Menstrual Disorders

Question 1

How long is the average menstrual cycle?

Answer 1

28 days

Question 2

How long does menstruation last?

Answer 2

2-7 days

Question 3

How much blood is lost during average menstruation?

Answer 3

30-40mls but less than 80mls over seven days is considered normal

Question 4

Menarche?

Answer 4

First time a girl starts her period

Question 5

What is the usual age for menarche?

Answer 5

10-16yrs

->average 12yrs

Question 6

When does menopause usually happen?

Answer 6

50-55yrs

Question 7

For menstrual cycle to be termed frequent, normal and infrequent, how may days would the cycle need to last?

Answer 7

Frequent = <24 days
Normal= 24-38 days
Infrequent= >38 days

Question 8

Heavy menstrual bleeding?

Answer 8

Difficult to quantify but some of the following:

-80mls over 7 days in someone with a regular cycle
-needing to change a menstrual product every 2 hours
-passage of clots >2.5cm
-bleeding through clothes

Question 9

If someone is passing a lot of clots throughout the day, what are they at risk of?

Answer 9

Anaemia

Question 10

List some uterine/ovarian pathologies which can cause heavy menstrual bleeding.

Answer 10

Uterine fibroids
Endometrial polyps
Endometriosis
Pelvic inflammatory disease
Endometrial hyperplasia/carcinoma
Polycystic ovarian syndrome

Question 11

List some systemic diseases and disorders which can cause heavy menstrual bleeding.

Answer 11

Coagulation disorder (e.g. Willebrand disease)
Hypothyroidism
Liver or renal disease

Question 12

What are some other potential causes of heavy menstrual bleeding?

Answer 12

Anticoagulant treatment
Herbal supplements (ginseng, gingko and soya)
Intrauterine contraceptive device

Question 13

What are fibroids?

Answer 13

Non-cancerous growths made of muscle and fibour tissue

Question 14

What are the symptoms of fibroids?

Answer 14

Can be asymptomatic
Heavy menstrual bleeding
Pelvic pain
Urinary symptoms
Pressure symptoms
Backache
Infertility
Miscarriage

Question 15

What investigation is used to make a diagnosis of fibroids?

Answer 15

Ultrasound

Question 16

Management of fibroids?

Answer 16

Symptom based

For HMB +/- small fibroids- COCP, POP Mirena

Large fibroids and fertility preservation- fibroid embolization, myomectomy

Submucosal fibroids- hysteroscopic fibroid resection

Question 17

If medical treatment of fibroids fails or the patient refuses, which procedure can be done?

Answer 17

Hysterectomy

Question 18

Endometriosis?

Answer 18

Endometrial tissue present outside the lining of the uterus

->during menstruation, this ectopic tissue behaves the same as endometrium and bleeds

Question 19

How can endometriosis present?

Answer 19

HMB
Most often presents with pelvic pain

->multi-system involvement, can be devastating as greatly affects quality of life

Question 20

What can endometriosis cause?

Answer 20

Infertility

Question 21

Symptoms of endometriosis?

Answer 21

Painful menstrual cramps that get worse over time
Lower back pain
Abnormal bleeding or spotting between periods
Pain during and after sex
Painful bowel movements/urination
Diarrhoea
Nausea
Blotting

->very hard to diagnose due to the symptoms. Commonly said it’s normal or heavy periods, often IBS if bowel symptoms but need to remember IBS is a diagnosis of exclusion so need to rule out endometriosis first

Question 22

Summarise the stages of endometriosis.

Answer 22

Stage 1- minimal

Stage 2- mild, more widespread and starting to infiltrate pelvic organs

Stage 3- moderate, peritoneum or other structures. Sometimes scarring and adhesions

Stage 4- severe, infiltrative, affecting many pelvic organs and ovaries, often with distortion of the anatomy and adhesions

Question 23

How is a diagnosis of endometriosis made?

Answer 23

Ultrasound
Diagnostic laparoscopy

Question 24

What are the management options for endometriosis?

Answer 24

Medical
Surgical
Analgesia

Question 25

Medical management of endometriosis?

Answer 25

COCP POP Mirena IUS Depot prvera GnRH Analogues

Question 26

Surgical management of endometriosis?

Answer 26

Ablation Hysterectomy endometrioma excision Pelvic clearance Hysterectomy

Question 27

Adenomyosis?

Answer 27

A condition where the endometrium becomes embedded in the myometrium

Question 28

Symptoms of adenomyosis?

Answer 28

Heavy menstrual bleed May be significant dysmenorrhoea (cramps)

Question 29

What is the definitive treatment of adenomyosis?

Answer 29

Hysterectomy ->may respond to hormone treatment partially

Question 30

Endometrial polpys?

Answer 30

Overgrowth of the endometrial lining, mostly benign

Question 31

How is diagnosis of endometrial polyps made?

Answer 31

Ultrasound or hysteroscopy

Question 32

Management of endometrial polyps?

Answer 32

Polypectomy

Question 33

What are some things to do when a patient presents with heavy menstrual bleeding?

Answer 33

Thorough history Pelvic examination Clotting profile Thyroid scan Pelvic ultrasound Laparoscopy if endometriosis is suspected

Question 34

What are some of the hormone treatment options for menstrual disorders?

Answer 34

Mirena IUS COCP POP Depot provera

Question 35

What are some of the non-hormone treatment options for menstrual disorders?

Answer 35

Mefenamic acid Tranexamic acid GnRh analogues Endomometrial ablation Fibroid embolization Hysterectomy

Question 36

What is the purpose of tranexamic/mefenamic acid?

Answer 36

Reduces blood loss ->TA by 60%, MA by 30% They do not regulate cycles

Question 37

What are the benefits of hormonal contraception in the management of menstrual conditions?

Answer 37

Makes period light, more regular and less painful

Question 38

What are the benefits of IUS or Depo-Prevera in the management of menstrual conditions?

Answer 38

Reduces bleeding May cause irregular bleeding Some women will be amenorrhagic

Question 39

What happens in endometrial ablation?

Answer 39

Permanent destruction of endometrium using different energy sources

Question 40

What are some of the pre-requisites for endometrial ablation?

Answer 40

Uterine cavity length <11cm Sub mucous fibroids <3cm Previous normal endometrial biopsy

Question 41

Hysterectomy?

Answer 41

Surgical removal of the uterus

Question 42

Total hysterectomy?

Answer 42

Cervix and uterus removed

Question 43

Subtotal hysterectomy?

Answer 43

Uterus removed, cervix left

Question 44

Hysterectomy can be done abdominally, vaginally or laparoscopically. What is the preferred choice these days?

Answer 44

Laparoscopic ->especially if smaller uterus and no complications. Recovery is quicker.

Question 45

If the patient has had a total hysterectomy, do they need to keep getting smears?

Answer 45

No, as cervix has been removed. Those with subtotal hysterectomy's still will need smears

Question 46

Risks of hysterectomy?

Answer 46

Infection DVT Bladder/bowel/vessel injury Altered bladder function Adhesions

Question 47

What is one guarantee of a hysterectomy?

Answer 47

Amenorrhoea- no periods

Question 48

Salpingo-oophorectomy?

Answer 48

Removal fallopian tubes and ovaries

Question 49

When may the ovaries and the uterus be removed?

Answer 49

Women with endometriosis or presence of ovarian pathology

Question 50

What is a disadvantage of ooporectomy?

Answer 50

Immediate menopause

Question 51

Which drug is recommended until the age of 50 for anyone who has to get an oophorectomy?

Answer 51

HRT

Question 52

What is an advantage of an oophorectomy?

Answer 52

Reduces risk of subsequent ovarian cancer

Question 53

Oligo/menorrhea?

Answer 53

Infrequent, absent or abnormally light menstruation

Question 54

There are manyyyyy causes of oligo/amennorhea. List some for awareness :)

Answer 54

Life changes: stress, ED/malnourishment, obesity, intense exercise Hormones: POP, mirena, depot injection Primary ovarian insufficiency Hyperprolactinemia Prolactinomas (adenomas on the anterior pituitary gland) Thyroid disorders: Graves Obstruction of the uterus, cervix and/or vagina

Question 55

What is polycystic ovary syndrome associated with?

Answer 55

Obesity Infertility

Question 56

What are the three main features of PCOS?

Answer 56

Irregular periods Excess androgen (hyperandrogegism) Polycystic ovaries ->2/3 required for diagnosis

Question 57

What are some features of excess androgen (hyperandrogegism)?

Answer 57

Excess facial or baby hair due to high levels of testosterone

Question 58

Management of PCOS?

Answer 58

Lifestyle adjustment with aim to achieve normal BMI

Question 59

Patients with PCOS need to have at least 3 periods a year. Why? How is this done?

Answer 59

To reduce risks of endometrial hyperplasia Can be done with either COCP, POP or mirena IUS

Question 60

What is dysfunctional uterine bleeding?

Answer 60

Common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable uterine or systemic disease ->treatment based on severity of symptoms