposits may not correspond with what?
Symptoms
What are the symptoms of endometriosis?
- Painful menstrual cramps that get worse over time
- Pain during & after sexual intercourse
- Lower back pain
- Painful bowel movements or urination
- Abnormal bleeding or spotting between menstrual periods
- Diarrhoea, nausea & blotting
What are stages of endometriosis?
Stage 1:Minimal
- Small patches, surface lesions or inflam on or around organs in the pelvic cavity
Stage 2:Mild
- More widespread & starting to infiltrate pelvic organs
Stage 3:Moderate
- Peritoneum (pelvic side walls) or other structures. Sometimes also scarring & adhesions
Stage 4:Severe
- Infiltrate & affecting many pelvic organs & ovaries, often with distortion of anatomy & adhesions
How is Endometriosis diagnosed?
DIAGNOSTIC LAPAROSCOPY
- Pelvic exam
- USS (may be normal)
How is endometriosis managed?
Management Options: Analgesia, Medical, Surgical
Medical —COCP, POP, Mirena IUS , Depot provera, GnRH Analogues
Surgical-Ablation, Hysterectomy endometrioma excision, pelvic clearance, Hysterectomy
Surgical management may be required as part of fertility treatment.
What is adenomyosis?
A condition where endometrium becomes embedded in myometrium
What are the features of adenomyosis & what is its definitive treatment?
HMB, May have significant dysmenorrhea
May respond to hormones partially
HYSTERECTOMY=definitve treatment
What are endometrial polyps?
Overgrowth of endometrial lining can lead to formation of pedunculated structures called polyps which extend into the endometrium
Are endometrial polyps mostly malignant?
NOOOO, mostly benign
How are endometrial polyps diagnosed and managed?
Diagnosis: USS or Hysteroscopy
Management: Polypectomy
How is HMB managed?
- Pelvic examination (Speculum,Bimanual) remember to look at cervix
- Clotting profile, thyroid function
- Pelvic USS
- Laparoscopy if endometriosis suspected
Management options depend on:
Impact on QoL, Underlying pathology,
Desire for further fertility etc
Endometrial Biopsy for all women aged 44 or above with HMB, refractory to medical treatment
What are some treatment options for menstrual disorders?
- Observation & monitoring
- Hormones
- Hormone containing IUD (Mirena)
- Endometrial resection (EMR)
- Endometrial ablation (NovaSure etc)
- Removal of fibroids or polyps
- Hysterectomy
What are non hormonal medical treatments available?
Tranexamic acid (antifibrinolytic) reduces blood loss 60%
Mefenamic acid (prostaglandin inhibitor) reduces blood loss 30% and pain
Both of them are taken at the time of periods, Do not regulate cycles
Suitable for those trying to conceive or avoiding hormones
What are the hormonal options for medical treatments?
Combined contraceptive pill (COCP)makes periods lighter, regular and less painful
LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
Oral progestogens eg Provera10mg
Day 5-25 cycle reduce bleeding +regulate
Day 15-25 may regulate cycle but does not reduce amount of bleeding
What is endometrial ablation - first & second generation?
Permanent destruction of endometrium using different energy sources
First generation ablation: under hysteroscopic vision – uses diathermy
Second generation ablation: thermal balloon, radio frequency
Pre-requisites:
Uterine cavity length <11 cm
Sub mucous fibroids < 3cm
Previous normal endometrial biopsy
60% will have no periods, 85% are satisfied, 15% will have subsequent hysterectomy
What is a hysterectomy?
Surgical removal of the uterus
- Abdo
- Vaginal
- Laparoscopic
Total hysterectomy=cervix & uterus removed
Subtotal hysterectomy=Uterus removed & cervix left
What are the risks of hysterectomy?
Infection/DVT/bladder/bowel/vessel injury/altered bladder function/adhesions
Guarantees amenorrhea
What is a salpingo-oopherectomy and when may it be done?
Removal of fallopian tubes & ovaries
Ovaries may be removed with uterus in women with endometriosis or presence of ovarian pathology
Disadvantages =
immediate menopause – recommended HRT till age 50
Advantages =Reduces risk of subsequent ovarian cancer
High risk of menopause in next 2 years even if ovaries conserved due to compromised blood supply
What is oligo/amennorhea?
Infrequent, absent or abnormally light menstruation
Important to check if its normal to the person
PCOS is a metabolic syndrome- How is diagnosis confirmed?
If 2 of 3 criteria met:
- Ultrasound appearance of ovary
- Biochemical hyperandrogenism
- Clinical hyperandrogenism with oligomenorrhoea, hirsutism, acne, infertility and obesity
What does PCOS result in?
Oligomenorrhea/amenorrhea
How is PCOS managed?
Management includes lifestyle adjustment with aim to achieve normal BMI
Symptom based treatment
At least 3 withdrawal bleeds required per year to prevent hyperplasia or endometrial protection achieved with either COCP, POP, mirena IUS or norethisterone
What is dysfunctional uterine bleeding (DUB)?
Common disorder of excessive uterine bleeding affecting premenopausal woman that is not due to pregnancy or any recognisable uterine or systemic diseases
(Exclude common causes PALM COEIN (acronym in revision doc))
What is the treatment of DUB?
Conservative/Medical surgical treatment based on severity of sym
GnRh analogues could be good bridging for patients who are nearly menopausal and have not responded to or declined other medical treatment and surgical management not desirable. GnRH analogues work as ant estrogen and produce a pseudo menopause .
upto 6 month therapy. If further desired by patient and no contraindication, should be given add back HRT till patient confirmed menopausal.
What is menopause?
A womans last ever period
What is the average age of menopause?
51
When does perimenopause occur?
For approx 5 years before menopause
What is premature menopause?
Menopause at 40 years or less
What happens during menopause?
Ovarian insufficiency-oestradiol falls
FSH from pituitary rises
Still some oestriol from conversion of adrenal androgens in adipose tissue
What levels fluctuate in perimenopause?
FSH levels
- A one off snapshot premenopausal level does not exclude perimenopause as a cause for symptoms
Is menopausal transition always natural?
May be natural or sudden following oophorectomy/chemo/RT
What are the symptoms of menopause?
- Vasomotor symptoms-Hot flushes/night sweats
- Vaginal dryness/soreness
- Low libido
- Muscle & joint aches
- ? Mood changes/poor memory-possibly related to vasomotor symptoms affecting sleep
How long do symptoms of menopause usually last (vasomotor)?
Usually lasts 2-5 years-but may be 10 years +
Osteoporosis is a silent change of menopause: what is it?
Reduced bone mineral density
DEXA scan - bone described as T score (individuals bone density compared with standards for age)
What is a problem of osteoporosis?
Fractured hip/Vertebra
What are the risk factors for osteoperosis?
Thin/caucasian/smoker/ high EtOH/+ve FH esp male or younger age /malabsorption Vit D or Calcium / prolonged low oestrogen amenorrhoea /oral corticosteroids / hyperthyroid
What is the prevention & treatment for osteoperosis?
Weight bearing exercise, adequate calcium & Vit D, HRT, bisphosphonates, denosumab -monoclonal Ab to osteoclasts, calcitonin
HRT can prevent & treat osteoporosis
Bisphosphonates=hormone free option-1st line treatment
What is frequent after hysterectomy even if ovaries conserved?
Prem Menopause
How can HRT be administered for symptom treatment in menopause?
1/ Local vaginal HRT oestrogen pessary/ring/cream
Local effects -minimal systemic absorption
Need to use longterm to maintain benefit
2/ Systemic oestrogen transdermal patch /gel or oral
Transdermal avoids first pass- less risk VTE
a/oestrogen only if no uterus b/oestrogen + progestogen if uterus present progestogen oral , patch or LNG IUS progestogen prevents endometrial hyperplasia from unopposed oestrogen
Oestrogen alone can cause endometrial hyperplasia & even cancer
How can the combined estrogen (E) & progestogen (P) HRT be administered?
-cyclical combined 14 days E + 14 days E+P
expect withdrawal bleed after the P
use if there may still be some ovarian function to avoid
inconvenience of irregular bleeding
-continuous combined 28 days E+P oral/patch
expect to be bleed-free ( after 1st 3 months)
use if > 1yr after LMP or age 54+
How can mirena be used and does it give contraceptive cover?
Any age can use Mirena LNG IUS 5 yrs + daily E and expect to be bleed free
NB Mirena + E gives contraceptive cover- other HRT regimes do not
Mirena has got enough progesterone to balance E HRT for 5 years
Mirena will give contraceptive cover up until age 55
What are the contraindications to systemic HRT?
NOT the same as contraindications to combined hormonal contraception- very few CI
1/Current Hormone dependent cancer breast/endometrium
2/ Current active liver disease
3/ Uninvestigated abnormal vaginal bleeding
4/ seek advice if prev VTE, thrombophilia, FH VTE
5/ seek advice if previous breast cancer or BRCA carrier
What are some contraindications to vaginal HRT?
Avoid for women taking aromatase inhibitor treatment for breast cancer -but may choose to use if symptoms affecting quality of life.
No other CI as minimal systemic absorption
What are some other examples of what is used as symptom treatment during menopause?
Selective Estrogen Receptor Modulators (SERMs)
E effect on selected organs
eg tibolone has E effect on flushes, bones but not endometrium
clonidine or SSRI SNRI antidepressants eg venlafaxine NOT recommended for vasomotor symptoms. Frequent side effects & few women benefit
phytooestrogen herbs eg red clover/soya
hypnotherapy/ exercise / cognitive behavioural therapy
Non hormonal lubricants for vaginal dryness
Regular eg Replens TM or Pre sex ‘Sylk’ TM
SERM’s-still has oestrogenic effect on breast tissue so there is an increased risk of breast cancer
What are the benefits and risks of HRT?
Benefit
vasomotor
local genital symptoms
osteoporosis
Risk
breast Ca if combined HRT
ovarian Ca
venous thrombosis if oral route
CVA if oral route
Not affect Alzheimers
Not increase CV risks if start before age 60
ie before atherosclerosis develops
What are some of the NICE guidance for the use of HRT?
For treatment of severe vasomotor symptoms, review annually
For women with premature ovarian insufficiency
HRT benefits outweigh risks till age 50
Not as first line for osteoporosis prevention / treatment (bisphosphonates instead)
Use vaginal oestrogen if vaginal symptoms
No absolute upper age limit or maximum duration of HRT use
What is andropause?
Testosterone falls by 1% a year after 30
DHEAS falls
Fertility remains
No sudden change
What is the difference between primary and secondary amenorrhoea?
Primary amenorrhoea: never had a period
delayed puberty if
>14yrs and no 2ndry sexual characteristics
>16 years if 2ndry sexual characteristics
Secondary amenorrhoea:
has had periods in past but none for 6 months
What are some causes of secondary amenorrhoea?
Pregnancy / Breast feeding
Contraception related- current use or for 6-9 months after depoprovera
Polycystic ovary syndrome
Premature ovarian insufficiency
What is important to ask in the Hx of secondary amenorrhoea?
Possibility pregnancy
Breastfeeding
Medicines including contraception incl opiates/antipsychotics/metoclopramide
Galactorrhoea /visual change ( prolactin ↑)
Acne / hirsutism /voice change ( androgen↑)
Weight change
Exercise /stress
Significant illness
What are some examinations and tests done in secondary amenorrhoea?
BMI, Cushingoid
Acne Hirsutism Virilised- enlarged clitoris/deep voice
Abdominal & bimanual exam ? Pelvic mass- pregnant uterus/ ovarian cyst
urine pregnancy test
bloods FSH oestradiol ( menopause)
prolactin
thyroid function
testosterone & SHBG – free androgen index
17 hydroxy progesterone ( CAH)
pelvic ultrasound- ?polycystic ovaries
What results are shown in early menopause?
Low oestradiol & raised FSH
How is secondary amenorrhoea managed?
Treat specific cause
BMI >20 <30 ideal for ovulation
Assume fertile and need contraception unless 2 yrs after confirmed menopause
If premature ovarian insufficiency offer HRT till 50
Emotional support incl Daisy network
Check for Fragile X relatives may wish testing
Need contraception as can ovulate at any time & therefore fall pregnant at any time
Fragile X-if male foetus is affected then they may be significantly handicapped
How is PCOS diagnosed?
Diagnosis-Need 2 out of 3 of the following:
oligo/amenorrhoea
androgenic symptoms: excess hair/acne
Polycystic ovarian morphology on scan
( ie may have PCOS with normal looking ovaries)
(Normal/high oestrogen levels
Increased androgens – acne/hirsutism
? Underlying cause is insulin resistance)
What causes a risk of endometrial hyperplasia?
If < 4 periods a year ( & not on hormonal contraception )
High/normal oestrogen levels & infrequent withdrawal bleeds – risk of endometrial hyperplasia
What can worsen PCOS (multiple cysts just below the surface) symptoms?
Weight gain as decreases SHBG levels so increase free androgen levels
Increased free androgen levels means androgenic symptoms will worsen – also less likely to ovulate regularly
What is the US definition of polycystic ovaries?
Small peripheral ovarian cysts x 10/0vary or
ovarian volume>12cm3
20% women have this on scan but no other features ie not PCO syndrome
Multicystic ovaries common in adolescents and not associated with PCOS- don’t diagnose PCOS till late teens
How is PCOS managed?
Weight loss/exercise to BMI 20-25
Can help all symptoms
Increases SHBG so less free androgens
Support & information– Verity patient support group
Antiandrogen
- combined hormonal contraception if no CI
- spironolactone
- eflornithine cream reduces facial hair growth
Endometrial protection
CHC, Mirena IUS
Oral provera 10 days every 90 days if no period to cause withdrawal bleed
Fertility Rx clomiphene / metformin usually effective for ovulation induction
Underlying cause – insulin resistance Metformin- may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss
