WCS24 Menstrual Disorders Flashcards
HPO axis
Hypothalamus
—(GnRH)—> Pituitary
—(FSH/LH)—> Ovary
—> Estrogen (Proliferative phase) + Progesterone (Secretory phase)
Variation in cycle
Usually due to variation in ***Follicular phase
Luteal phase: 14 days (stable)
Normal menstruation and menstrual cycle (+ SpC Revision)
- Frequency
- 24-38 days
- Infrequent period: Reduction in frequency (Less frequent than every **35 days) of periods where intervals may vary between 6 weeks and 6 months
- Frequent periods: More often than every **21 days - Regularity
- Variation +/- 2-20days
- Irregular: Cycle-to-cycle variation of ***20 days in individual cycle lengths over a period of 1 year - Duration of flow
- 4.5-8 days
- Prolonged menstrual bleeding: menstrual periods **>8 days in duration on a regular basis, often associated with heavy menstrual bleeding
- Shortened menstrual bleeding: menstrual bleeding of **2 days, very uncommon - Volume of flow
- 5-80 mL
- Heavy menstrual bleeding (HMB): Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms
- Light menstrual bleeding: Changes after uterine surgery (e.g. surgical termination of pregnancy) - No Intermenstrual bleeding
Volume of flow
History:
- Duration / Days of bleeding
- Presence / Size of clots
- Anaemia symptoms
***Pictorial bleeding assessment chart
- Score >=100, specificity + sensitive >80% when used to diagnose Menorrhagia
Abnormal uterine bleeding (AUB)
- Common clinical problem (15-25% of women during reproductive years)
- Significant physical, emotional, sexual, social and financial burden
- Impair quality of life
5 areas:
1. Disturbance of **frequency
2. **Irregular menstrual bleeding
3. Disturbance of **duration of flow
4. Disturbance of **volume of flow
5. ***Intermenstrual bleeding
DDx:
1. Pregnancy complications (miscarriage, ectopic pregnancy etc.)
2. Benign pelvic pathology (polyp, leiomyoma, adenomyosis etc.)
3. Genital tract infection (cervicitis, endometritis)
4. Malignancy
5. Endocrine (thyroid, hyperprolactinaemia, Cushing etc.)
6. Systemic illness (hepatic, renal, coagulopathy)
7. Trauma
8. Stress
9. Medication / Iatrogenic (IUCD, hormones)
FIGO system 2 (causes):
Structural (***PALM):
- Polyp (e.g. Endometrial: size, number, location)
- Adenomyosis
- Leiomyoma (i.e. Fibroid)
- Malignancy, Hyperplasia
Non-structural (***COEIN):
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not otherwise classified
Dysfunctional uterine bleeding
- Abnormal uterine bleeding (AUB) but ***absence of recognisable pathology / pregnancy
- diagnosis by exclusion
2 types:
- Ovulatory
- Anovulatory
Heavy menstrual bleeding (HMB)
- ***Excessive menstrual blood loss
- Interferes with physical, emotional, social, material quality of life
- Occur alone / in combination with other symptoms
Subjective / Objective assessment:
- ***>80 ml per cycle
Adenomyosis
- Benign invasion of myometrium by ***ectopic endometrium glands
- accompanied by hyperplasia of adjacent smooth muscle
Criss-Cross appearance + Islands of blood in uterine wall
Leiomyoma (Uterine fibroids)
- Benign overgrowth of ***myometrium
- 40% of reproductive age women
- Location, Number, Size of fibroids
- Types:
1. Subserosal
2. Intramural
3. Submucosal
4. Mixed
History taking in AUB
- Bleeding pattern
- quantity, frequency of changing pads / tampons
- presence of clots
- timing during menstrual cycle
- impact on QOL - Symptoms of anaemia
- headache
- palpitations
- SOB
- dizziness
- fatigue
- pica - Sexual / Reproductive history
- contraception use
- STD
- cervical screening
- possibility of pregnancy
- desire for future pregnancy
- known infertility - Associated symptoms
- fever, chills
- increasing abdominal girth
- pelvic pressure / pain
- bowel / bladder dysfunction
- vaginal discharge / odour - Symptoms associated with systemic cause for AUB
- overweight
- obesity
- PCOS
- hypothyroidism
- hyperprolactinaemia
- hypothalamic disorder
- adrenal disorder - Chronic medical illness
- inherited bleeding disorders (coagulopathy, blood dyscrasias, platelet function disorders)
- SLE / CT diseases (causing thrombocytopenia)
- liver disease
- renal disease
- CVS disease - Medication
- hormonal contraceptives
- anticoagulants
- SSRI
- antipsychotic
- tamoxifen
- herbal (e.g. ginseng) - Family history
- coagulation / thromboembolic disorders
- hormone-sensitive cancers
Physical examination
- Vital signs
- BP
- pulse
- weight
- BMI - Neck
- thyroid exam - Abdomen
- tenderness
- distension
- striae
- palpable mass
- hepatomegaly - Skin
- pallor
- bruising
- petechiae
- signs of hirsutism (male hair pattern distribution, acanthosis nigricans) - Pelvic exam
- vulva
- vagina
- cervix
- anus
- urethra
- exclude local lesion e.g. cervical polyp - Bimanual exam of uterus + adnexal structures
- Rectal exam
- if bleeding from rectum suspected / risk of concomitant pathology - Pap smear, cervical, vaginal cultures if at risk for STD
Investigations (+ SpC Revision)
- ***Pregnancy test / Serum hCG (all women are pregnant unless proven otherwise)
- ***CBC with Hb, platelet
- Other lab test as clinically indicated
- TFT: TSH
- Free testosterone (for PCOS)
- Prolactin
- Clotting profile
Lab test NOT routinely recommended:
- Ferritin test
- Female hormonal profile
- Thyroid function (unless symptomatic)
- Clotting profile (if HMB since menarche / family history of coagulopathy)
- Cervical screening
- Endocervical swab
- for Chlamydia in Postcoital / Intermenstrual bleeding - Endometrial assessment
- Endometrial aspiration
- Pelvic USG
- Saline infusion sonohysterography (SIS)
- Hysteroscopy
Ultrasound scan
***1st line imaging modality for AUB
- Transvaginal (higher frequency, clearer image, cannot see big mass clearly, not suitable in young girls / women not sexually active)
- Transabdominal
- Transrectal
When:
- Uterus palpable abdominally
- Pelvic mass present
- Failed medical treatment
Average endometrial thickeness
- Normal postmenopausal women: ***4mm
- Endometrial polyp: 10mm
- Endometrial hyperplasia: 14mm
- Endometrial carcinoma: 20mm
Disadvantage:
- Less sensitive than SIS
- Prediction of endometrial pathology in premenopausal women is not reliable
—> ∵ vary from 4mm (in Follicular phase) to 16mm (in Luteal phase)
- CANNOT replace endometrial biopsy
Saline Infusion Sonohysterography (SIS)
Instill 5-15 mL normal saline into uterine cavity using infant feeding tube
Better detection of **Endometrial polyp and **Submucosal fibroid
2D SIS is highly sensitive for Endometrial polyp and Submucosal fibroid
Disadvantage: More expensive + limited availability compared to USG
MRI?
More sensitive than Transvaginal USG in identification of ***Fibroids, esp. submucosal
Slightly more sensitive than USG in diagnosing ***Adenomyosis
However, chance of identifying important additional findings from MRI has to be weighed against waiting time + cost
—> not routinely recommended for all AUB
Endometrial aspiration / Biopsy
Most common out-patient device: ***Pipelle
- Simple, quick, safe, convenient
- Adequate samples in 87-97% of the time
- Detect 67-96% endometrial carcinoma
Disadvantages:
- **Blind sampling, may miss a **focal lesion e.g. Polyp
- CI in pregnancy, acute pelvic inflammatory disease, clotting disorder, cervical infection / pathology
NICE guideline:
- persistent intermenstrual / persistent irregular bleeding
- infrequent heavy bleeding who are obese / having polycystic ovary syndrome
- taking tamoxifen
- treatment for HMB unsuccessful
HKCOG guideline:
- **all women with AUB >=40
- women with risk factor for **endometrial carcinoma irrespective of age
- ***persistent symptoms
- failed medical treatment
Risk factors for endometrial cancer
SOGC:
- Age: 50-54
- Obesity
- Nulliparity
- PCOS (Polycystic ovary syndrome)
- DM
- HNPCC
HKCOG:
- **Obesity
- **PCOS
- **Lynch syndrome
- Family history of gynaecological / GI malignancy
- **Unopposed estrogen therapy
- ***Tamoxifen therapy
- Persistent / long standing AUB
- Not responding to medical treatment
Diagnostic hysterosocpy
Visualisation of whole **endometrial cavity + cervical canal
- allow **targeted endometrial biopsy
- done without anaesthesia and via vaginoscopic approach
Disadvantages:
- ***NOT evaluate myometrium / ovaries
- Risks: perforation, infection, false passage
Management of AUB
- Establish causes
- Explanation / Counselling
- Observation
- Correction of anaemia
- Control of bleeding pattern
Control of bleeding pattern
Immediate:
1. **Dilation + **Curettage (remove tissue from inside uterus) —> only control that cycle, no long term effects, unknown mechanism of action
2. Premarin (IV) (not done now, unknown mechanism of action, stabilise vessel)
Short-term:
1. NSAID e.g. **Mefenamic acid (Ponstan)
2. Anti-fibrinolytic agents e.g. **Tranexamic acid (Transamin)
3. **Hormones e.g. **Combined pills, **Progestogen, **Danazol, **GnRHa (Leuprolide: can shrink fibroid + control menorrhagia, given pre-op only due to potential rebound (SpC OG))
—> **NOT give COC with Tranexamic acid together
—> Thrombotic risk
Long-term:
1. **Progestogen releasing IUCD (Mirena)
2. **Hysterectomy —> abdominal, vaginal, laparoscopic approach
3. **Endometrial ablation —> resection, laser, microwave (only done when no organic causes identified)
4. **Uterine artery embolisation (UAE)
5. High intensity focused ultrasound (HIFU) —> cause fibroid to internal change, necrosis, reduction in size
Mirena (Progestogen releasing IUCD)
Prevention of endometrial proliferation
- licensed for **Menorrhagia management
- improves **Dysmenorrhea
- Full benefit may not be seen for 6 months
Surgical treatment
Indication:
- Medical therapy fails / not tolerated
- patients’ choice / impact on QOL
- concomitant uterine pathology
- Endometrial ablation
- Myomectomy
- Hysterectomy
Intermenstrual bleeding
History:
1. Menstrual history
2. Bleeding pattern
- How irregular
- Amount
- When (Intermenstrual / Menstrual / Postmenstrual)
- Provoking factors
- postcoidal
- trauma - Associated symptoms
- anaemic symptoms
- abdominal pain / discomfort
- stress and anxiety - Contraception
- Drugs
Physical exam
1. Pallor
2. Bleeding tendency
3. Constitutional signs
4. Abdominal mass, ascites
Pelvic exam
1. Local lesion —> Biopsy
2. Uterine size
3. Adnexal mass
4. Rectal exam
Management of Intermenstrual bleeding
- Cervical polyp —> ***Simple avulsion
- Endometrial / Fibroid polyp —> ***Hysteroscopic excision
- CIN/CA of cervix —> ***Colposcopy, Excision, Radiotherapy
Amenorrhoea / Infrequent periods
Infrequent period: Reduction in frequency (Less frequent than every 35 days) of periods where intervals may vary between 6 weeks and 6 months
(Frequent periods: More often than every 21 days) (SpC Revision)
Amenorrhoea: Complete cessation of periods ***> 6 months
- Primary: Absence of spontaneous onset of periods by 16 yo
- Secondary: Absence of period for >= 6 months when a patient has regular periods before and >= 12 months when patient has irregular cycles all along
Causes:
Physiological:
1. Pre-puberty
2. Pregnancy
3. Lactation
4. Menopause
Pathological:
1. **Anatomical causes in genital tract
2. **Endocrine dysfunction
—> HPO axis interruption
—> others
Anatomical causes in genital tract
Congenital:
1. Absence of uterus (with / without absent vagina)
2. Androgen insensitivity syndrome (aka testicular feminisation) (46XY with female phenotype)
3. ***Outflow tract obstruction (imperforate hymen / transverse vaginal septum)
Acquired:
1. ***Endometrial damage
- Traumatic (Asherman’s syndrome)
- Chronic endometritis (pelvic tuberculosis)
- Endometrial resection / ablation
2. Cervical stenosis (extremely rare): Surgical trauma, Infective
3. Vaginal stenosis (extremely rare): Chemical inflammation
Endocrine dysfunction
HPO axis interruption
Ovary
1. **Ovarian failure: genetic, autoimmune, iatrogenic, galactossaemia, idiopathic
2. **PCOS
Pituitary
1. **Pituitary failure: adenoma, infarction (Sheehan’s syndrome), encephalitis, irradiation
2. **Hyperprolactinaemia: prolactinoma, primary hypothyroidism, chronic renal failure, drug-induced (e.g. Antipsychotics)
Hypothalamic
1. Congenital (Kallmann syndrome)
2. Functional causes: weight loss, anorexia nervosa, excessive exercise, stress, debilitating illness
Others
1. Thyroid disease
2. Adrenal disease
3. Obesity —> ↓ SHBG, ↑ free testosterone
History taking in endocrine dysfunction
- Detailed menstrual history
- menarche
- cycle length, duration - Sexual and contraceptive history
- Secondary sexual characteristics
- breast, axillary, pubic hair development - Cyclical abdominal pain
- Marked weight loss / gain
- ***Hyperandrogenism e.g. acne, excessive hair, baldness
- ***Presence of galactorrhoea
- Vasomotor symptoms e.g. hot flushes, night sweating
- Symptoms of an intracranial space occupying lesion e.g. morning headache, vomiting, visual disturbance
- Psychological stress / excessive exercise
- Drug history
- History of previous surgery e.g. surgical termination of pregnancy, endometrial ablation
- Family history of early menopause, PCOS
***Physical examination / Investigations in Endocrine dysfunction
- Height, weight, BMI
- Secondary sexual characteristics e.g. breast, axillary, pubic hair development (Tanner staging)
- Galactorrhoea
- Hyperandrogenism e.g. acne, excessive hair, baldness
- Gynaecological exam: imperforate hymen, presence of uterus / vagina
- Detailed neurological including smell + ophthalmic exam
***Investigations:
1. FSH
2. Prolactin
3. TSH, T4
4. Cortisol
Polycystic ovary syndrome (PCOS)
Rotterdam Diagnostic criteria (2 out of 3):
1. Oligo / anovulation
2. Clinical / Biochemical signs of hyperandrogenism + exclusion of other etiologies (Congenital adrenal hyperplasia, Androgen-secreting tumours, Cushing’s syndrome)
3. Polycystic ovaries on screening
- >=20 follicles of 2-9mm in diameter in >=1 ovary
OR
- increased ovarian volume (>=10 cm^3)
Diagnosis of PCOS in ***adolescents is controversial
- Androgenism (e.g. acne) is common
- High incidence of multi-follicular ovaries in this life stage
Oligo / Amenorrhoea
Concerns:
1. **Infertility (Anovulation) —> may need Ovulation induction
2. **Osteoporosis (Low Estradiol in POI) —> HRT
3. ***Endometrial cancer (Unopposed Estradiol in PCOS) —> Regular bleeding induction (Cyclical progestogen (given for 1 week every 2-3 months) (JC106))
Treatment of Anovulation (Ovulation induction)
FSH + Prolactin
1. ↑ Prolactin (Hyperprolactinaemia)
- **Bromocriptine
- **Cabergoline
- Normal / Low FSH (PCOS / Hypothalamic)
- Optimise weight
- Drugs
—> **Aromatase inhibitor e.g. Letrozole
—> **Clomiphene citrate
—> ***GnRH agonist —> pulsatile manner via pump
—> Gonadotrophin injection (SE: Ovarian hyperstimulation syndrome)
—> Insulin sensitising agents e.g. Metformin
- Surgery
—> Ovarian drilling (reduce the amount of androgen producing tissue in ovaries) - ↑ FSH (Ovarian insufficiency)
- Donor eggs
Dysmenorrhea
- Painful cramps occur with menstruation
- Most commonest causes of pelvic pain
- up to 80% prevalence
Primary:
- **absence of underlying pathology
- onset typically **6-12 months after menarche
- peak prevalence occurring in ***late teens / early twenties
Secondary:
- results from specific pelvic pathology (e.g. Endometriosis, Adenomyosis)
DDx of Dysmenorrhea
- ***Endometriosis —> Cyclic
- ***Adenomyosis
- Pelvic inflammatory disease —> Chronic pelvic pain
- Fibroids —> fibroid polyp associated with HMB (fibroids do not typically present with dysmenorrhea)
- Interstitial cystitis
- IBS
Diagnosis and Management of Dysmenorrhea
Diagnosis: Clinical
Endometriosis: Laparoscopy (Gold standard)
USG to exclude ovarian cysts
Medical treatment:
1. **NSAID (1st line)
2. Hormonal
—> **COC
—> ***Progestin (IM, intrauterine, SC)
Other treatment (SpC Revision):
3. Regular exercise
4. Local heat (continuous, low-level, topical heat therapy)
5. Stop smoking
Insufficient evidence:
6. Acupuncture
7. Dietary supplements
Endometriosis (Felix Lai)
Clinical features (Triad):
1. **Dysmenorrhoea
2. **Dyspareunia
3. ***Infertility
(4. Chronic pelvic pain)
Location:
Descending order of frequency:
- Ovaries —> Cul-de-sac —> Posterior broad ligaments —> Uterosacral ligaments —> Uterus —> Fallopian tubes —> Sigmoid colon and appendix —> Round ligaments
Types of endometriosis:
1. Bladder and ureteral endometriosis
2. Bowel endometriosis
3. Abdominal wall endometriosis
4. Thoracic (lung) endometriosis
Classification:
1. Peritoneal deposits (superficial peritoneal lesions)
- Ovarian lesions (endometrioma / endometriotic cyst / chocolate cyst)
- Ectopic endometrial tissue within the ovary bleeds —> haematoma surrounded by duplicated ovarian parenchyma - Deeply infiltrating endometriosis (DIE)
- Solid endometriosis mass situated >5 mm deep to peritoneum
- Generally found in rectovaginal septum, rectum, rectosigmoid colon, bladder, ureter and other pelvic fibromuscular structures such as vagina and uterine ligaments
Risk factors:
1. Nulliparity
2. Prolonged exposure to endogenous estrogen
- Early menarche <12
- Late menopause >55
Diagnosis:
1. Transvaginal / Transabdominal USG
2. Laparoscopy (Gold standard)
Treatment:
1. Medical
- **NSAID
- **COC / POC
- ***Injectable (Depo-provera)
- Gonadotropin-releasing hormone (GnRH) agonist + Add-back therapy
- Danazol
- Surgery
- **Resection / Ablation of endometrial implants, endometriomas (cystectomy), adhesions (adhesiolysis) (Fertility preserved)
- **Hysterectomy +/- ***BSO (BSO: endometriosis is an estrogen-dependent disease)
Summary
- AUB, HMB
- Intermenstrual bleeding
- Amenorrhoea
- PCOS —> Ovulation induction
- Dysmenorrhea
