NICE Endometriosis, Heavy mental bleeding, menopause Flashcards
What first investigation should be performed for all HMB?
FBC
For whom should a coagulation should be performed?
If HMB started since menus or Fhx coagulation disorder.
Should you start treatment for HMB without imaging?
If from history and examination low risk fibroids/uterine cavity abnormality/histological abnormality/adenomyosis
What are the 1st line investigations other than bloods?
USS or hysteroscopy
Which women should have hysterscopy as 1st line Ix?
Recurrent IMB
Risk factors for endometrial pathology
What is standard technique of OP hysteroscopy?
OP: Analgesia, miniature hysteroscope 3.5mm or smaller
Vaginoscopy
Which women should have endometrial Bx at hysterscopy?
Endometrial Bx if high risk: IMB, persistent irregular bleeding, infrequent heavy bleeding, obese, PCOS, tamoxifen, unsuccessful medical Tx HMB
For which women should have USS as first line?
USS – uterus palpable abdominally, hx or exam of pelvic mass, examination inconclusive/difficult (obese)
TVUS if Sx of ?adenomyosis -dysmenorrhoea, bulky/tender uterus – If decline TAUS or MRI
Main Qs when deciding which Tx?
?Trying to conceive
?Wants to retain fertility/uterus
1st line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis
LNG-IUS – irregular PVB 6 months
2nd line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis
- Non hormonal: TXA, NSAIDS
- Hormonal: COCP, cyclical POP
For submucosal fibroids, what treatment should be consider
TCRF
Treatment options for fibroids >3cm
o Non hormonal TXA/NSAIDS
o Hormonal: LNG-IUS, COCP, POP, uliprostal acetate
o UAE
o Surgical: Myomectomy, hysterectomy – pretreatment GnRH analogue if fibroids enlarged/distort the uterus
Discuss route and total/subtotal, keep ovaries V not
What major complication needs to monitored for ulipristal acetate?
Serious liver injury
When should LFTs be checked when using ulipristal acetate?
Before starting, monthly for first 2 courses, once new treatment started
How should ulipristal acatete be given/prescribed?
5 mg OD for 3 months, start 1st week of menstruation.
Can give up to 4 courses.
Start no sooner than 1st week of 2nd menstruation.
Which patients should be considered for ulipristal acatate?
- No underlying liver damage
- Surgery and UAE no suitable
- premenopausal
- fibroids >3cm
- Hb <102
If considering hysterectomy, what 4 factors of the pre-surgery and surgical treatment should be considered and discussed with the patient?
Pretreatment GnRH analogue
Route
Total/subtotal
+/- oopherectomy/salpingectomy
If >45 how to diagnose peri menopause/menopause
o Perimenopause: Vasomotor + irregular peroids
o Menopause: No peroids for 12 months, no contraception
o Based on symptoms if no uterus
Consider FSH testing for the menopause for which patients?
- Consider FSH age 40-45, perform if <40
- Not taking COCP/progesterone
5 main group of symptoms of the menopause (other than menstrual irregularity/termination)
- Vasomotor
- MSK – joint/muscle pain
- Effect on mood
- Urogenital – vaginal dryness
- Sexual difficulties
Treatments for vasomotor symptoms
- Offer HRT
o Oestrogen + progesterone with uterus
o Oestrogen alone no utuerus - 2nd line – SSRI/SNRI or clonidine
- Isoflavens or black cohosh
o Multiple preperations, safety uncertain
Treatment for psychological symptoms
- HRT
- CBT – no evidence SSRI/SNRI improve mood
Treatment for altered sexual function?
- Consider testosterone supplement if HRT not effective
Treatment for urogenital atrophy
- Offer vaginal oestrogen
- If does not relieve consider increasing dose
- Symptoms may come back when stop, adverse effects V rare, report PVB
- Can use moisturisers & lubricants alone
For women with a uterus commencing HRT, for how long is unscheduled bleeding considered normal?
3 months, after 3 months must be reported
What medications should not be given to women with breast cancer who are taking tamoxifen
- Do not give SSRIs paroxetine/fluoxetine
Which route of HRT has lower risk of VTE?
o Increased risk, higher if PO vs transdermal – transdermal same as baseline
o If RF VTE e.g. BMI >30 consider transdermal – if very high risk (FHx VTE/hereditary thrombophilia) – refer to haemotologist
Does HRT commenced <60 years increase risk of CVD?
No
CVD risk not CI for HRT
Small increase risk of stroke with PO HRT
Does HRT increase risk of T2DM
No
Does HRT increase risk of breast cancer?
- Oestrogen alone no increased risk BC
- Progesterone + oestrogen small increased risk, realated to duration of Tx and reduces after stopping
- E.g. 10 yrs combine continuous – increased cases 40/1000
Does HRT affect the risk of osteoporosis?
- Risk of fragility frscture is lower when taking HRT, decreases on TX stopped
How to diagnose premature ovarian failure?
- <40 yrs +
- Menopausal Sx, no/infrequent peroids +
- FSH x 2 4-6 weeks
Management of POF
- Offer HRT or COCP – continue until age of natural menopause
- HRT has beneficial effect on BP vs COCP
- Both offer bone protection
- HRT not contraceptive
- Give advice on bone and CV health & symptoms Mgmt
Suspect endometriosis if 1 or more of:
Chronic pelvic pain
Dysmenorrhoea effecting daily activities/QoL
Deep pain during/after intercourse
Period related/cyclical GI symptoms, painful bowel movements
Period related/cyclical urinary symptoms,
Infertility with any 1 above
Initial Ix
Pain/symptoms diary
Offer pelvic examination abdo and BM
Consider USS
Initial Tx if fertility not priority
Analgesia
Hormonwal - COCP/POP
Neuromodulators
If no improvement refer - Gynaecology/paediatric and adolescent gynaecology (<17) or specialist Endometriosis service (deep Endo, involving bladder/bowe/ureter)
If USS +/- MRI can laparoscopy be offered?
Yes
What needs to be explained to patient consider laparoscopy?
What involves + potential surgical Tx
How could effect Endo Sx
benefits and risk
Possible need for further Sx
Alternatives
Surgical considerations for fertility is priority vs not priority?
