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
