Abnormal uterine bleeding Flashcards by Luke Allison

What do we mean by menorrhagia?

Heavy cyclical periods, which interfere with physical, social and emotional quality of life.

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In terms of volume, what is the definition of menorrhagia?

More than 80 mL of menstrual blood loss (MBL) per period. This represents 2 SDs above the mean, which is about 40 mL.

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What is the incidence of true menorrhagia in Western Europe?

9-15%

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What are the different way you might diagnose menorrhagia?

Subjective assessment based on history

Pictorial blood loss assessment charts

Objective assessment (only really performed during clinical trials - rarely used diagnostically)

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What are the causes of menorrhagia?

U BLEEDDD

Uterine polyps/fibroids

Bleeding disorders (e.g. Von willebrand disease)/

Likey no underlying pathology (50%)

Endometriosis

Endometrial carcinoma

pelvic inflammotory Disease, intrauterine Devices, thyroid Disease

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How do fibroids lead to menorrhagia?

Enlarge uterine cavity, thereby increasing surface area of endometrium from which menstruation occurs.

Produce prostaglandins, which have been implicated in aetiology of menorrhagia.

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What is the most common cause of menorrhagia?

Dysfunctional uterine bleeding (DUB), which basically means idiopathic menorrhagia.

It is a diagnosis of exclusion.

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What is the most complication associated with menorrhagia?

Iron deficiency anaemia

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What are the signs in a history that point to a diagnosis of true menorrhagia?

Presence of clots and flooding

Wearing double sanitary towel protection (internal and external)

Nocturnal soiling

Interference with work and social events

Menstrual pain, worst when flow is at its heaviest

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What investigations might you in a patient with menorrhagia?

FBC

TFTs

Clotting screen

Ultrasound - fibroids and adnexal masses

Endometrial biopsy

Cervical smear

Diagnostic hysteroscopy

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With which patients with menorrhagia would you perform an endometrial biopsy?

All women aged over 45 OR in those who have risk factors in history such as persistent intermenstrual bleeding or suspicious findings on ultrasound, or risk factors such as PCOS or high BMI.

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What might hysteroscopy reveal in a patient with menorrhagia?

Endometrial polyps

Submucous fibroids

Endometritis

Endometrial carcinoma

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What are the two main types of medical therapy used in the management of menorrhagia?

Antifibrinolytics

Hormone preparations

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What is the most effective and most commonly used antifibrinolytic in the management of menorrhagia?

Tranexamic acid

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How does tranexamic acid work?

Inhibits activation of plasminogen to plasmin.

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What is the most important side effect of tranexamic acid?

Increased risk of clotting

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Apart from antifibrinolytics, what other non-hormonal treatment can be used to menorrhagia?

Prostaglandin inhibitors - NSAIDs such as aspirin and mefenamic acid

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What is the first line NSAID used in the management of menorrhagia?

Mefenamic acid

Do women prescribed tranexamic acid for the management of menorrhagia take it all month round or only during menses?

Only during menses

What are the different types of hormonal therapy that can be used in the management of menorrhagia?

Progestogens

Intrauterine systems - such as hormone coil

Combined oral contraceptive pill

Danazol

Gonadotrophin-releasing hormone agonists

What are the main side effects of intrauterine systems used in the management of menorrhagia?

It is a contraceptive, so temporary infertility

Amenorrhea occurs in up to 50% of long term users

What are the main side effects of the combined oral contraceptive pill?

Increased risk of thrombosis

Spotting in the first few months of use

Slight increase risk of breast, cervical and liver cancerIncreased risk of developing gallstones

What is Danazol, one of the types of hormonal therapies used in the management of menorrhagia?

A testosterone derivative which has a number of effects on the hypothalamic-pituitary-ovarian axis.

It is not commonly used due to the androgenic side effects, but is very effective in treatment menorrhagia.

How do gonadotrophin-releasing hormone agonists work to treat menorrhagia?

They suppress the pituitary-ovarian function, effectively inducing a temporary menopausal state.

Why can gonadotrophin-releasing hormone agonists not be used as a long term option to treat menorrhagia?

There is a subsequent bone density loss. This relegates their clinical use to that of pre-operative aids.

What are the first line drugs used in the treatment of menorrhagia?

This depends on whether the patient requires contraception or not. Either hormonal therapy (intrauterine systems are first line before COCP) or tranexamic and/or mefenamic acid.

What are the surgical options for patients with dysfunctional uterine bleeding (idiopathic menorrhagia)?

Endometrial ablation Hysterectomy

What are the most common operative complications of endometrial ablation?

Uterine perforation - causes trauma to the GI and GU tracts, major blood vessels resulting in peritonitis and haemorrhage. Fluid overload - the use of non-electrolytic solutions such as 1.5% glycine for pressures needed to distend uterine wall predispose to absorption of large quantities of fluid. Sepsis

What are the short term complications of a hysterectomy?

Fever - often not associated with infection UTI Wound infection Haemorrhage Urinary tract damage - ureter (1 in 200) and bladder (1 in 100) Bowel damage - (1 in 200)Incontinence

What are the longer term complications of a hysterectomy?

Pain Regret Vaginal vault prolapse

What is the rate of complications of hysterectomies?

Half of women undergoing abdominal hysterectomies A quarter of those undergoing vaginal hysterectomy

What is the definition of post-menopausal bleeding?

Vaginal bleeding that occurs 12 months after the menopause

What proportion of women with post-menopausal bleeding will be found to have a malignancy?

What is the most common cause of post-menopausal bleeding?

Atrophic changes to any part of the female genitalia due to oestrogen deficiency. However, all other causes especially cancer must be ruled out to make this diagnosis.

What are the causes of post-menopausal bleeding associated with the ovaries?

Carcinoma of the ovary Oestrogen secreting tumour

What are the causes of post-menopausal bleeding associated with the uterine body?

Myometrium: submucous fibroid Atrophic changes of the endometrium Polyps Simple or atypical carcinoma

What are the causes of post-menopausal bleeding associated with the cervix?

Atrophic changes Squamous carcinoma Adenocarcinoma

What are the causes of post-menopausal bleeding associated with the vagina?

Atrophic changes

What are the causes of post-menopausal bleeding associated with the urethra?

Urethral caruncle (associated with oestrogen deficiency) Haematuria

What are the causes of post-menopausal bleeding associated with the vulva?

Vulvitis Dystrophies Malignancy

As well as bleeding, what are the local symptoms of oestrogen deficiency?

Vaginal dryness Soreness Superficial dyspareunia

What investigations should be done in all women with post-menopausal bleeding?

Ultrasound examination of pelvis Hysteroscopic examination of uterine cavity Endometrial biopsy

What should the endometrial thickness be in post-menopausal women?

Less than 5mm

What is the most common method of endometrial biopsy?

By pipelle