Women's Health Flashcards
What 6 questions on history help to quantify heavy menstrual bleeding?
- flooding through clothing
- unable to leave house on heaviest days
- frequent pad/tampon changes
- clots >50c piece
- bleeding >7days
- anaemia Sx (fatigue, pallor or dizziness)
What is the PALM-COEIN classification for abnormal uterine bleeding?
Polyps (most common in 20-60yo, cause 10% of HMB)
Adenomyosis (most common in perimenopause)
Leiomyoma (fibroids; most common in perimenopause, cause 30% of HMB)
Malignancy or hyperplasia (Ovarian, Endometrial or Cervical)
= PALM; structural
Coagulopathy (non-specified blood clotting disorders cause 50% of HMB)
Ovulatory (anovulatory cycles, thyroid dysfunction)
Endometrial (endometriosis)
Iatrogenic (anti-coagulants, fish oil)
Not yet classified
= COEIN; non-structural
Name 6 risk factors for Endometrial Ca
- Anovulatory cycles
- PCOS
- PHx / FHx endometrial or colon Ca
- unopposed oestrogen or tamoxifen
- obesity
- increasing age after perimenopause
Name 4 Ex that may help identify the CAUSE of heavy menstrual bleeding
- Signs of hypothyroidism
- Signs of hyperandogenism
- Speculum
- Bimanual pelvic
Name the baseline tests for Ix of heavy menstrual bleeding
bHCG
FBE + ferritin
Pelvic US ideally on D5-10 of cycle (when endometrium is thinnest)
Consider Ix for other causes - TSH, hormonal screen inc. prolactin, coags, VWF)
Outline the step-wise management of heavy menstrual bleeding
Symptomatic management - tranexamic acid + NSAIDs
Medical management - LNG-IUD > cOCP > cyclical norethisterone or long-acting progestogens
Gynaecological referral if abnormal US or Sx ongoing >6m after above
What are the presenting Sx of polycystic ovarian syndrome?
Menstrual irregularity
Overweight
Hirsutism and/or acne
Subfertility
Impaired glucose or diabetes
What is the diagnostic criteria for PCOS?
2/3 of:
- oligo/anovulation (irregular periods <21 or >35 days if >3y post-menarche)
- clinical or biochemical hyperandrogenism
- polycystic ovarian morphology on US
What tests are required to diagnose PCOS?
NONE if irregular periods AND clinical hyperandrogenism, otherwise add SHBG + free testosterone (FAI)
If normal, add pelvic US if >8y post-menarche
PLUS ALWAYS r/o other causes - TSH, FSH/LH, prolactin
+/- consider Ix for CAH, Cushing’s or adrenal tumours
Name the 6 areas to consider for PCOS management
- Lifestyle + weight - encourage calorie deficit + 30mins mod-vig exercise/day
- Clinical hyperandrogenism - cosmetic +/- cOCP, add spironolactone if required after 6m (contraception required to prevent pregnancy due to teratogenic effect)
- Menstrual cycle regularity - cOCP (increase SHBG + reduce free androgens) > progestogens + metformin to improve ovulation and reduce insulin resistance
- Fertility - weight loss if indicated + metformin while awaiting fertility specialist
- Metabolic health - smoking cessation, annual BP, lipids if BMI >25 then per CVD risk, diabetes screen (FG, A1c or OGTT) every 1-3y
- MH / SEWB
What are the presenting symptoms of endometriosis (think 4 categories)?
- Pain - severe, recurring or persistent >6m, ovulation, deep dyspareunia, back/leg pain
- Bleeding - Heavy, irregular, extended or post-coital bleeding +/- clots, dark or old blood pre- or at end of period
- Bowel + bladder - pain with bowel or bladder movements, bleeding from bowel or in urine, IBS Sx (constipation, diarrhoea or colic)
- Other - chronic fatigue, bloating or pain not during period or ovulation, subfertility (30%), fainting, nausea, depression
What are the differentials for endometriosis / lower abdominal pain?
STI -> PID
Ectopic pregnancy
Ovarian torsion
IBS
What Ex and Ix should be completed for work-up of endometriosis?
Ex: palpate abdomen ?tenderness ?guarding + vaginal exam ?tenderness ?uterine size ?nodules ?ovarian cysts
Ix:
TA+TV US (may be negative or detect endometriomas, if specialised may detect deep infiltrative endometriosis of the bowel, bladder or rectovaginal septum)
+/- MRI (specialist only)
Note laparoscopy for histological verification remains gold standard
Outline the Mx of endometriosis
- Refer to gynaecologist for confirmation of diagnosis +/- treatment (laparoscopic removal of tissue +/- medications eg. GnRH agonist (Zoladex implant) to suppress oestrogen, progestogens, anti-progestogens)
- NSAIDs and other pain meds (amitriptyline, duloxetine, pregabalin)
- Period suppression - OCP, NuvaRing, Implanon, DMPA, Mirena (together or individually)
- Multidisciplinary pain management - pelvic floor physiotherapy, psychologist, pain specialist
Define:
- Menopause
- Early Menopause
- Premature Menopause (aka premature ovarian insufficiency)
- Perimenopause
- Postmenopause
- Menopause: the last period (typically 45-55yo, average 51yo), known retrospectively only once >12m has passed
- Early Menopause: menopause from 40-45yo
- Premature Menopause (aka premature ovarian insufficiency): menopause before 40yo
- Perimenopause: fluctuating hormones during the time before the last period (can be 5-10y prior)
- Postmenopause: >12m after the last period
How is menopause diagnosed? When is FSH used?
Menopause is a clinical diagnosis if >45yo w irregular bleeding
FSH used if <45yo or when ammenorhoea is due to IUD or endometrial ablation
- If <45yo, FSH >30 needs to be repeated after at least 4-6 weeks later to Dx early/premature menopause
- If >45yo w IUD: FSH >30 (twice at least 6w apart) -> discontinue contraception after further 12m; FSH <30 -> repeat test in 6-12m
Menopause Sx
Vasomotor: hot flushes, night sweats
Genito-urinary: vaginal dryness, dyspareunia, recurrent UTI, incontinence
Cognitive: anxiety/low mood/irritability, reduced concentration, sleep disturbance, reduced libido
Other: muscle/joint pains, fatigue, central weight gain
Menopause DDx
Thyroid disorder
Depression
Anaemia (+/- Fe def)
Unstable diabetes
Medications (SSRI, TCA, vasodilators, CCB, opiates, cholinergics)
What 6 Ex should be completed for Women’s Midlife Health Screening?
BMI (height / weight)
Waist circumference
BP + CVD
Pelvic exam +/- CST
Breast exam
Thyroid exam
What Ix should be completed for Women’s Midlife Health Screening?
CST
Mammogram
Fasting lipids
Fasting glucose
UEC + LFT
FBE + Ferritin
FOBT
+ consider TSH, Vit D + DEXA
Other than menopause Sx, what other issues should be addressed in midlife women?
CVD risk (inc. diabetes)
Osteoporosis
Mood + sleep
Cancer screening (cervical, breast, bowel, skin)
SNAP
Contraceptive needs
Outline 5 NON-hormonal Mx options for genito-urinary menopause Sx
- Wear clean, cotton underwear
- Avoid tight clothing
- Continence aids
- Use soap-free hypo-allogenic moisturisers and barrier creams (eg. twice weekly Replens)
- Use water or silicon-based lubricants (or natural oils if not using condoms)
Outline the NON-hormonal Mx options for menopause vasomotor Sx
Lifestyle changes - light layers, fans, water spray bottles, reduce EtOH + caffeine, quit smoking, physical activity and maintaining a healthy weight
Mindfulness and CBT
Non-hormonal pharmaceutical options inc. SSRI/SNRI (Escitalopram/Venlafaxine/Desvenlafaxine/Paroxetine), Gabapentin, Clonidine
What are the 5 contraindications for MHT?
- Oestrogen-dependent cancer (breast, endometrial, ovarian); liaise w oncologist
- Thrombophilia or high risk VTE/DVT
- Undiagnosed vaginal bleeding
- Untreated hypertension
- Severe active liver disease
Menopause hormone therapy - general approach
Offer to women w menopausal Sx, early or premature menopause (bone sparing and reduces CVD risk), osteoporosis <60yo, within 10y of last period
Use lowest effective MHT dose (except in early/premature menopause) monitored by self-reported Sx (eg. Greene scale)
Review within 2-6 months to titrate regimen depending on benefits / AEs, need, new options, CVD + breast Ca risk
Then review annually
Menopause hormone therapy - early (<45yo) and premature (<40yo) menopause in women WITH a uterus
High dose long-term therapy until 50yo
- Continuous high dose oestrogen + cyclical or continuous progestogen
- cOCP
- Tibolone
Menopause hormone therapy - menopausal transition in women WITH a uterus
Lowest effective dose
- low dose cOCP if low CVD risk + <50yo
- continuous oestrogen + cyclical progestogen + contraception
- continuous oestrogen + levonorgestrel IUD
Menopause hormone therapy - postmenopausal women WITH a uterus
Lowest effective dose
- continuous oestrogen
+ continuous progestogen (if menopause >1-2y ago) vs cyclical progestogen (if menopause <1y ago)
vs levonorgestrel IUD
- Tibolone (if menopause >1-2y ago)
- SERM
