Year 2 - Week 4 - Vaginal Bleeding Flashcards
What is the term of excessive period blood loss?
Menorrhagia
What volume constitutes menorrhagia?
> 80ml per menses
What is the definition of menorrhagia?
Excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.
What can menorrhagia cause?
Anaemia
What length is the typical period cycle?
21-35 days
What term describes infrequent menstruation?
Oligomenorrhoea
What is the definition of oligomenorrhoea?
Interval of greater than 35 days between menses.
What can cause oligomenorrhoea?
Breastfeeding
Excessive exercise
PCOS
Endocrine disorders
Anorexia
What is the term for the absence of menstruation?
Amenorrhoea
What is the difference between primary and secondary amenorrhoea?
Primary - P has never had a period
Secondary - periods have ceased
What is the term for too frequent menstrual cycles?
Polymenorrhoea
What is the definition of polymenorrhoea?
Periods which occur more frequently than every 21 days.
What is the cause of polymenorrhoea?
Can be puberty influences
Can also be due to endocrine disorders
What is the typical length of bleeding in a menses?
3-7 days
Which term describes painful periods?
Where is the pain felt?
Dysmenorrhoea
Low anterior pelvic pain
In which phase of the cycle are PMS symptoms often experienced?
Luteal phase
Which term describes any bleeding variation from the normal menstrual cycle?
Abnormal uterine bleeding
Which is the most common type of abnormal uterine bleeding?
Heavy menstrual bleeding
What is the name of the bleeding which occurs between clearly defined cyclical menses?
Intermenstrual bleeding
What are the causes of abnormal bleeding using acronym PALM COIEN
Polyms
Adenomyosis
Leiomyoma (Fibroids)
Malignancy or hyperplasia
Coagulopathy
Ovulatory disorders
Iatrogenic (e.g, exogenous hormones)
Endometrial
Not yet classfied
What is Day 1 of the cycle?
First day of period
What are the first and second phases of the menstrual cycle?
First phase - Follicular phase - FSH stimulates the development of a dominant follicle on the surface of the ovary.
Second phase - Luteal phase - LH rises and triggers the follicle to release the ovum.
How far from menstruation does ovulation occur?
14 days before
Which part of the cycle can vary in length - resulting in the variation of cycle lengths between women?
The follicular phase.
What happens if the ovum is not fertilised?
The corpus luteum degenerates, oestrogen and progesterone levels all and blood vessels of endometrium constrict, shed as menstrual blood.
What does the corpus luteum do?
Produces progesterone which prepares the endometrium for implantation.
If a woman presents with heavy menstrual bleeding - what questions should you ask?
Nature of the symptoms
What is ‘normal’ for the patient’s menstrual cycle - length, duration, and any variation in the pattern
The patient’s age
How do the symptoms affect the woman’s quality of life?
Has the patient attended cervical screening as scheduled (where appropriate) and what were the results
Sexual history, including contraceptive use and future plans
Pregnancy history. Could the patient be pregnant now?
Medical history - especially conditions such as endometriosis and coagulation disorders
Surgical history
Family history of coagulation disorders
Drug history - including previous treatment for menorrhagia
Related symptoms - e.g. pelvic pain, inter-menstrual bleeding
When is a physical exam required if the patient has heavy menstrual bleeding?
If they also have any other symptoms - e.g. inter-menstrual bleeding, pelvic pain, dysmenorrhoea, pressure symptoms
If a woman has heavy menstrual bleeding and NO other symptoms - what is the appropriate next step?
Initiation of pharmacological treatment
When should you investigate secondary amenorrhoea?
When the periods have stopped for at least 6 months.
What is the most common cause of amenorrhoea?
Pregnancy
Which women with heavy menstrual bleeding (HMB) should be referred on the 2-week-wait pathway?
Those with symptoms suggestive of cancer
Which symptoms are suggestive of cancer in Ps with HMB?
Pelvic or abdominal mass
Ascites
Suspicious ultrasound
Abnormal appearance of cervix on examination
Mass of vagina/vulva or ulceration
Post-menopausal bleeding
When do you refer a woman with HMB?
Complications (e.g. compressive symptoms - dyspareunia, pelvic pain, constipation, urinary symptoms)
P has iron deficiency anaemia & has failed to respond to treatment, and other causes excluded
Menorrhagia has not improved despite initial treatment
Fibroids >3cm
How can the HPAA be disrupted to cause amenorrhoea?
Extreme weight gain / loss
Excessive exercise
Chronic illness
What causes hyperprolactinaemia?
Pregnancy
Puerperium
Stress
Breastfeeding
Pituitary tumour
Drugs (anti-psychotics, SSRIs)
Hypothyroidism
What signs can indicated hyperpolactinaemia?
Galactorrhea
Infertility
Hirsutism
Loss of libido
Hx of hypothyroidism
Drug Hx
Prolactinomas - can cause pressure symptoms - e.g. headaches and visual-field defects
What can cause hypopituitarism?
Surgery
Trauma
Irradiation
Infiltration (Sarcoidosis, tumour)
Sheehan’s
What percentage of couples in the general population conceive naturally within 1 year if they are having regular sex?
84%
What proportion of couples in the Uk have difficulty conceiving?
1 in 7
In approx what percentage of couples with infertility is no cause found?
25%
What are the main causes of infertility?
Ovulatory disorders (25%)
Tubal damage (20%)
Male infertility (30%)
Uterine or peritoneal (10%)
Unknown - 25%
What questions should you ask in a subfertility history?
Woman’s age
Previous pregnancies
How long have they been trying?
Frequency of intercourse?
Previous contraception and when was it stopped?
Menstrual history cycle
Previous gynae history and smear history
Previous STIs/pelvic infections?
Systemic symptoms/history of systemic disease?
Medications (inc OTC)
Alcohol and recreational drugs
Smoking status
At what age does a decrease in fertility occur in men and women?
Men = 40-45
Women = mid-30s
When should a couple be referred for subfertility?
If they have failed to conceive after 12m of regular unprotected intercourse
When might you decide to refer a couple earlier than 1 year for infertility?
If the women is >36
Those with a known cause of infertility or predisposing factors for infertility
Women undergoing medical treatments which may result in infertility - e.g. cancer treatment
Women unable to have vaginal intercourse
What lifestyle factors can affect fertility?
Smoking
Drinking
Regular intercourse
Health BMI
Caffeine - max 200mg/day. No caffeine if undergoing IVF
Tight Fitting Underwear
How can we support couples going through infertility treatment?
Acknowledge stress
Support
Offer resources
Link to support groups
Refer to counselling
Who should be referred for IVF?
Women <40 not conceived >2yrs trying or 12 cycles of artificial insemination. They get 3 full cycles of IVF - unless woman hits 40 during this - in which case stop after the current cycle.
Women 40-42 - not conceived >2 yrs or 12 cycles AI - offer 1 IVF cycle provided they have never had IVF previously, is no evidence of low ovarian reserve and there has been a discussion of implications of IVF and pregnancy at this stage.
What can cause amenorrhoea?
HPAA dysfunction
Hyperprolactinaemia
Hypopituitarism
High levels of gonadal hormones
Ovarian problems
Anatomical problems (e.g. Ashermann’s syndrome - endometrium is scarred following surgery)
What are the ovarian causes of amenorrhoea?
PCOS - excess androgen production
Ovarian carcinoma
Ovarian failure (menopause)
What do you check levels of for PCOS?
Androgen levels - high levels can indicate PCOS
What is the diagnostic criteria for PCOS?
Rotterdam criteria - need 2 out of 3:
- polycystic ovaries on US
- oligomenorrhoea or anovulation
- clinical or biochemical signs of hyperandrogenism
What types of abnormal bleeding are there?
Intermenstrual bleeding
Postcoital bleeding
What can cause spotting?
STD (chlamdiya) or PID
What type of cells are found in
- the cervical canal
- the outside of the cervix
What is name if these two meet on the outer cervix?
- Columnar cells
- Squamous cells
Ectropion
What are the risk factors for an ectropion?
High levels of oestrogen - so pregnancy or contraceptive pill
What is the term for severe or persistent pain with menses?
Dysmenorrhoea
What is the difference between primary and secondary dysmenorrhoea?
Primary = no underlying pathology - common in young women and smokers
Secondary = caused by pathology
What can cause secondary dysmenorrhoea?
Fibroids
PID
Endometriosis
Adenomyosis
Adhesions
Anatomical abnormalities
What is endometriosis?
Endometrial tissue that is deposited in sites outside the uterus lining.
What are the symptoms of endometriosis?
Chronic pelvic pain
Pain on intercourse
Infertility
Urinary tract symptoms
Painful defecation
Backache
Bleeding at extrapelvic sites
What is the gold standard investigation for endometriosis?
Laparoscopy
If Ps do not have severe or unusual symptoms of endometriosis, what is acceptable first line treatment?
Mirena coil = first line
Contraceptive pill or NSAIDs,
Tranexamic acid or Mefanamic acid
When is dysunfctional uterine bleeding the most common?
At the extremes of the fertile years = v young or perimenopause
What can cause excessive menstrual bleeding?
Fibroids
Hypothyroidism
Bleeding disorders
Cirrhosis of liver
What should you check in a P with HMB?
FBC + serum ferritin
What is the potential problem of running two packs of contraceptive pills together to stop a period?
Breakthrough bleeding
What treatment can be prescribed to postpone menstruation?
Norethisterone - start 3 days before period is due. When ceased - should have a period 2-3 days later.
If progesterone.
Is not a contraceptive in this manner,
What are the progesterone-only options for contraception?
Progesterone only pill
Injectable contraceptives
Implantable contraceptives
Mirena IUS or non-hormonal copper IUD
What are the risks of the COC?
Can inc risk of VTE - from 5-10 per 100k to 20 per 100k.
Decreases overall risk of cancer BUT can small increase risk of breast cancer & inc risk of cervical cancer (depending how long used for).
What are the side effects of the COC?
Nausea
Headaches
Breast tenderness
Mood changes
Change in libido
Can inc BP
Breakthrough bleeding
On the COC - how many periods is it recommended you have a year?
4
What is the risk of injectable or implantable contraception?
May cause reduced bone mineral density
Not immediately reversible
May have unschedule bleeding for months
What are the types of emergency contraception?
IUD - can be used 5 days post intercourse
Levonelle - progesterone only pill - up to 72 hours
Ulipristal acetate - progesterone receptor modulator that inhibits ovulation & acts on endometrium to prevent implantation - 5 days
