Abnormal vaginal bleeding

Question 1

What is amenorrhoea?

Answer 1

Absence of periods by 16 years

OR

Absence of bleeding for >6 months

Occurs in 3-4% women

Question 2

Most common congenital causes of amenorrhoea

Answer 2

Mullerian agenesis: congenital absence of all or part of the uterus and vagina

Occurs in 1 : 5000 live births

Causes 15% cases primary amenorrhoea

Ovaries do not develop from mullerian duct so patient may have secondary sexual characteristics but due to lack of uterus are infertile

Imperforate hymen/ transvaginal septum

Question 3

Most common acquired causes of amenorrhoea

Answer 3

• Intrauterine adhesions (Asherman’s) or intrauterine scarring due to endometrial curettage
• Cervical stenosis due to cone biopsy or infection

Question 4

Most common endocrine causes of amenorrhoea

Answer 4

Premature ovarian failure

PCOS

Primary hypothalamic pituitary dysfunction

Question 5

What is premature ovarian failure?

Answer 5

Loss of ovulation <40 years

Question 6

Clinical features associated with amenorrhoea

Answer 6

Outflow obstruction: cyclical pelvic pain, absence of os and bulky uterus full of debris is typical of cervical stenosis, blueish buldge if hymen intact

Mullerian agenesis may be asymptomatic apart from amenorrhoea

Question 7

Diagnostic approach to primary amenorrhoea

Answer 7

Are secondary characteristics present? If yes do a pelvic USS to look for uterus

If uterus present: think outflow obstruction

If uterus present but no obstruction: consider secondary causes

No uterus = mullerian agenesis

Secondary characteristics absent: do hormone profile

Question 8

Investigations for secondary amenorrhoea

Answer 8

TFTs: both hypo and hyperthyroidism can cause amenorrhoea

Prolactin tests: give progesterone, if bleed occurs amenorrhoea could be due to PCOS or prolactinoma

If prolactin raised do an MRI

Question 9

Investigations for amenorrhoea

Answer 9

Pregnancy test

Hormone profile

TFTs

Imaging, pelvic USS, hysteroscopy, MRI head

Karyotyping

Question 10

Management of amenorrhoea

Answer 10

Aim is to restore function and fertility

If woman is <50 and doesn’t want to conceive HRT given to prevent osteoporosis

Hypothalamic-pituitary dysfunction cause: treat with gonadotrophins

Prolactinomas treated with dopamine agonists e.g. bromocriptine or cebergoline

Surgery for outflow obstruction

Question 11

What is oligomenorrhoea?

Answer 11

Menstruation with >35 days between

Question 12

Causes of oligomenorrhoea

Answer 12

Associated with failed ovulation

Endocrine dysfunction: PCOS, hyper/ hypothyroidism, hyperprolactinaemia

Stress, weight loss

Iatrogenic: contraceptives

Question 13

What is menorrhagia?

Answer 13

Heavy periods

20% gynae consultations are for menorrhagia

Excessive menstrual blood loss is classified as 80 mL or more and/or a duration of more than 7 days

• The average blood loss during menses is 30–40 mL, and 90% of women have losses less than 80 mL.

Excessive menstrual bleeding is also defined as the need to change menstrual products every one to two hours, passage of clots greater than 2.54 cm, and/or ‘very heavy’ periods as reported by the woman.

Question 14

Causes of menorrhagia

Answer 14

Uterine and ovarian pathologies: fibroids, polyps

Systemic diseases and disorders: coagulation disorder, hypothyroidism, liver or renal disease

Iatrogenic causes: anticoagulants, chemo

Herbal supplements (for example ginseng, ginkgo, and soya) — these may cause menstrual irregularities by altering oestrogen levels or coagulation parameter

IUD: copper coil

Question 15

Investigations for menorrhagia

Answer 15

FBC: assess need for iron supplements or blood

Refer to haem if coag disorder suspected

USS: pelvic mass palpated or anomaly suspected

Endometrial biopsy

Question 16

Management of menorrhagia

Answer 16

TXA: 50% reduction in bleeding

Mefenamic acid: NSAID, 25% reduction in bleeding

COCP: if not contraindicated

Oral progestogens

Mirena coil

GnRH agonists: act on pituitary and cause amenorrhoea but only used short term as predisposes to osteoporosis and £££

Surgical: endometrial ablation/ hysterectomy

Question 17

What is dysmenorrhoea?

Answer 17

Pain during period that interferes with daily activities

Primary = not associated with pelvic pathology

Secondary = caused by underlying pathology, most common being endometriosis which affects 70% with dysmenorrhoea

Adenomysis (cells of endometrium found in myometrium), fibroids and PID can also cause secondary dysmenorrhoea

Question 18

Hx of dysmenorrhoea depending on cause

Answer 18

1) Primary dysmenorrhoea: pain precedes and acompanies menstruation, no abnormal findings

2) Endometriosis: heavy periods, dyspareunia, associated w fixed, retroverted uterus and uterosacral nodularity

3) Adenomyosis: prolonged heavy periods and bulky uterus

4) Fibroids: pain, pressure on bladder and bowels

5) PID: hx of STI, discharge, cervicitis, pelvic mass

Question 19

Causes of intermenstrual or post coital bleeding

Answer 19

Physiological changes

Hormonal imbalance

Infection

Drug use

Benign tumours

Malignancy

Question 20

Investigations for intermenstrual bleeding/ post coital bleedig

Answer 20

Pregnancy test

Cervical cytology

Triple swabs to look for infective cause

Imaging