Reproductive CBL session 2 Flashcards
- You are a GP.
- Alison, a 47-year-old mother of two, presents with heavy menstrual bleeding of 10-days duration.
- She has had recurrent episodes over the past six-months.
- She has a husband and uses no methods of contraception.
- She has no past medical history of note, and is otherwise well.
What questions would you ask?
Impact on quality of life
Pattern of menstrual bleeding; is it regular? Does she get intermenstrual or postcoital bleeding?
Amount of blood. Ask about clots and ‘flooding’. How she manages it, impact on day-to-day life.
Any associated pain? May lead to SOCRATES if so.
Symptoms of anaemia: fatigue, dizziness, short of breath
Bladder or bowel symptoms.
Pressure symptoms in pelvis.
Ask about past cervical screening and outcomes/when was her last smear?
Family history of gynaecological problems/malignancy.
Alison’s ideas, concerns and expectations.
What volume of bleeding in a period is considered to be heavy menstrual bleeding?
No specific volume anymore – historically 80ml but no longer considered meaningful. The updated NICE definition of heavy menstrual bleeding is excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.
- You are a GP.
- Alison, a 47-year-old mother of two, presents with heavy menstrual bleeding of 10-days duration.
- She has had recurrent episodes over the past six-months.
- She has a husband and uses no methods of contraception.
- She has no past medical history of note, and is otherwise well.
What specific signs would you look for on examination?
Consider starting pharmacological treatment for heavy menstrual bleeding without investigating the cause if the woman’s history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis. (NICE Heavy Menstrual Bleeding updated 2021)
Signs of anaemia: pallor, tachycardia
Bimanual examination for thickening of uterus, masses, enlargement.
Uterine tenderness.
Speculum examination for polyps, cervical ectopy
What is an important consideration when carrying out speculum and/or bimanual examinations?
Presence of a chaperone and informed consent.
On examination, the uterus appears to be enlarged and thickened. Although Alison found the examination uncomfortable, she did not have any specific tenderness
What imaging would you request?
What blood tests would you request?
Blood test- FBC- iron levels, WBC- Infection, hormones, TFTS, clotting
Imaging- Transvaginal US, hysteroscopy, pelvic US
What are some differential diagnoses for heavy menstrual bleeding?
Dysfunctional uterine bleeding (most common)
Uterine fibroids
Endometrial polyps/hyperplasia/cancer
Pelvic inflammatory disease
Hypothyroidism
Bleeding disorders e.g. Von Willebrands disease (usually present earlier in life)
Adenomyosis
How would you, as Alison’s GP, manage her symptoms
Reassure; often uterine fibroids shrink and cause no further problems after menopause. Consider impact of treatment on fertility.
Manage menorrhagia, fibroids and can do surgica management
How do you manage menorrhagia from fibroids?
Hormonal management: levenorgesterel-releasing intrauterine system (LNG-IUS/Mirena), progesterone-only pill, COC pill
Non-hormonal management: Mefanamic acid (NSAID, can reduce pain and blood loss by 30%), tranexamic acid (antifibrinolytic, can reduce blood loss by 60%)
How are fiborids managemed?
If fibroids large and symptomatic, can manage medically using gonadotropin releasing hormone analogues. These shrink fibroids, but can grow back after discontinuation
What is the surgical management for fibroids?
Endometrial ablation (thermal balloon)
Uterine artery embolisation
Hysterectomy
What are some causes of R iliac fossa in young fenales?
Acute appendicitits
Acute mesenteric adenitis
PID
Ectopic pregnancy
Endometriosis
Overian cyst rupture/haemorrhage/torsion
Ovairan torsion
Crohns disease
What questions do you ask a 19 year old who has r iliac fossa pain?
Anything like this before?
Pain- SOCRATES
Other symptoms: Nausea/vomiting/diarrohea/constipation
Sexual hisotyr
Previous history of ectopic pregnancy or miscarriage
Pregnancy test
FBC
Serum beta- HCG (Confirms pregnancy and reduce over 48 hours if a miscarriage has occurred)
Transvagianl US scan if positive pregnancy test or no suspicion of appendicitis
What is the definition of an ectopic pregnancy?
A pregnancy implanted outside the uterine cavity
What is the management of an ectopic pregnancy?
If clinically stabled and pain free, mass less than 35mm with no visible heartburn, serum HCG levels less than 1,000 IU/L or less and able to return to follow up. Expectant management or medical= Methotrexate
Surgical- Salpingectomy (remove tube/ectopic prengnacy?. If second ectopic and only 1 remaining tube consider salpingectomy (empty tube). This will increase risk of ectopic in furture, will often do IVF
