Week 204 Menorrahia & Gynae

Question 0

What are fibroids (uterine leiomyomas)?

Answer 0

Benign muscular uterine growths which can cause heavy menstrual bleeding

Question 1

What are the 3 main causes of menorrhagia?

Answer 1

Dysfunctional Uterine Bleeding (primary menorrhagia)
Fibroids (uterine leiomyoma)
Endometriosis

Question 2

What is endometriosis?

Answer 2

Endometrium (uterine tissue) found outside of the uterus “ectopic endometrium”. It can cause painful periods, persistent pain in the peliv area and infertility.

Question 3

What is Dysfunctional Uterine Bleeding?

Answer 3

Menorrhagia (bleeding >80ml in a period) with no organic cause

Question 4

What are the 5 types of fibroid you can get?

Answer 4

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

Question 5

What causes the excess bleeding with submucous fibroids?

Answer 5

They increase surface area of the endometrial lining of the uterus therefore causing more to be shed during periods

Question 6

On examination what finding would make DUB a much more likely cause of menorrhagia than fibroids?

Answer 6

If the uterus were normal sized. Fibroids tend to enlarge the uterus

Question 7

Where would you likely palpate a 20-22 week size uterus due to fibroid mass?

Answer 7

At the umbilicus

Question 8

What investigations might you perform to help make a diagnosis for menorrhagia?

Answer 8

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

Question 9

If a patient with menorrhagia is anaemic what would you treat her with and what should you warn her with the treatment?

Answer 9

Iron supplements e.g. Ferrous Sulphate 200mg bd

May turn her stools black

Question 10

What medical options are there to treat menorrhagia?

Answer 10

• 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)

Question 11

If you wish to reduce bleeding and pain which med treatments are most useful?

Answer 11

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

Question 12

What is currently first-line treatment for menorrhagia ?

Answer 12

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)

Question 13

How does Mefenamic Acid work?

Answer 13

Inhibits prostaglandin synthesis

Question 14

How does Tranexamic Acid work?

Answer 14

It is a plasminogen-activator inhibitor thereby inhibiting dissolution of thrombosis which leads to menstrual flow (prevents breakdown of clots)

Question 15

List some side-effects for the levonorgestrel IUS (Mirena)

Answer 15

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

Question 16

What treatment might be best for a woman who is severely anaemic or bleeding continuously?

Answer 16

• GnRH analogue e.g. leuprorelin acetate (Prostap) or triptorelin IM
• High dose Progestogens e.g. medroxyprogesterone acetate 10mg tds until amenorrhoea (limited)

Question 17

How do GnRH analogues work?

Answer 17

By down regulating GnRH receptors > reducing release of LH & FSH which inhibits oestrogen and androgen release from ovaries

Question 18

What are the side effects of GnRH analogues?

Answer 18

Hot flushes and bone demineralisation (osteoporosis) so use is limited to 6-12 months

Question 19

What surgical options are available for treating menorrhagia? And what must you be sure of before opting for one of them?

Answer 19

• Endometrial ablation
• Hysterectomy
  The patient must be sure that she has completed her family or at least that every medical treatment has failed

Question 20

What is endometrial ablation?

Answer 20

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

Question 21

What is a molar pregnancy?

Answer 21

A non-viable one either due to embryo/foetus or insufficient placenta - will not come to term

Question 22

If a lady comes in 8 weeks pregnant with bleeding what should you do?

Answer 22

History (inc details of what passed and how much, obstetric Hx, gynae Hx)
Examine - abdo, speculum, bimanual
Investigation - FBC, G&S, hCG, USS

Question 23

What are the main causes for subfertility?

Answer 23

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)