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Year 4 - O&G > O&G - Menstrual Dysfunction > Flashcards

O&G - Menstrual Dysfunction Flashcards

1
Q

What is a Hysteroscopy?

A

Endoscopic examination of the uterine cavity

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2
Q

When should you do a coagulation screen for women with Heavy Menstrual Bleeding (HMB)?

A
  1. They have had HMB since period began
  2. Hx or FHx suggesting coagulation disorder
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3
Q

What blood tests might you do for a woman with HMB?

A

FBC!!

  • Coagulation screen - not routine, ony if indicated
  • Ferritin - not routine, only if indicated
  • TFT - not routine, only if symptoms suggest thyroid disease
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4
Q

Women with HMB should be offered hysteroscopy if … ?

A

Hx suggests:

  1. Submucosal fibroids or polyps
    • symptoms such as persistent intermenstrual bleeding
  2. Endometrial pathology
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5
Q

What are some risk factors for endometrial pathology?

A
  1. Persistent intermenstrual / persistent irregular bleeding
  2. Infrequent HMB + obese or PCOS
  3. Tamoxifen (SERM - selective oestrogen receptor modulator - acts as oestrogen receptor antagonist + partial agonist –> uses in oestrogen receptord +ve breast Ca)
  4. Treatment for HMB has been unsuccessful previously
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6
Q

If a pt doesn’t want hysteroscopy, what other investigation can be offered?

A

Pelvic ultrasound

  • Not as good as hysteroscopy for identifying uterine causes of HMB
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7
Q

If a pt declines a hysteroscopy under normal analgesia (OTC painkillers prior to procedure) - what can be offered?

A

Hyteroscopy under GA or local anaesthesia

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8
Q

What test might be done during hysteroscopy if pt is at high-risk of endometrial pathology?

A

Endometrial biopsy

Following are risk factors that put a pt at ‘high-risk’ of endometrial pathology:

  1. Persistent intermenstrual / persistent irregular bleeding
  2. Infrequent HMB + obese or PCOS
  3. Tamoxifen (SERM - selective oestrogen receptor modulator - acts as oestrogen receptor antagonist + partial agonist –> uses in oestrogen receptord +ve breast Ca)
  4. Treatment for HMB has been unsuccessful previously
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9
Q

When should a pelvic ultrasound be offered to women with HMB?

A

Offer pelvic ultrasound if pt has HMB + any of:

  1. Uterus is palpable abdominally
  2. Hx or examination suggests pelvic mass
  3. Examination inconclusive or difficulty e.g. obese
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10
Q

What is Adenomyosis?

A

Adenomyosis - characterised by presence of ectopic endometrial tissue

in the myometrium

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11
Q

What are the features of Adenomyosis?

A

Features of Adenoymosis:

  1. Dysmenorrhoea (painful menstruation) - can worsen to chronic pain
  2. Menorrhagia i.e. HMB –> can cause anaemia
  3. Tender (not always), enlarged, boggy uterus
  4. Often occurs after pregnancy - particularly C-section or TOP (can breach endometrial/myometrial junction)
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12
Q

How is Adenomyosis managed?

A

Woman NOT finished with childbearing –> symptom management:

  • 1st line = IUS i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen ↓ menstrual blood loss by ~ 90%
  • 2nd line - consider:
    1. Tranexamic acid
    2. NSAIDs
    3. COCP
  • 3rd line = Oral or IM progesterone treatments - may suppress menstruation
  • 4th line = surgery
    • Endometrial ablation
    • Hysterectomy - only definitive treatment

Woman finished with childbearing:

  • Endometrial ablation
  • Hysterectomy - only definitive treatment
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13
Q

What investigation should be suggested to women with HMB + features suggesting Adenomyosis?

  • Dysmenorrhoea
  • HMB
  • Tender, bulky uterus on examination
A

Transvaginal ultrasound

(in preference to transabdominal US or MRI - but offer these if transvaginal is declined)

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14
Q

What is Endometrial ablation?

A

Destruction of endometrium down to basalis layer (various methods) often using heat based technique

  • Advise:
    • Avoid subsequent pregnancy + contraception
  • 20% of women need repeat by 5-yrs
  • 30% become amenorrhoeic
  • Can be done under GA but often under short anaesthetic as day-case or local anaesthesia as outpatient
  • Risks:
    1. Haemorrhage
    2. Infection
    3. Uterine perforation
    4. Failed procedure
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15
Q

What are Uterine Fibroids?

A

Fibroids - are benign tumours arising from the myometrium of the uterus (often composed of smooth muscle but can contain fibrous tissue)

  • Common! 1 in 3 women develop fibroids during their life
  • Often asymptomatic
  • Most common in 30-50 yrs
  • Develop in response to oestrogen (thus don’t progress post-menopause)
  • More common in Afro-Caribbean women & obese women
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16
Q

Who are fibroids more common in?

A

Black Afro-Caribbean

(occur ~20% of white and ~50% black in later reproductive years)

17
Q

What are the features of Fibroids?

A

May be Asymptomatic !!

  1. menorrhagia (HMB)
  2. dysmenorrhoea - lower abdo pain, cramping during menstruation
    • can have lower back pain
  3. bloating
  4. urinary symptoms (larger fibroids) - e.g. frequency
  5. constipation
  6. pain/discomfort during sex
  7. subfertility
  8. hard, irregular uterine mass palpable on examination
18
Q

How can fibroids complicate pregnancy?

A
  1. Pain - due to degeneration
  2. Abnormal lie of fetus
  3. Obstruction (if cervical fibroid)
  4. Difficult C-section
19
Q

What are the different types of Fibroids?

A
  • Submucous: > 50% of fibroid mass projects into endometrial cavity
  • Intramural: located in myometrium
  • Subserous: > 50% of fibroid mass extends outside uterine border
  • Cervical: (uncommon)
  • Peduncalated: mobile & prone to torsion
  • IV leiomyomatosis: (very rare) fibroid enters circulation via pelvic veins, then to vena cava and causing complications in heart
20
Q

What is the investigation of choice in suspected Uterine Fibroids?

A

Ultrasound

Transvaginal > trans-abdominal

21
Q

How are Uterine Fibroids managed?

A

If symptoms minimal –> no treatment

  1. GnRH anologues (Gonadotropin-releasing hormone) - shrink fibroids (only used prior to surgery)
  2. Myomectomy - surgical resection of uterine fibroids (fertility maintained)
    • Can be done: open, laproscopically or hysteroscopically (depends on location of fibroid)
  3. Hysterectomy - if > 45-yrs or women who no longer want fertility
  4. Uterine artery embolization - artery is catheterized using polyvinyl alcohol powder or gelatin sponge
22
Q

What are endometrial polyps?

A

Endometrial Polyps (adenoma) - are focal overgrowth of endometrium

  • Malignant in < 1%
  • Commoner > 40-yrs
  • Management:
    • Resection during hysteroscopy
    • Histological assessment of resected polyp
23
Q

How are Fibroids < 3cm in diamater managed?

Note: Fibroids < 3cm, Adenomyosis and women with no identifiable pathology have their HMB managed the same way

A

Woman NOT finished with childbearing –> symptom management:

  • 1st line = IUS i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen ↓ menstrual blood loss by ~ 90%
  • 2nd line - consider:
    1. Tranexamic acid
    2. NSAIDs
    3. COCP
  • 3rd line = Oral or IM progesterone treatments - may suppress menstruation
  • 4th line = surgery
    • Endometrial ablation
    • Hysterectomy - only definitive treatment

Woman finished with childbearing:

  • Endometrial ablation
  • Hysterectomy - only definitive treatment
24
Q

How are fibroids > 3cm in diameter managed?

A

Pharmacological:

  • Non-hormonal:
    1. NSAIDs
    2. Tranexamic acid - antifibrinolytic
  • Hormonal:
    1. Ulipristal acetate (used at lower dose than for emergency contraception)
    2. IUS i.e. Mirena (levonorgestrel)
    3. COCP
    4. Progesterone-only contraceptives

Surgical:

  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
25
Q

A pt is takeing Ulipristal acetate for management of symptoms of uterine fibroids.

What rare but serious side effect can occur?

How is this monitored?

A

SE: liver injury

(cases have been severe enough to require liver transplant)

Monitoring: LFTs before starting & every month during first 2 treatment courses

26
Q

How do you manage a pt with symptomatic fibroids > 3cm who is not eligble for surgery?

A

Offer ulipristal acetate 5 mg (up to 4 courses) IF

they meet the following criteria:

  1. HMB and
  2. Fibroids > 3cm and
  3. +/- haemaglobin < 102 g/L
27
Q

How do we define heavy menstrual bleeding?

A

Not measured via blood loss

but

Best measured by impact on woman’s life

28
Q

What is an indicator of excessive blood loss during menstruation?

A

Blood clots in menstruation

(also tiredness)

29
Q

What does the term Adnexal refer to?

E.g. Adnexal mass

A

Relating to in or near the uterus, fallopian tubes, ovaries or connecting tissue

30
Q

Describe the possible positions the uterus can lie in.

A
  1. Anteverted
  2. Retroverted
  3. Retroflexed
31
Q

What is the normal range for endometrial thickness?

A

Depends on the timing of the ultrasound scan in relation to menstrual cycle!

Endometrium is thickest during secretory phase (luteal phase) ~ 16mm

32
Q

A pt presents with Heavy Menstrual Bleeding.

What red-flags would warrant a 2-WW referral?

A
  • Age > 45-yrs
  • inter-menstrual bleeding
  • post-menopausal bleeding
  • post-coital bleeding
  • abnormal examination findings e.g.
    • pelvic mass
    • lesion on cervix
  • treatment failure after 3-months
33
Q

What are some indications for hysteroscopy?

A
  1. Sterility - inability to conceive
  2. Infertility - inability to complete a full term healthy pregnancy
  3. Menstrual disorders
  4. Suspicious US endometrial findings
  5. Check-ups:
    • after intrauterine interventions
    • after treatment of endometrial hyperplasia with medication
  6. Lost IUD
34
Q

How is HMB managed in women with no identifiable pathology?

(Same as fibroids < 3cm and adenomyosis)

A

Woman NOT finished with childbearing –> symptom management:

  • 1st line = IUS i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen ↓ menstrual blood loss by ~ 90%
    • ​Advised to try for at least 6-months
  • 2nd line - consider:
    1. Tranexamic acid
    2. NSAIDs
    3. COCP
  • 3rd line = Oral or IM progesterone treatments - may suppress menstruation
  • 4th line = surgery
    • Endometrial ablation
    • Hysterectomy - only definitive treatment

Woman finished with childbearing:

  • Endometrial ablation
  • Hysterectomy - only definitive treatment
35
Q

How long is it recommended that women try non-surgical interventions for their HMB?

A

at least 6 months for IUS (Mirena)

and at least 3-months for other e.g. NSAIDs, tranexamic acid, COCP and progesterone-only

36
Q

Using the acronym PALM COEIN name causes of HMB.

A
  • P - Polyp
  • A - Adenomyosis
  • L - Leimyoma (fibroids)
  • M - Malignancy
  • C - Coagulopathy e.g. Von Willebrand’s disease
  • O - Ovarian dysfunction e.g. PCOS
  • E - Endometrial processes (most controlled by oestrogen) e.g. hypothyroidism
  • I - Iatrogenic
  • N - Not yet classified
37
Q

What does this image show?

A

Uterine fibroids

(seen via laproscopic surgery)

Year 4 - O&G (12 decks)

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