13. Menstrual Problems

Question 1

What is the normal Age of:

1. Menarche?
2. Menopause?

Answer 1

1. 13 years old

2. 51 years old

Question 2

What triggers Menstruation?

Answer 2

Fall in Progesterone 2 weeks after Ovulation (if not Pregnant)

Question 3

What is the definition of:

1. Menorrhagia?
2. Dysmenorrhoea?
3. Intermenstrual Bleeding?
4. Post-Coital Bleeding?
5. Oligomenorrhoea?

Answer 3

1. Heavy Periods
2. Painful Periods
3. Bleeding between Periods
4. Bleeding after Intercourse
5. Infrequent Periods

Question 4

What is asked in a Menstrual History?

Answer 4

1. Subjective
2. Clots / Flooding / Pads + Tampon
3. Pain +/- Heavy Flow or Premenstrual

Question 5

What is looked for in a Menstrual Examination?

Answer 5

1. General
2. Abdominal
3. Speculum
4. Bimanual

Question 6

What Investigation are done for Menstrual Complications?

Answer 6

1. Full Blood Count - if Menorrhagia
2. Endometrial Biopsy
3. Chlamydia
4. Thyroid / Coagulation
5. Pregnancy
6. Ultrasound
7. Hysteroscopy / Laparoscopy

Question 7

What are the Likely causes of Menstrual Problems in Early Teens?

Answer 7

1. Anovulatory Cycles
2. Congenital Abnormality - Rare
3. Coagulation Problems - Rare

Question 8

What are the Likely causes of Menstrual Problems in Teens - 40s?

Answer 8

1. Chamydia
2. Contraception Related
3. Endometriosis / Adenomyosis
4. Fibroids
5. Andometrial / Cervical Polyps
6. Dysfunctional Bleeding

Question 9

What are the Likely causes of Menstrual Problems in 40’s Menopause?

Answer 9

1. Perimenopausal Anovulation
2. Endometrial Cancer
3. Warfarin
4. Thyroid Dysfunction
5. Pregnancy - Always consider this

Question 10

What is the FIGO Classifications of Abnormal Uterine Bleeding?

Answer 10

PALM COEIN
P - Polyp
A - Adenomyosis
L - Leiomyoma
M - Malignancy / Hyperplasia
C - Coagulation (e.g. Von Willebrands Disease)
O - Ovarian (e.g. PCO / Perimenopausal Anov. Cycles)
E - Endocrine (e.g. Thyroid)
I - Iatrogenic (e.g. Warfarin)
N - Not Classified Yet

Question 11

What is Dysfunctional Uterine Bleeding?

Answer 11

Abnormal Bleeding but no Structural / Endocrine / Neoplastic / Infectious causes found (yet)

Question 12

What is Endometriosis?

Answer 12

Endometrial Type Tissue found Outside the Uterine Cavity - Usually the Ovary / Pouch of Douglas / Pelvic Peritoneum

Question 13

What are the Symptoms of Endometriosis?

Answer 13

1. Asymptomatic
2. Premenstrual Pain
3. Dysmenorrhoea
4. Deep Dyspareunia (Painful Sexual Intercourse)
5. Subfertility
6. Retrograde Bleed?
7. Peritoneal Metaplasia?

Question 14

What are the Sign of Endometriosis?

Answer 14

1. None
2. Tender Nodules in the Rectovaginal Septum
3. Limited Uterine Mobility
4. Adnexal Mass

Question 15

How is a Diagnosis of Endometriosis made?

Answer 15

1. Laparoscopy
2. MRI
3. Ultrasound Endometrioma

Question 16

What are the Endometriosis Sites?

Answer 16

1. Small Bowel / Appendix / Caecum / Sigmoid Colon / Peritoneum
2. Bladder / Ureter / Uterine Serosa / Umbilicus
3. Fallopian Tube / Ovary / Rectovaginal Septum / Uterovesical Fold

Question 17

What is the Medical Treatment of Endometriosis?

Answer 17

1. Progesterone (Oral / Injection / Mirena)
2. Combined Oral Contraceptive Pill
3. GnRH Analogues

Question 18

What is the Surgical Treatment of Endometriosis?

Answer 18

1. Excision of Deposits from Peritoneum / Ovary
2. Diathermy / Laser Ablation of Deposits
3. Hysterectomy AND Oophorectomy

Question 19

What is Adenomyosis?

Answer 19

Endometrial Tissue found in the Deep Myometrium

Question 20

What are the Signs / Symptoms of Adenomyosis?

Answer 20

1. Heavy Painful Periods

2. Bulky Tender Uterus

Question 21

How is Adenomyosis Diagnosed?

Answer 21

1. Ultrasound
2. Laparoscopy
3. Hysteroscopy
4. MRI
5. Histology Uterine Muscle - Not Endometrial Biopsy

Question 22

What is the Treatment of Adenomyosis?

Answer 22

1. Mirena
2. Ablation
3. Hysterectomy
   Note - Often failed Medical Management/ Ablation and Diagnosed on Pathology after Hysterectomy

Question 23

What are Fibroids?

Answer 23

Benign, Smooth Muscle Growths (Leiomyoma)

Question 24

What are the 3 types of Fibroids?

Answer 24

1. Sub-Mucous Fibroids - Protrude into Uterine Cavity
2. Intramural Fibroids - Within Uterine Wall
3. Sub-Serous Fibroids - Project out of the Uterus into the Peritoneal Cavity

Question 25

What are the Symptoms of Fibroids?

Answer 25

1. Asymptomatic 2. Pressure Symptoms 3. Menorrhagia (If Large) 4. Intermenstrual Bleeding - Submucous / Polyp 5. May grow fast in Pregnancy - Pain, Malpresent / Obstruct

Question 26

What are the Treatment of Fibroids?

Answer 26

1. Nothing 2. Standard Menorrhagia Treatment 3. GnRH Analogues 4. Ulipristal Oral Treatment 5. Transcervical Resection Sub-Mucous Fibroids 6. Myomectomy 7. Hysterectomy

Question 27

What are the treatments for Dysfunctional Uterine Bleeding?

Answer 27

1. Reassurance - No sinister Pathology 2. Fertility Conserving Treatment 3. Endometrial Ablation 4. Hysterectomy Note - 3 and 4 if family complete

Question 28

What is Fertility Conserving Treatment?

Answer 28

1. Tranexamic Acid - Reduces Blood Loss 2. Mefenamic Acid - Reduces Blood Loss 3. Combined Oral Contraceptive Pill - For Bleeding / Pain 4. Mirena Progestogen - Reduces Blood Loss

Question 29

What is Endometrial Ablation?

Answer 29

One off removal of Endometrium to below the Basal Layer, through the Cervix. Can use: 1. Diathermy 2. Thermal Balloon

Question 30

What is a Hysterectomy?

Answer 30

Surgical Removal of the Uterus

Question 31

What are the Routes of Hysterectomy?

Answer 31

1. Abdominal 2. Vaginal 3. Laparoscopically Assiested Vaginal Hysterectomy

Question 32

What are the Types of Hysterectomy?

Answer 32

1. Total Hysterectomy - Uterus and Cervix Removed | 2. Subtotal Hysterectomy - Uterus Removed, Cervix Left

Question 33

What is a Salpingo-Oophorectomy?

Answer 33

Removal of the Fallopian Tubes + Ovaries | Note - Need HRT till 50