Mennorhagia Flashcards
What is menorrhagia?
Menstrual blood loss tha interferes with a womans QoL
Normla blood loss is about 30-40 ml, most women will not have blood loss >80
What is dysfunctional uterine bleeding?
abnormal uterine bleeding without any obvious pathology, usually presenting as menorrhagia. This is a diagnosis of exclusion
Potential causes of menorrhagia?
local causes:
-benign/malignant tumours, PID, endometriosis
Systemic causes:
-thyroid disease, vWD, ITP
Key things to ask in a menorrhagia hx?
- Duration of bleeding, and how much of that time it is heavy (clots, doubling up)
- Symptoms of anaemia
- Symptoms of clotting disorder e.g. bruising, bleeding gums
- Sudden change in blood loss, intermenstrual and post-coital bleeding
- Local pressure effects and pain
Examination/ix in menorrhagia?
- abdominal and bimanual examination where relevant.
- If the uterus is enlarged, a mass is felt, or there is tenderness consider referral
Investigations can include FBC, TFTs (generally not recommended), clotting, and pelvic/trans-vaginal USS. These are undertaken dependent on clinical suspicion
- All women should have a cervical smear if due
What are fibroids?
commonest tumour of the female genital tract, typically occurring in women >35 years.
Different types of fibroids?
Intramural are within the uterine wall
- Subserous project from the peritoneal surface
- Submucous project from the uterine cavity
- Intraligametary are between the layers of the broad ligament
Symptoms of fibroids?
Most are asymptomatic, however some women will present with menorrhagia and local pressure effects.
Ix for fibroids?
All patients should have a pregnancy test, alongside FBC. Pelvic/ trans-vaginal USS is usually sufficient to confirm the presence and size of a fibroid
Further investigations can include
- Saline infusion USS
- MRI
- Endometrial sampling or hysteroscopy with biopsies, where leiomyosarcoma is suspected
Complications of fibroids?
-Subfertility and complications on pregnancy (abortion, preterm labour, obstructed labour).
More commonly, complications are histological
- Hyaline degeneration of fibroids leads to painful, enlarged, soft fibroids
- Red degeneration (necrobiosis) occurs in pregnancy due to infarction of the fibroid
- Calcification of fibroids often occurs in postmenopausal women
- Sarcomatous change to malignancy is rare, but can occur
- Infection resulting in abscess is also rare
Management of fibroids?
Expectant management is appropriate in peri-menopausal women. Usually, first line management is medical
- Antifibrinolytic agents
- Hormonal contraceptives e.g. COCP, IUS
- Progesterone receptor inhibitors, SPRMs, or GnRH agonists (mifepristone, ulipristal acetate) can be used pre-surgery to shrink fibroids
Surgical management is indicated where there are pressure symptoms, or medical management has not controlled symptoms adequately. The option depends on desire to preserve fertility
- Hysterectomy is definitive
Hannah Cooke, 2016/17
- Myomectomy can be used as a surgical option in patients wishing to preserve their fertility, GnRH agonists are used prior to this to shrink to fibroids
- Uterine artery embolization is another first-line option
What is Anovular Dysfunctional Uterine Bleeding
Anovular DUB is characterised by a prolonged irregular cycle, for example many days of bleeding following 6 – 8 weeks of amenorrhoea
- The bleeding is characteristically heavy and persistent to the end of the cycle, often with clots
Anovular DUB occurs due to a failure of ovulation, resulting in excessive oestrogen production from the unruptured follicle. This leads to endometrial hyperplasia (either cystic glandular or adenomatous).
Management is with progestogens in the second half of the cycle (noresthisterone from day 5 to day 26, or depo-provera
- Where symptoms do not respond, surgical management is recommended
What is Ovular Dysfunctional Uterine Bleeding
related to a failure of spiral artery constriction and prostaglandin dysfunction
Management is usually medical, this is reviewed after 3 months
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management of Ovular Dysfunctional Uterine Bleeding?
Management is usually medical, this is reviewed after 3 months
- If the patient requires contraception alongside treatment use the COC or mirena coil
- If the patient doesn’t require contraception use either mefenamic acid (prostaglandin synthetase inhibitor) or tranexamic acid (antifibrinolytic therapy)
Surgical therapy will cause fertility loss. Options include endometrial ablation and hysterectomy.
