Menstrual Disorders

Question 1

What is the normal loss of blood during a menstrual cycle?

Answer 1

Less than 80ml over 7 days - 16 tsp
Average is 30-40ml
Average duration is 2-7 days

Question 2

What is the average length of the menstrual cycle?

Answer 2

28 days

Question 3

When is the average menarche?

Answer 3

10-16 years, average is 12 years

Question 4

What is the average age for menopause?

Answer 4

50-55 years

Question 5

What are disturbances of menstruation?

Answer 5

Menstrual frequency
Irregular menstrual bleeding - absent or irregular
Abnormal duration of flow
Abnormal menstrual volume

Question 6

What are the normal and abnormal limits of frequency of periods?

Answer 6

Frequent is under 24 days
Normal is 24-38
Infrequent is more than 38 days

Question 7

What are the normal and abnormal limits of regularity of period?

Answer 7

Absent/ amenorrhoea
Regular is less than 20 days variation in 12 months and irregular is more than 20 days

Question 8

What are the normal and abnormal limits of volume of periods?

Answer 8

Heavy is more than 80ml
Normal is 5-80ml
Light is less than 5ml

Question 9

What is the definition of heavy menstrual bleeding?

Answer 9

Bleeding over 80ml over 7 days and/ or need to change menstrual products every one to two hours and/ or bleeding through clothes
Affecting patients QoL

Question 10

What is a common health complication of heavy menstrual bleeding?

Answer 10

Anaemia

Question 11

What are some uterine and ovarian pathologies causing HMB?

Answer 11

Uterine fibroids
Endometrial polyps
Endometriosis and adenomyosis
PID and pelvic infection
Endometrial hyperplasia or carcinoma
Polycystic ovary syndrome

Question 12

What are some systemic disease which can cause HMB?

Answer 12

Coagulation disorders - Willebrand disease
Hypothyroidism
Liver or renal disease

Question 13

What are some iatrogenic causes of HMB?

Answer 13

Anticoagulation treatment
Herbal supplements - ginseng, ginkgo and soya
Intrauterine contraceptive device (CU IUD)

Question 14

What does PALM COEIN stand for?

Answer 14

Polyps, Adenomyosis, Leiomyoma/ fibroid and Malignancy
Coagulopathy, Ovulation dysfunction, Endometrium, Iatrogenic and Not classified

Question 15

What are fibroids?

Answer 15

Non cancerous growths made of muscle and fibrous tissue
Also called myoma and leiomyoma

Question 16

What is the presentation of fibroids?

Answer 16

May be asymptomatic
HMB, pelvic pain, urinary symptoms, pressure symptoms, backache, infertility and miscarriage

Question 17

How are fibroids diagnosed?

Answer 17

US

Question 18

What is the management for fibroids?

Answer 18

HMB and small - COCP, POP and Mirena
Large and fertility preservation - embolization and myomectomy
Submucosal - hysteroscopic resection
Hysterectomy

Question 19

What is endometriosis?

Answer 19

Endometrial tissue present outside the lining of the uterus
During menstruation this ectopic tissue behaves the same as endometrium and bleeds
Affects women of reproductive age

Question 20

What are the symptoms of endometriosis?

Answer 20

Painful menstrual cramps that get worse over time, pain during and after intercourse, lower back pain, painful bowel movements/ urination, abnormal bleeding and diarrhoea, nausea and blotting

Question 21

What are the stages of endometriosis?

Answer 21

Minimal - small patches, surface lesions or inflammation in pelvic cavity
Mild - infiltrates pelvic organs
Moderate - peritoneum
Severe - pelvic organs and ovaries

Question 22

How is endometriosis diagnosed?

Answer 22

Pelvic examination
US and diagnostic laparoscopy

Question 23

What are the management options for endometriosis - medical?

Answer 23

COCP, POP, Mirena IUS, depot provera and GnRH analogues

Question 24

What is the surgical management for endometriosis?

Answer 24

Ablation, hysterectomy endometrioma excision and pelvic clearance hysterectomy
Surgery may be needed for fertility treatment

Question 25

What is adenomyosis?

Answer 25

Endometrium becomes embedded in the myometrium HMB and significant dysmenorrhoea May respond to hormones but definitive treatment is hysterectomy

Question 26

What are endometrial polyps?

Answer 26

Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into the endometrium Mostly benign

Question 27

How is endometrial polyps diagnosed and managed?

Answer 27

US or hysteroscopy Polypectomy

Question 28

What is the management of HMB?

Answer 28

History, pelvic exam, clotting profile, thyroid function, pelvic US, laparoscopy and management options Biopsy if above 44 years old

Question 29

What are some non-hormonal treatments for menstrual disorders?

Answer 29

Mefenamic acid, tranexamic acid and GnRH analogues Endometrial ablation, fibroid embolization and hysterectomy

Question 30

What does tranexamic acid do?

Answer 30

Antifibrinolytic Reduces blood loss by 60%

Question 31

What does mefenamic acid do?

Answer 31

Prostaglandin inhibitor Reduces blood loss by 30% and pain

Question 32

Describe endometrial ablation

Answer 32

Permanent destruction of endometrium using different energy sources Under hysteroscopic vision or thermal balloon and radio frequency

Question 33

What are the pre-requests for endometrial ablation?

Answer 33

Uterine cavity length more than 11cm Submucosal fibroids less than 3cm Previous normal endometrial biopsy

Question 34

What are the types of surgical removal of the uterus?

Answer 34

Abdominal, vaginal and laparoscopic - LAVH and TLH Total - cervix and uterus removed Subtotal - uterus and cervix left

Question 35

What are the risks of hysterectomy?

Answer 35

Infection, DVT, bladder, bowel, vessel injury, altered bladder function and adhesions

Question 36

What are the advantages and disadvantages of oophorectomy?

Answer 36

Immediate menopause - recommend HRT till age 50 Reduces risk of subsequent ovarian cancer

Question 37

What is amennorhoea?

Answer 37

Infrequent, absent or abnormally light menstruation

Question 38

What are the causes of amennorrhoea?

Answer 38

Life changes (stress, eating disorders, obesity and exercise), hormones, primary ovarian insufficiency, polycystic ovarian disease, hyperprolactinemia, thyroid disorders and obstructions

Question 39

What is polycystic ovary syndrome?

Answer 39

Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met US appearance of ovary Biochemical hyperandrogenism Clinical hyperandrogenism

Question 40

What is polycystic ovary syndrome associated with?

Answer 40

Associated with infertility and obesity Results in amenorrhoea

Question 41

What is the management for polycystic ovary syndrome?

Answer 41

Lifestyle adjustments - normal BMI Symptom based treatment 3 withdrawal bleeds required to prevent hyperplasia COCP, POP and Mirena IUS

Question 42

What is dysfunctional uterine bleeding (DUB)?

Answer 42

Common disorder of excessive uterine bleeding affecting premenopausal women Underlying physiology is ovarian hormonal dysfunction Exclude PALM COEIN

Question 43

What is the management for dysfunctional uterine bleeding (DUB)?

Answer 43

GnRh analogues - cause a pseudo menopause Up to 6 months therapy Add back HRT till patient is confirmed menopausal