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
