Menstrual disorders

Question 1

Define dysfunctional uterine bleeding

Answer 1

any symptomatic variation from normal menstruation (regularity, frequency, duration, volume) when not pregnant. Includes IMB
normal - 24-38 day cycle, variation of no more than 9 days, duration up to 8 days, volume - subjectively intervening with life

Question 2

What are the physiological/endocrine factors that can impact on bleeding?

Answer 2

Thyroid - hypothyroidism can cause HMB (mainly causes Oligo- or amenorrhoea)
HPA - responsible for normal menstrual cycle
coagulation cascade/clotting factors

Question 3

What are the risk factors for DUB?

Answer 3

• obesity
• PCOS
• Tamoxifen
• Hypothyroidism
• Nulliparity
• unopposed estrogen
• Lynch syndrome
• diabetes

Question 4

What are two non hormonal treatments for DUB and what are their MOA?

Answer 4

• TXA - inhibits fibrinolysis and slows clot break down

- NSAIDs - inhibit prostaglandin production in the endometrium –> vasoconstriction and reduced bleeding

Question 5

What is the incidence of PMS?

Answer 5

40%

Question 6

What is the pathogenesis of PMS?

Answer 6

• sensitivity to progesterone (elevated in luteal phase)

- serotonin and GABA receptors being activated by progesterone and estrogen

Question 7

What is the definition of PMS?

Answer 7

cyclical emotional or physical symptoms that are worse in the luteal phase and improve with menstruation
symptom free week during menses
interfere with daily activities

Question 8

How should PMS be managed?

Answer 8

• exclude other pathology
• confirm diagnosis with symptom diary
• treat with COCP/SSRI/CBT/VIt B6/Topical estrogen/GnRH agonist/TAH + BSO (???)

Question 9

Why is normal menstruation self limiting?

Answer 9

• shedding of functional layer of endometrium
• vasoconstriction within basal layer
• coagulation cascade
• muscle contraction of myometrium compressing uterus and vessels

Question 10

How effective is the mirena for menorrhagia?

Answer 10

90% of cases but may take up to 6 months to work

Question 11

How effective is ablation for treatment of menorrhagia?

Answer 11

97% effective

Question 12

list 4 disadvantages of ablation for treatment of menorrhagia

Answer 12

still require contraception (if fall pregnant risk of placentation issue)
may require repeat procedure
risks of procedure itself
cannot easily sample endometrium in future (risk of endometrial cancer)

Question 13

What regimen of SSRI would you use as first line treatment for someone with PMS?

Answer 13

10mg citalopram in luteal phase e.g day 15 -28

Question 14

List 5 advantages of uterine artery embolisation of treatment of fibroids

Answer 14

• avoid surgery/anaesthesia
• shorter hospital stay
• potentially fertility sparing
• potentially cheaper than surgical management
• shorter recovery time

Question 15

list 5 disadvantages of uterine artery embolisation (when cf myomectomy)

Answer 15

• unproven for fertility sparing
• more post procedure pain than surgical management
• higher re-operation rate
• requires arterial anatomy compatible with embolisation
• exposure to radiation

Question 16

give 2 examples of 1st generation endometrial ablation methods

Answer 16

diathermy loop

roller ball ablation

Question 17

Give 2 examples of 2nd generation endometrial ablation methods

Answer 17

microwave ablation

impedance control ablation

Question 18

List 5 absolute contraindications to endometrial ablation

Answer 18

• pregnancy
• endometrial hyperplasia/cancer
• active genital tract infection
• previous myomectomy or classical c/s (as may weaken myometrium)
• small uterus (<4cm)

Question 19

List 3 relative contraindication to endometrial ablation

Answer 19

• uterine pathology such as septum
• uterus >10cm
• condition predisposing to malignancy e.g. LYNCH syndrome