Normal and Abnormal Menstruation

Question 1

Define menstruation

Answer 1

Monthly bleeding from reproductive tract induced by hormonal changes of the menstrual cycle

Question 2

How would you measure the length of a menstrual cycle?

Answer 2

From the start of the last period to the start of the next period

Question 3

What is a normal length of menstruation?

Answer 3

2-8 days (mean 5 days)

Question 4

What is the normal length of the menstrual cycle?

Answer 4

21-35 days (mean 28 days)

Question 5

What is the normal amount of blood loss?

Answer 5

60-80 ml

Question 6

Define menorrhagia

Answer 6

Heavy or prolonged Menstrual Bleeding that occurs at expected intervals of the menstrual cycle and is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life

Question 7

Define intermenstrual bleeding

Answer 7

Uterine bleeding that occurs between clearly defined cyclic and predictable menses

Question 8

Define abnormal uterine bleeding

Answer 8

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration and heavy), regularity, timing (delayed or frequent) or is non-menstrual (post-coital bleeding, intermenstrual bleeding, post-menopausal bleeding)

Question 9

What are the gynae causes of heavy menstrual bleeding?

Answer 9

Dysfunctional uterine bleeding - commonest
Uterine fibroids
Adenomyosis
Uterine polyps (more cause of irregular bleeding)
Endometriosis (doesn’t usually present as heavy menstruation)
Gynae malignancy (but usually presents as prolonged intermenstrual bleeding, post-coital bleeding, postmenopausal bleeding)
IUCD (intrauterine contraceptive device) - copper coil

Question 10

What are the three underlying factors that lead to menorrhagia?

Answer 10

Coagulopathy
Ovulatory
Endometrial dysfunction

Question 11

Dysfunctional uterine bleeding can be irregular or regular cycles. T or F?

Answer 11

True
Irregular = anovulatory
regular = ovulatory

Question 12

What are uterine fibroids?

Answer 12

Benign tumours of the myometrium made of smooth muscle cells and collagen fibres

Question 13

What are two other names for uterine fibroids and what do they mean?

Answer 13

Leiomyoma - mainly smooth muscle

Fibromyoma - mainly collagen fibres

Question 14

What proportion of women of reproductive age will get uterine fibroids?

Answer 14

20%

Question 15

What are the non-gynae causes of heavy menstrual bleeding

Answer 15

Hypothyroidism
von Willebrand disease (deficiency of von Wilebrand factor)
Taking anticoagulants eg warfarin

Question 16

How do uterine fibroids present?

Answer 16

• Asymptomatic - commonest
• Menstrual disorder - menorhhagia, irregular bleeeding, IMB
• anaemia
• Pressure symtoms - urinary frequency, constipation
• pelvic pain
• Sensation of heaviness in abdomen or vaginally
• Infertility and recurrent miscarriage (usually submucosal)

Question 17

Risk factors for development of fibroids

Answer 17

• Black ethnicity
• obesity
• early menarche
• nulliparity
• FH

Question 18

What age range do fibroids commonly present?

Answer 18

30-50 yrs

Question 19

What would you find on examination fo a women with fibroids?

Answer 19

• nothing
• palpable pelvic mass (abdo exam)
• Enlarged, often irregular, firm, non-tender uterus (vaginal exam)
• signs of anaemia

Question 20

Describe the pathophysiology of fibroids

Answer 20

tumours of the smooth muscle cells of the uterine myometrium, containing smooth muscle and collagen

They start as multiple, single-cell seedlings distributed throughout the uterine wall.

These then increase in size very slowly over many years, stimulated by oestrogens and progestogens.

As the fibroid grows, the central areas may not receive an adequate blood supply and undergo benign degeneration often followed by calcification.

Question 21

What is the cause of fibroids?

Answer 21

Not known
Combination of genetic change and hormones and growth factors
Perhaps due to ischaemic injury during menstruation

Question 22

What are the different types of fibroids?

Answer 22

Subserosal
Intramural - commonest
Submucosal

Question 23

What do you need to suspect if there is a rapidly growing fibroid in older women?

Answer 23

Sarcoma rather than fibroid

Question 24

What are the differential diagnoses of fibroids?

Answer 24

• endometriosis
• polyps
• ovarian mass
• adenomyosis
• uterine cancer
• PID
• dysfunctional uterine bleeding
• sarcoma
• pelvic mass - large bowel tumour, appendix abscess

Question 25

What investigations would you do for fibroids?

Answer 25

• pregnant test
• FBC - anaemia
• pelvic and transvaginal ultrasound scan
• hystroscopy with biopsy
• endometrial biopsy (for endometrial cancer, hyperplasia)

(MRI if USS is unclear)

Question 26

How do you manage fibroids?

Answer 26

Depends on:

• symptoms
• fertility
• contraception use or not

Pharmacological

• expectant management (watch and wait and managing symptoms only)
• ibuprofen- reduces menstrual blood loss
• tranexamic acid - atifibrinolytic
• combined pill
• Mirena
• GnRH analogues - to reduce the size of fibroids before surgery

Surgery
- myomectomy - if want to maintain reproductive protential or uterus; can be
o laparoscopic
o hysteroscopic (for submucosal)
o laparotomy (also called abdominal myomectomy)
- total hysterectomy
- histroscopic endometrial ablation - don’t remove the fibroid, just burn the endometrium to control menorrhagia
- Uterine artery embolisation - fertility sparing (but can cause ovarian failure)

Question 27

When would you operate on a patient with fibroids?

Answer 27

• excessively enlarged uterine size.
• Pressure symptoms are present.
• Medical management is not sufficient to control symptoms.
• The fibroid is submucous and fertility is reduced.