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menstural disorders Flashcards

1
Q

what are fibroids?

A

benign tumours of myometrium
also known as leiomyomas
can become malignant
stimulated by oestrogen

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2
Q

how can fibroids classified?

A

intramural - within myometrium and do not protrude out or in
submucosal - develops immediately below endometrium and thus protrudes into the uterine cavity
subseroal - protrudes into and distorts the serosal surface of uterus

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3
Q

what are the risk factors for developing fibroids?

A 
early menarche
age
overweight 
FHx
ethnicity
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4
Q

what are the differentials

A

endometrial polyp
leiomyosarcoma
ovarian tumour

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5
Q

what are the clinical features of fibroids?

A

majority are asymptomatic
may have menorrhagia
may have pressure symptoms e.g. urinary frequency, retention, abdo distension
subfertility due to obstructive effects

acute pelvic pain from red degeneration

on examination - non tender uterus but solid mass/enlarged uterus may be palpable on bimanual exam

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6
Q

what is red degeneration?

A

sudden disruption in fibroid blood supply e.g. may be torsion of pedunculated fibroid or in pregnancy where fibroid is rapidly growing

fibroid undergoes necrosis and haemorrhage
leads to N,V and low grade fever and acute abdo pain

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7
Q

what investigations should be performed if a fibroid is suspected?

A

pelvic USS

MRI rarely used unless sarcoma suspected

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8
Q

what is a degenerate fibroid?

A

The fibroid outgrows its blood supply and thus can degenerate.
this mainly occurs slowly but can be rapid (red degeneration)
fibroid dies and releases substances causing pain, swelling and low grade fever

types:
- hyaline degeneration - asymptomatic
- red degermation

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9
Q

what is zolidex?

A

GnRH analogue
can be used to treat fibroid by supressing ovulation to shrink fibroid (useful pre -op)
only can use for 6 months due to osteoporosis risk

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10
Q

what defines heavy menstrual bleeding?

A

excessive menstrual blood loss (>80ml) that impacts a woman physically, emotionally and socially

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11
Q

what is the aetiology behind heavy menstrual bleeding?

A

structural causes: (PALM)
- polyps - endometrial/cervical - usually not painful, PCB/ IMB
- adenomyosis
- leiomyomas/ fibroids
- malignancy/ hyperplasia - may be vaginal/cervical hyperplasia provoked by ovarian tumour
non-structural: (COEIN)
- Cogaulopathy
- ovarian dysfunction - hypothyroid, PCOS
- endometriosis
- iatrogenic - intrauterine copper device
- not classified = dysfunctional uterine bleeding (60% of cases)

other = pregnancy = ectopic, miscarriage, placenta praevia
also obesity

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12
Q

what is adenomyosis

A

presence of endometrial tissue in the myometrium of the uterus
(variant of endometriosis)
the endometrial tissue breaks through into myometrium

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13
Q

what are the clinical features of heavy menstrual bleeding?

A

menorrhagia
symptoms associated with anaemia - SoB, tired, pallor
symptoms depending on cause
examination may reveal cause e.g. bimanual examination may be able to feel irregular uterus as a sign of fibroids

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14
Q

what investigations could you do in someone presenting with menorrhagia?

A

FBC, INR, sometimes TFTs, specific blood tests for cause e.g. von Willebrand factor (if history of clotting disease, heavy periods since puberty)

pregnancy test
cervical smear
high vaginal and endocervical swabs
transvaginal USS to assess endometrium and ovaries

hysteroscopy +/- endometrial biopsy

  • can use pipelle/ curettage
  • indicated if persistent heavy bleeding, >45yrs or failure of pharm methods
  • to exclude endometrial malignancy hypoplasia
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15
Q

how is heavy menstrual bleeding managed (1st, 2nd and 3rd line treatments)

A

Levonorgestrel - releasing intrauterine system (LNG-IUS) - first line

  • max 5 years of use , min 12 months, warn patient of irregular bleeding and persist for 6 months for it to settle
    - contraceptive too.

transexamic acid/ mefenamic acid or COCP - second line

- no contraceptive effect for first 2 
- COCP has contraceptive  effect too

progesterone only (oral, depo, implant) - 3rd line

  • oral norethisterone (taken day 5-26) does not work as a contraceptive when taken this way but still effects fertility
    - depo and implant will act as contraceptive too.
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16
Q

how does levonorgestrel - releasing intrauterine system (LNG-IUS) help with heavy menstrual bleeding?

A

progesterone

Thins the endometrium and can shrink any fibroids

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17
Q

how does transexamic acid work to help with heavy menstrual bleeding?

A

Transexamic acid:

- binds plasminogen and prevents fibrinolysis. taken during menses to reduce bleeding.

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18
Q

what are the side effects of transexamic acid?

A 
nausea, 
dizziness
tinnitus 
rash 
abdo cramps
indegrestion, diarrhoea 
headache
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19
Q

when is transexamic acid contraindicated?

A

fibrinolytic disorders
DVT risk
following DIC
history of convulsions

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20
Q

what is mefenamic acid? how does it help in heavy menstrual bleeding?

A

type of NSAID
inhibits COX to reduce prostaglandin release, less spasming of spiral arteries and thus reduced ischaemia and shedding of endometrium
less myometrial contractions

also offers analgesic effect

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21
Q

what is ulipristal acetate

A

progesterone receptor modulator
shrinks fibroids/ endometrial tissue to reduce bleeding
can also be useful pre-op before fibroid removal

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22
Q

what surgical management is available for heavy menstrual bleeding?

A

endometrial ablation

hysterectomy - only definitive treatment (can do subtotal or total (cervix removed too))

uterine artery embolization

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23
Q

what is endometrial ablation?

A

removal of endometrium including basal layer but myometrium is left.
good for women who no longer want to get pregnant
can be performed with laser, cold coagulation, microwaves or resection
under local anaesthetic as an outpatient

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24
Q

what are the side effects of endometrial ablation?

A

pain and period cramping
vaginal discharge
hyponatraemia

less common = infection, perforation, bleeding

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25
when is uterine artery embolization used?
only for fibroids (when a cause of heavy menstrual bleeding) causes reduction in blood supply to fibroid and thus degeneration/ shrinkage for those >3cm can be performed by radiologist via femoral artery
26
what is the treatment for fibroids?
Can just leave them if not causing much trouble medical: - levonorgestrel IUS - Ulipristal acetate - Zolidex surgery: - endometrial ablation - for fibroid <3cm - uterine artery embolization - for fibroids >3cm
27
what is the treatment for fibroids?
Can just leave them if not causing much trouble medical: - levonorgestrel IUS - Ulipristal acetate - Zolidex surgery: - hysteroscopy and transcervical resection of fibroid - myomectomy (good if children wanted in future) -open or hysteroscopic - endometrial ablation - for fibroid <3cm - uterine artery embolization - for fibroids >3cm - hysterectomy - last resort for big fibroids with impact on quality of life
28
what are the features of adenomyosis?
endometrial tissue grows into myometrial wall - dysmenorrhoea - menorrhagia - bulky tender uterus
29
what should be considered for fibroids >3cm
``` unlikely medical management will have much effect consider - uterine artery embolization - myomectomy - hysterectomy ```
30
what should be considered for fibroids <3cm?
1st line LNG - IUS 2nd line tranexamic acid/ mefenamic acid/ COCP 3rd line progesterone
31
what are the problems with myomectomy?
adhesions, pain | haemorrhage (rarely)
32
Define amenorrhoea. What are the 2 types ?
lack of periods can be primary - never had a period: - diagnosed at 14 if no other sexual characteristics - diagnosed at 16 if sexual characteristics or can be secondary - periods stopped for >6months
33
what is the aetiology behind amenorrhoea?
physiological - pregnancy, pre-puberal, menopause hypothalamus: - suppression - low BMI, excessive exercise can supress GnRH secretion - psychiatric disorder, sarcoidosis, thyroid can supress it - kallman syndrome pituitary - tumours e.g. mass effect (acromegaly, cushings) or hyperprolactinaemia - sheehans syndrome - radiation, autoimmune - post contraception - prolonged suppression, takes a while to reset ovarian: - turners, PCOS, premature ovarian failure
34
what is the aetiology behind amenorrhoea?
physiological - pregnancy, pre-puberal, menopause hypothalamus: - suppression - low BMI, excessive exercise can supress GnRH secretion - psychiatric disorder, sarcoidosis, thyroid can supress it - kallman syndrome pituitary - tumours e.g. mass effect (acromegaly, cushings) or hyperprolactinaemia - sheehans syndrome - radiation, autoimmune - post contraception - prolonged suppression, takes a while to reset ovarian: - turners, PCOS, premature ovarian failure adrenal: congenital adrenal hyperplasia genital tract: ashermans (uterine adhesions), imperforate hymen thyroid - hypo or hyperthyroidism
35
what is the mechanism by which pituitary tumours can cause amenorrhoea?
prolactinoma - hyperprolactinaemia supresses GnRH other tumours can have a mass effect to supress GnRH
36
what is: - Kallman syndrome? - Sheehans syndrome?
Kallman syndrome = X linked recessive disorder, GnRH neurons fail to migrate sheehans: post partum pituitary necrosis due to massive obstetric haemorrhage
37
what is congenital adrenal hyperplasia?
21 hydroxylase enzyme deficiency results in ability to make cortisol, ACTH is thus very high and causes hyperplasia. this results in androgen excess (clitoromegaly, acne, hirsutism, early pubic hair) amenorrhoea (due to high androgens)
38
what is cryptomenorrhoea?
amenorrhoea due to blockage e.g. imperforate hymen
39
how does imperforate hymen present?
cyclic adbo pain but no periods
40
what is the mechanism behind which hypo and hyperthyroidism can cause amenorrhoea?
hypothyroid --> results in high TSH and TRH which promotes prolactin release. hyperprolactinaemia inhibits GnRH and LH/FSH hyperthyroid --> increases SHBG due to increased T3/4. thus less free oestrogens
41
what defines oligomenorrhoea?
irregular periods with intervals >35days or <9 periods / yr
42
what are the common causes of oligomenorrhoea?
``` PCOS contraceptive hormones perimenopause thyroid/ diabetes eating disorders medications - antiepileptics/ psychotics ```
43
For someone presenting with primary amenorrhoea what should we look for in examination?
signs of turners, galactorrhoea, growth retardation, mass pituitary tumour effects, thyroid disease, androgen excess
44
what factors are suggestive of premature ovarian failure?
low LH/ FSH <40 high prolactin low O +P
45
what investigations should be done if there is secondary amenorrhoea?
pregnancy test bloods - TFT, prolactin, LH/FSH/O/P if suspected ashermans - refer to gynae for USS to visualise pelvic cavity
46
how is CAH tested for?
17 hydroxyprogesterone (raised in CAH) because levels build up when it cant be converted to cortisol
47
how is amenorrhoea and oligomenorrhoea managed?
osteoporotic prophylaxis - if O is low there is a risk of osteoporosis - treat underlying cause, give ADCAL, consider COCP/HRT depends on cause to how its managed - PCOS - metformin, - hirsutism - spirolactone and cryproterone acetate - acne - Abx and benzyl peroxide - infertility - clomifene / IVF
48
what is PCOS?
Polycystic ovarian syndrome - characterised by excess androgens and polycystic ovaries (multi immature ovaries = cysts)
49
what is the pathophysiology behind PCOS?
There is excess LH secretion due to increased GnRH pulses LH causes androgen secretion by ovaries. although there is excess LH, the excess androgens prevent LH surge and ovulation and thus instead all follicles develop and none dominate - follicles arrest and cysts develop there is also insulin resistance high insulin inhibits hepatic production of SHBG means more free androgens ovaries are insulin sensitive and respond by making more androgens also abnormal lipid levels. multifactorial aeitology
50
what are the risk factors for PCOS?
diabetes obesity family history
51
what are the clinical features of PCOS?
``` variable amenorrhoea/ oligomenorrhoea infertility acne, hirsutism , male pattern baldness chronic pelvic pain HTN acanthosis nigricans depression obesity - central fat deposition ```
52
what are the differentials for PCOS?
Hypothyroid - obese, hair loss, insulin resistance cushings - central fat, acne, hirsutism, insulin resistance, depression hyperprolactinaemia - amenorrhoea, acne, hirsutism
53
what is the Rotterdam criteria?
2 or more needed for diagnosis: - clinical/ biochemical features of hyperandrogenism - oligo/amenorrhoea (<6/9 menses/year) - polycystic ovaries on imaging (12 or more follicles in one ovary or ovarian volume >/= 10cm3 new criteria says top one must be present and either or of the other 2
54
what blood tests are needed for PCOS diagnosis?
LH - raised FSH - normal (LH:FSH raised is most important indicator even if both in normal range - a level of 3:1 is enough) Testosterone is raised SHBG is low progesterone is low rule out differentials - TFT, prolactin (note mildly elevated prolactin can be seen in PCOS)
55
how is PCOS investigated?
Hx bloods transvaginal USS - numerous peripheral ovarian follicles and volume >10cm3
56
how is PCOS managed?
amenorrhoea: - these women have high O and no P (no ovulation) and thus at risk of endometrial hyperplasia and cancer. - can give low dose COCP to help with cycles/ protect - or progesterone only (Dydrogesterone) - aim for atleast 3 bleeds/ year to protect the endometrium obesity/ insulin resistance - diet/ exercise to loose weight and improve insulin sensitivity - orlistat can be used - pancreatic lipase inhibitor - metformin - improves insulin sensitivity and ovulatory function infertility: - clomifene +/- metformin - first line for those wishing to conceive with BMI >25 (due to risks limited use to 6cycles/ months min) hirsutism - treated cosmetically - antiandrogen drugs - spironolactone, cyproterone or finasteride (avoided in pregnancy because teratogenic) - eflornithine - topical cream that can help reduce the growth rate of facial hair also may give statins
57
what risks are associated with treating PCOS infertility with clomifene?
ovarian hyperstimulation syndrome multiple pregnancy ovarian cancer
58
what are the complications of PCOS?
``` diabetes infertility endometrial cancer TIA/stroke HTN ``` miscarriage, gestational diabetes
59
what is offered to women wanting to conceive who have a BMI <25 or clomifene is contraindicated?
laparoscopic ovarian drilling - diathermy / laser to reduce amount of androgen producing tissue can also offer gonadotrophins
60
what is primary and secondary dysmenorrhoea?
primary - painful periods without underlying pelvic pathology secondary - painful periods with underlying pelvic pathology
61
what are the risk factors for dysmenorrhoea?
``` early menarche long periods heavy periods smoking nulliparous ```
62
what are the clinical features of dysmenorrhoea?
painful periods - lower abdominal / pelvic pain can radiate to lower back and anterior thighs - usually cramping in nature. nausea, vomiting, dizziness, malaise may have diarrhoea too on examination may be unremarkable or tender uterus
63
what are the differentials for dysmenorrhoea?
``` endometriosis adenomyosis IBD PID IUD - painful on insertion adhesions ```
64
what are the red flags for dysmenorrhoea?
post coital bleed intermenstrual bleeding pelvic mass
65
what should be covered in history of someone presenting with dysmenorrhoea?
work out if primary or secondary - more likely primary if started at menarche associated symptoms - rectal pain, changes to bowel habits, bloating can be associated with endometriosis - vaginal discharge and STI
66
what are you looking for on examination of someone with dysmenorrhoea?
unremarkable if primary dysmenorrhoea | tender uterus, fixed retroverted uterus = endometriosis
67
what are the features of primary dysmenorrhoea?
starts with menarche unremarkable examination starts just before period starts and lasts around 72 hours.
68
how would you investigate someone with dysmenorrhoea?
STI screen - high vaginal and endocervical swab Transvaginal USS / pelvic USS - to exclude pelvic pathologies (endometriosis, adenomyosis) laparoscopy - gold standard for endometriosis
69
how can transvaginal USS / pelvic USS diagnose endometriosis?
may find ovarian endometriomas can demonstrate 'kissing ovaries' where bilateral endometriomas adhere can demonstrate any bowel involvement from pelvic motility
70
how can transvaginal USS demonstrate adenomyosis?
globular uterine configurations poorly defined endometrial/ myometrial interface intramyometrial cysts heterogenous myometrial echotexture
71
how is adenomyosis diagnosed for definite?
histologically after hysterectomy
72
what are the typical findings on laparoscopy for endometriosis?
chocolate cysts, adhesions, peritoneal deposits
73
how is dysmenorrhoea managed?
conservative - stop smoking, hot water bottles pharmacology: - analgesia - mefenamic acid/ ibuprofen, paracetamol - hormonal control - COCP, POP, mirena, GnRH analogies - all help to supress ovulation and thus growth of endometrium, blood loss and inflammation (good for endometriosis, adenomyosis and also primary). Also aromatase inhibitors. surgical
74
what are the surgical options for endometriosis?
removal of endometrial tissue by excision, fulgaration and laser ablation or hysterectomy and removal of ovaries = ultimate cure (need HRT till menopause)
75
what are the surgical options for adenomyosis?
uterine artery embolization - block supply of blood to cause lesion to shrink endometrial ablation/ resection hysterectomy
76
what is the pathophysiology behind endometriosis?
condition whereby endometrial tissue is found outside of uterine cavity usually diagnosed between ages 25 to 40
77
what is endometriosis?
for unknown reason endometrial tissue can grow in various places: - ovaries, fallopian tubes, uterosacral ligament, pelvic peritoneum, umbilicus, pouch of douglas, bowels, bladder, lungs because of this the tissue is responsive to O+P and thus grows and during menstruation there is inflammation and shedding of the tissue leading to pain and bloating or other symptoms depending on site bouts of inflammation can result in scarring and further problems e.g. can affect fertility e.g if in fallopian tubes symptoms improve with pregnancy and menopause
78
what are the risk factors for endometriosis?
early menarche short menstrual cycles long periods heavy bleeds family history defects in ovaries and fallopian tubes
79
what are the differentials of endometriosis?
PID - can present with pain and menorrhagia IBS/IBD - pain, bloating, change in bowel habit ectopic pregnancy fibroids
80
what are the clinical features of endometriosis ?
cyclic pain / dysmenorrhoea subfertility dyspareunia depends on where it affects: - bowels - change in bowel habbit, rectal pain, dyscherzia (pain on defaecation) - lungs - haemothorax if bleeding into pleural cavity - bladder - dysuria
81
what is found on examination in endometriosis?
fixed retroverted uterus general tenderness may have uterosacral ligament nodules
82
what are the risk factors for adenomyosis?
high parity uterine surgery C section (all of above allow endometrial tissue to break through into myometrium) family history often associated with fibroids
83
what is the pathophysiology behind adenomyosis?
Thought to occur when the endometrial stroma is allowed to communicate with the myometrium after uterine damage e.g. after pregnancy, C section, uterine surgery, surgical management of miscarriage/termination invasion of endometrium can be focal or diffuse
84
where is adenomyosis commonly found?
posterior wall of uterus
85
what are the symptoms of adenomyosis?
menorrhage and dysmenorrhoea = main 2 pain is cyclic and reduces with menopause (responsive to O) dyspareunia irregular bleeding
86
what is found on examination in adenomyosis?
symmetrical tender enlarged boggy uterus
87
how is premature ovarian insufficiency diagnosed?
women <40yrs and menopausal symptoms and elevated FSH on 2 blood samples taken 4-6 weeks apart
88
how is premature ovarian insufficiency managed?
HRT, COCP - continue till natural age of menopause unless contraindicated
89
what are the causes of acute pelvic pain?
pregnancy related - miscarriage, ectopic, rupture of corpus luteum cyst, placental abruption and uterine rupture gynaecological - PID, ovulation, dysmenorrhoea, rupture or torsion of ovarian cyst, degenerative changes to fibroid, pelvic tumour, endometriosis other - IBS, strangulated hernia, appendicitis, interstitial cyst
90
what investigations would you want to do for acute pelvic pain?
``` urinalysis and MSU high vaginal and endocervical swabs pregnancy test FBC urgent USS - for ectopic, torsion of ovarian cyst laparoscopy ```
91
how is chronic pelvic pain defined?
intermittent / constant pain in lower abdo/pelvis lasting for atleast 6 months and not occurring exclusively with menstruation or sexual intercourse and not associated with pregnancies
92
what is the cause of chronic pelvic pain?
``` endometriosis adhesions IBS interstitial cystitis MSK nerve entrapment pelvic organ prolapse fibromyalgia, depression, sleep disorder ``` may be multifactorial and also pain may exist beyond pathology (central sensitisation) psychological and social factors can also be involved in the cause (big emphasis on the fact that its multifactorial and social aspects play a role in the learning objectives) e.g. can be due to previous sexual abuse
93
what questions should be asked in a history of someone with chronic pelvic pain?
pattern of pain associated symptoms - bowel, bladder, vagina red flags: - IMB, PMB, post coital bleeding - bleeding per rectum - new bowel symptoms and >50 - new pain after menopause - pelvic mass - excessive weight loss - suicidal ideation
94
How can we investigate Chronic pelvic pain
FBC, CRP, bloods screen for STI especially chlamydia MSU and urinalysis CA125 esp if >50 and IBS type symptoms transvaginal USS - look for adnexal masses diagnostic laparoscopy
95
how is chronic pelvic pain managed?
due to multifactorial causes, need an MDT approach - address emotional, psychological and physical factors. - may need psychiatrist or psychosexual counselling cyclic pain - Mirena coil or COCP can be trailed analgesia - NSAIDs, neurological agents manage any underlying cause sometimes hysterectomy
96
list some causes of: a) intermenstrual bleeding b) post coital bleeding c) post menopausal bleeding
a) infection, malignant, fibroid, endometriosis, pregnancy, hormonal contraception b) cervical ectropion, infection, vaginitis, malignancy c) malignancy, vaginal atrophy, HRT use

gynaecology (7 decks)

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