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CFB > WCS24 Menstrual Disorders > Flashcards

WCS24 Menstrual Disorders Flashcards

1
Q

HPO axis

A

Hypothalamus
—(GnRH)—> Pituitary
—(FSH/LH)—> Ovary
—> Estrogen (Proliferative phase) + Progesterone (Secretory phase)

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2
Q

Variation in cycle

A

Usually due to variation in ***Follicular phase

Luteal phase: 14 days (stable)

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3
Q

Normal menstruation and menstrual cycle (+ SpC Revision)

A
  1. 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
  2. Regularity
    - Variation +/- 2-20days
    - Irregular: Cycle-to-cycle variation of ***20 days in individual cycle lengths over a period of 1 year
  3. 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
  4. 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)
  5. No Intermenstrual bleeding
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4
Q

Volume of flow

A

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

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5
Q

Abnormal uterine bleeding (AUB)

A
  • 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

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6
Q

Dysfunctional uterine bleeding

A
  • Abnormal uterine bleeding (AUB) but ***absence of recognisable pathology / pregnancy
  • diagnosis by exclusion

2 types:
- Ovulatory
- Anovulatory

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7
Q

Heavy menstrual bleeding (HMB)

A
  • ***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

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8
Q

Adenomyosis

A
  • Benign invasion of myometrium by ***ectopic endometrium glands
  • accompanied by hyperplasia of adjacent smooth muscle

Criss-Cross appearance + Islands of blood in uterine wall

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9
Q

Leiomyoma (Uterine fibroids)

A
  • Benign overgrowth of ***myometrium
  • 40% of reproductive age women
  • Location, Number, Size of fibroids
  • Types:
    1. Subserosal
    2. Intramural
    3. Submucosal
    4. Mixed
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10
Q

History taking in AUB

A
  1. Bleeding pattern
    - quantity, frequency of changing pads / tampons
    - presence of clots
    - timing during menstrual cycle
    - impact on QOL
  2. Symptoms of anaemia
    - headache
    - palpitations
    - SOB
    - dizziness
    - fatigue
    - pica
  3. Sexual / Reproductive history
    - contraception use
    - STD
    - cervical screening
    - possibility of pregnancy
    - desire for future pregnancy
    - known infertility
  4. Associated symptoms
    - fever, chills
    - increasing abdominal girth
    - pelvic pressure / pain
    - bowel / bladder dysfunction
    - vaginal discharge / odour
  5. Symptoms associated with systemic cause for AUB
    - overweight
    - obesity
    - PCOS
    - hypothyroidism
    - hyperprolactinaemia
    - hypothalamic disorder
    - adrenal disorder
  6. Chronic medical illness
    - inherited bleeding disorders (coagulopathy, blood dyscrasias, platelet function disorders)
    - SLE / CT diseases (causing thrombocytopenia)
    - liver disease
    - renal disease
    - CVS disease
  7. Medication
    - hormonal contraceptives
    - anticoagulants
    - SSRI
    - antipsychotic
    - tamoxifen
    - herbal (e.g. ginseng)
  8. Family history
    - coagulation / thromboembolic disorders
    - hormone-sensitive cancers
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11
Q

Physical examination

A
  1. Vital signs
    - BP
    - pulse
    - weight
    - BMI
  2. Neck
    - thyroid exam
  3. Abdomen
    - tenderness
    - distension
    - striae
    - palpable mass
    - hepatomegaly
  4. Skin
    - pallor
    - bruising
    - petechiae
    - signs of hirsutism (male hair pattern distribution, acanthosis nigricans)
  5. Pelvic exam
    - vulva
    - vagina
    - cervix
    - anus
    - urethra
    - exclude local lesion e.g. cervical polyp
  6. Bimanual exam of uterus + adnexal structures
  7. Rectal exam
    - if bleeding from rectum suspected / risk of concomitant pathology
  8. Pap smear, cervical, vaginal cultures if at risk for STD
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12
Q

Investigations (+ SpC Revision)

A
  1. ***Pregnancy test / Serum hCG (all women are pregnant unless proven otherwise)
  2. ***CBC with Hb, platelet
  3. 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)

  1. Cervical screening
  2. Endocervical swab
    - for Chlamydia in Postcoital / Intermenstrual bleeding
  3. Endometrial assessment
    - Endometrial aspiration
    - Pelvic USG
    - Saline infusion sonohysterography (SIS)
    - Hysteroscopy
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13
Q

Ultrasound scan

A

***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

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14
Q

Saline Infusion Sonohysterography (SIS)

A

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

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15
Q

MRI?

A

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

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16
Q

Endometrial aspiration / Biopsy

A

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

17
Q

Risk factors for endometrial cancer

A

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

18
Q

Diagnostic hysterosocpy

A

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

19
Q

Management of AUB

A
  1. Establish causes
  2. Explanation / Counselling
  3. Observation
  4. Correction of anaemia
  5. Control of bleeding pattern
20
Q

Control of bleeding pattern

A

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

21
Q

Mirena (Progestogen releasing IUCD)

A

Prevention of endometrial proliferation
- licensed for **Menorrhagia management
- improves **Dysmenorrhea
- Full benefit may not be seen for 6 months

22
Q

Surgical treatment

A

Indication:
- Medical therapy fails / not tolerated
- patients’ choice / impact on QOL
- concomitant uterine pathology

  1. Endometrial ablation
  2. Myomectomy
  3. Hysterectomy
23
Q

Intermenstrual bleeding

A

History:
1. Menstrual history
2. Bleeding pattern
- How irregular
- Amount
- When (Intermenstrual / Menstrual / Postmenstrual)

  1. Provoking factors
    - postcoidal
    - trauma
  2. Associated symptoms
    - anaemic symptoms
    - abdominal pain / discomfort
    - stress and anxiety
  3. Contraception
  4. 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

24
Q

Management of Intermenstrual bleeding

A
  1. Cervical polyp —> ***Simple avulsion
  2. Endometrial / Fibroid polyp —> ***Hysteroscopic excision
  3. CIN/CA of cervix —> ***Colposcopy, Excision, Radiotherapy
25
Q

Amenorrhoea / Infrequent periods

A

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

26
Q

Anatomical causes in genital tract

A

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

27
Q

Endocrine dysfunction

A

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

28
Q

History taking in endocrine dysfunction

A
  1. Detailed menstrual history
    - menarche
    - cycle length, duration
  2. Sexual and contraceptive history
  3. Secondary sexual characteristics
    - breast, axillary, pubic hair development
  4. Cyclical abdominal pain
  5. Marked weight loss / gain
  6. ***Hyperandrogenism e.g. acne, excessive hair, baldness
  7. ***Presence of galactorrhoea
  8. Vasomotor symptoms e.g. hot flushes, night sweating
  9. Symptoms of an intracranial space occupying lesion e.g. morning headache, vomiting, visual disturbance
  10. Psychological stress / excessive exercise
  11. Drug history
  12. History of previous surgery e.g. surgical termination of pregnancy, endometrial ablation
  13. Family history of early menopause, PCOS
29
Q

***Physical examination / Investigations in Endocrine dysfunction

A
  1. Height, weight, BMI
  2. Secondary sexual characteristics e.g. breast, axillary, pubic hair development (Tanner staging)
  3. Galactorrhoea
  4. Hyperandrogenism e.g. acne, excessive hair, baldness
  5. Gynaecological exam: imperforate hymen, presence of uterus / vagina
  6. Detailed neurological including smell + ophthalmic exam

***Investigations:
1. FSH
2. Prolactin
3. TSH, T4
4. Cortisol

30
Q

Polycystic ovary syndrome (PCOS)

A

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

31
Q

Oligo / Amenorrhoea

A

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))

32
Q

Treatment of Anovulation (Ovulation induction)

A

FSH + Prolactin
1. ↑ Prolactin (Hyperprolactinaemia)
- **Bromocriptine
- **Cabergoline

  1. 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)
  2. ↑ FSH (Ovarian insufficiency)
    - Donor eggs
33
Q

Dysmenorrhea

A
  • 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)

34
Q

DDx of Dysmenorrhea

A
  1. ***Endometriosis —> Cyclic
  2. ***Adenomyosis
  3. Pelvic inflammatory disease —> Chronic pelvic pain
  4. Fibroids —> fibroid polyp associated with HMB (fibroids do not typically present with dysmenorrhea)
  5. Interstitial cystitis
  6. IBS
35
Q

Diagnosis and Management of Dysmenorrhea

A

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

36
Q

Endometriosis (Felix Lai)

A

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)

  1. Ovarian lesions (endometrioma / endometriotic cyst / chocolate cyst)
    - Ectopic endometrial tissue within the ovary bleeds —> haematoma surrounded by duplicated ovarian parenchyma
  2. 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

  1. Surgery
    - **Resection / Ablation of endometrial implants, endometriomas (cystectomy), adhesions (adhesiolysis) (Fertility preserved)
    - **    Hysterectomy +/- ***BSO (BSO: endometriosis is an estrogen-dependent disease)
37
Q

Summary

A
  1. AUB, HMB
  2. Intermenstrual bleeding
  3. Amenorrhoea
  4. PCOS —> Ovulation induction
  5. Dysmenorrhea

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