Week 204 Menorrahia & Gynae Flashcards
What are fibroids (uterine leiomyomas)?
Benign muscular uterine growths which can cause heavy menstrual bleeding
What are the 3 main causes of menorrhagia?
Dysfunctional Uterine Bleeding (primary menorrhagia)
Fibroids (uterine leiomyoma)
Endometriosis
What is endometriosis?
Endometrium (uterine tissue) found outside of the uterus “ectopic endometrium”. It can cause painful periods, persistent pain in the peliv area and infertility.
What is Dysfunctional Uterine Bleeding?
Menorrhagia (bleeding >80ml in a period) with no organic cause
What are the 5 types of fibroid you can get?
Pedunculated - with stem, usually on outside surface of uterus
Intramural - within myometrium
Submucous - pushing into endometrium towards uterine cavity
Subserous - outside surface of uterus
Intracavitary - within the uterus
What causes the excess bleeding with submucous fibroids?
They increase surface area of the endometrial lining of the uterus therefore causing more to be shed during periods
On examination what finding would make DUB a much more likely cause of menorrhagia than fibroids?
If the uterus were normal sized. Fibroids tend to enlarge the uterus
Where would you likely palpate a 20-22 week size uterus due to fibroid mass?
At the umbilicus
What investigations might you perform to help make a diagnosis for menorrhagia?
FBC to confirm or exclude iron deficiency anaemia
USS - prob not required if examination reveals a normal sized uterus
Outpatient endometrial biopsy - normally on for those > 40 yrs as below that age endometrial malignancy is rare. May be performed in a younger female if failure to respond to med tx
If a patient with menorrhagia is anaemic what would you treat her with and what should you warn her with the treatment?
Iron supplements e.g. Ferrous Sulphate 200mg bd
May turn her stools black
What medical options are there to treat menorrhagia?
- Tranexamic Acid (antifibrinolytic) 1g tds only during period reduces
- Mefenamic Acid (NSAID) 500mg tds can be used with TA
- Combined Oral Contraceptive Pill (reduced bleeding by 20-30% and improves dysmenorrhea)
- Oral Progestogens (Norethisterone or Medroxy)
If you wish to reduce bleeding and pain which med treatments are most useful?
Either Tranexamic Acid with Mefenamic Acid (as TA reduces bleeding by 50% and MA reduces bleeding and pain)
Or COCP (reduces bleeding by 20-30% and helps pain
Theses are currently all second line treatments
What is currently first-line treatment for menorrhagia ?
Levonorgestrel-releasing IUS (Mirena coil) Reduces blood loss by up to 90%, by 1yr 30% are amenorrhoeic and excellent contraceptive (almost as good as being sterilised)
How does Mefenamic Acid work?
Inhibits prostaglandin synthesis
How does Tranexamic Acid work?
It is a plasminogen-activator inhibitor thereby inhibiting dissolution of thrombosis which leads to menstrual flow (prevents breakdown of clots)
List some side-effects for the levonorgestrel IUS (Mirena)
May have irregular bleeding for a few months post insertion
Progestogenic side effects: breast tenderness and bloating though this is rare as small amount released daily
What treatment might be best for a woman who is severely anaemic or bleeding continuously?
- GnRH analogue e.g. leuprorelin acetate (Prostap) or triptorelin IM
- High dose Progestogens e.g. medroxyprogesterone acetate 10mg tds until amenorrhoea (limited)
How do GnRH analogues work?
By down regulating GnRH receptors > reducing release of LH & FSH which inhibits oestrogen and androgen release from ovaries
What are the side effects of GnRH analogues?
Hot flushes and bone demineralisation (osteoporosis) so use is limited to 6-12 months
What surgical options are available for treating menorrhagia? And what must you be sure of before opting for one of them?
- Endometrial ablation
- Hysterectomy
The patient must be sure that she has completed her family or at least that every medical treatment has failed
What is endometrial ablation?
Destruction of the endometrium down to basalis layer
Highly effective
Novasure = electrical impedance
Thermachoice = thermal balloon
80-90% sig. Improvement, 20% require further procedure by 5yrs
What is a molar pregnancy?
A non-viable one either due to embryo/foetus or insufficient placenta - will not come to term
If a lady comes in 8 weeks pregnant with bleeding what should you do?
History (inc details of what passed and how much, obstetric Hx, gynae Hx)
Examine - abdo, speculum, bimanual
Investigation - FBC, G&S, hCG, USS
What are the main causes for subfertility?
Ovulation Disorder
Sperm Dysfunction
Tubal disease
Endometriosis
Coital failure, cervical mucus disorders, uterine abnormalities
Unexplained (failure to conceive within 2 yrs in absence of pathology)
