Flashcards in Abnormal menstrual/intermenstrual bleeding Deck (40):
What can be considered as abnormal bleeding for a menstrual cycle?
*Abnormal in volume -heavy
*irregularity in timing
*infrequent or frequent menstrual bleeding
*prolonged or shortened menstrual bleeding
*Intermenstrual, postcoital, premenstrual and postmenstrual spotting
What is used to classify abnormal uterine bleeding?
FIGO classification system PALM COEIN
The FIGO classification system PALM COEIN for abnormally menstrual bleeding, what is the PALM for?
PALM Structural issues
*Malignancy and hyperplasia of genital tract
The FIGO classification system PALM COEIN for abnormally menstrual bleeding, what is the COEI for?
COEIN Non-structural issues
*Coagulopathy ie. von Willebrand's disease, thrombocytopenia
*Ovulatory dysfunction e.g. PCOS, hypothyroidism
*Endometrial primary disorders e.g. inflammatory response
*Iatrogenic cause e.g. exogenouse sex steroid administration
The FIGO classification system PALM COEIN for abnormally menstrual bleeding, what is the N for?
Not yet classified
What is the clinical and objective definition of heavy menstrual bleeding (HMB) also known as menorrhagia?
Clinical: Excessive menstrual blood loss that interferes with the woman's physical, emotional, social and material quality of life
Objective: blood loss of >80mL in otherwise normal menstrual cycle, which can lead to iron deficiency
What are the causes of heavy menstrual bleeding?
*Majority have no histological/pathological abnormality =dysfunctional uterine bleeding
*Uterine fibroids 30%
*Copper coil IUD
*Chronic pelvic infection
*Endometrial and cervical malignancy
*Rare = von Willebrand's disease, thyroid disease
What indicates excessive menstrual bleeding in a history?
'Flooding' and the passage of large clots
What do you want to find out when taking a history about heavy menstrual bleeding?
*Nature of bleeding
*related symptoms -pelvic pain?
*impact on quality of life
What laboratory tests should be carried out for a women with HMB?
*FBC to assess whether they are anaemic
*Coagulation disorders considered when pt has had
>heavy menstrual bleeding since periods started
>have personal or family history suggesting coagulation disorder
*Thyroid function tests if other signs and symptoms suggest thyroid disease
When symptoms suggestive of underlying pathology for HMB what other investigations may you consider?
When would you offer an outpatient hysteroscopy to woman with HMB?
If their history suggests submucosal fibroids, polyps or endometrial pathology
When would you offer pelvic ultrasound to a woman with HMB?
*their uterus is palpable abdominally
*history or examination suggests pelvic mass
*examination inconclusive or difficult (obese women)
When would you offer transvaginal ultrasound to a woman with HMB?
*history of significant dysmenorrhoea
*have a bulky, tender uterus on examination suggesting adenomyosis
When no pathology is indicated for HMB what is the 1st line management?
Levonorgestrel-releasing intrauterine system
When no pathology is indicated for HMB what contraceptives can be used to manage it? Place in order of best to worst
1st - Levonorgestrel-releasing intrauterin system
2nd - Combined oral contraceptive pill or cyclical oral progesterone
3rd - Long-acting progesterone (Depo)
What non-hormonal agents can be used to control menstrual bleeding?
*NSAIDs e.g. mefenamic acid
When would you not investigate the cause of HMB? What would you do?
*History and examination suggest low risk of fibroids, uterine cavity abnormality, hsitological abnormality, adenomyosis
*Start phamacological treatment without investigation of cause
What is adenomyosis?
The endometrium tissue grows and breaks through into the myometrium
What are fibroids?
Benign growths of the uterus
If a woman is trying to conceive but having HMB, what can you treat them with?
*NSAIDs e.g mefenamic acid
After all management fails, what can be done to manage HMB?
What is postcoital bleeding?
*Non-menstural bleeding after sexual intercourse
What are the causes of postcoital bleeding?
*Cervical or endometrial polyps
What is the aetiology of postcoital bleeding?
When the cervix is not covered in healthy squamous epithelium, it is more likely to bleed after mild trauma
How do we manage postcoital bleeding?
*Vaginal swabs for infection
*If polp evident, it is evulsed and sent for histology
*Ectropian can be frozen with cryotherapy
*Colposcopy can be done to exclude malignant cause
What is intermenstrual bleeding?
Bleeding from the vagina at any time during the menstrual cycle other than during normal menstruation
What are the causes of intermenstrual bleeding?
*Vaginal causes: adenosis, vaginitis, tumours
*Cervical causes: chlamydia, gonorrhoea, polyps, ectropian, cancers(most often PCB)
*Uterine causes: fibroids, polyps, cancer, adenomyosis, endometritis
Ovary causes: ovarian cysts
*Iatrogenic cause: tamoxifen, missed pill, following smear, drugs altering clotting parameters SSRIS, steroids
What investigations should be done for intermenstrual bleeding?
*Always exclude pregnancy and STIs
*Blood tests may includ: FBC, CLotting, TFT, FSH/LH if onset of menopause suspected
*Transvaginal ultrasound to look for structural abnormalities
What is the management of a cervical ectropian?
*Watch and wait -can resolves after COCP stopped or after pregnancy
*Cauterised with silver nitrate
What is the management of endometrial polyps?
*Can be avulsed and biopsied
What is the management of fibroids?
*Small can be removed hysteroscopically
*Uterine artery embolisation
*Medical management drugs that reduce oestrogen levels
When should women with intermenstrual bleeding be referred?
*Abnormal-looking cervix, suspicious of cancer =urgent referral
*Cervical polyp that is not easily removed in primary care
*Pelvic mass on examination/USS
*Women at high risk of endometrial cancer:
>family history of hormone-dependent cancer
>prolonged and irregular cycle
>women who take tamoxifen
*Women aged >45
*Age <45 persistent symptoms
*Women with no cause found on examination for postcoital bleeding
What is meant by primary amenorrhoea?
*Failure to menstruate by age 16
What is secondary amenorrhoea?
*Cessation of establisjed menstruation for 6months in the absence of a pregnancy
What are the causes of primary amenorrhoea?
*Delayed puberty -which is when secondary sex characteristics are not present by the age of 14years
>Androgen insensitivity syndrome
*If puberty development normal otherwise, then consider:
>Congenital absence of uterus
>Low body weigh and excessive exercise
What are the causes of secondary amenorrhoea?
(After excluding pregnancy)
*Hypothalmic amenorrhoea (e.g. stress, excessive exercise)
*Polycystic ovarian syndrome (PCOS)
*Premature ovarian failure
What investigations are done for amenorrhoea?
*Pregnancy test -urine or serum bHCG
*FSH and LH (gonadotrophins)
*Androgen levels i.e. testosterone
What do low or high levels of gonadotrophins allow you to determine in amenorrhoea?
*Low levels indicate a hypothalmic cause
*Raised levels suggest an ovarian cause