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Flashcards in Menstrual disorders Deck (31):
1

Define menorrhagia

>80ml menstrual loss/period

2

Etiology (3 categories and most common)

1. Systemic
->Thyroid
->Coagulopathies
->PCOS
2. Local
->Fibroids
->PID
->Endometrial Ca
->Endometriosis/adenomyosis
->DUB
->Endometrial polyps, endometritis
->Miscarriage
3. Iatrogenic
->IUCD
->Iron deficiency anaemia
->anticoagulants

Most commonly:
->PCOS
->Fibroids
->Miscarriage
->Endometritis
->PID
->DUB
->Polyp

3

Important history in menorrhagia

Gynaecological history->LMP, menarche, cycle length/regularity, heaviness, pap smear, surgical/procedural
Obstetric history
Frequency, inter-menstrual/post coital
Clots, floodigs, ++double sanitary
protection
Lethargy, breathless
Sexual history
Contraceptive use
Menstural pain
Dysmenorrhea
Premenstural pain (endoM)
Hx PCOS + risk of endoM Ca
Thyroid symptoms, clotting
Missed periods, hot flushes

4

Possible explanation to woman who has had tubal ligation, prior was on OCP and now has heavy periods

OCP reduces menstrual loss so may have been hiding her menorrhagia.
Many women blame tubal ligation for heavy periods

5

Is D&C therapeutic

No, it is a diagnostic procedure

6

Physical examination in menorrhagia

General-> including vitals
Thyroid- obese, dry skin, breathless, edema, goiter,
Anemia,
PCOS,
Stigmata of liver disease/coagulopathy
Abdominal
Vaginal/bimanual/pap smear if overdue
Visual fields

7

Investigations in menorrhagia

FBC
Iron studies

Depending on presentation->
LFTs, coagulation
TSH
Prolactin
Gonorrhea/chlamydia
VWF, Factor 7/8 deficiency->important to exclude in the young patients
Pelvic USS/Hysteroscopy/Biopsy in older and younger w/ risk factors (InterM/post-coital bleeding)

8

Management overview for menorrhagia

1. Correct anemia
2. Treat systemic disorders or focal pathology
3. Attempt control by medical therapy
4. If fails consider->ablation, hysterectomy

9

Medical management of menorrhagia

1. Tranexamic acid (80% reduction, taken on heavy bleeding days) + mefenamic acid (50% reduction, commence 5-7 days before menstruation)
2. COCP, Mirena (most effective, 95% reduction in blood loss), long acting progestogens
3. Danazol
4. GnRH agonist

10

Surgical options for menorrhagia

1. Endometrial ablation-> 50% amenorrheic, 40% reduced, 10% unchanged. For mid-late 40s
2. Hysterectomy

11

Role of GnRH agonists in menorrhagia

produce reversible,
temporary menopausal. Preoperative
state= corrects iron deficiency,
-ve size of fibroids,
-ve surgical blood loss

12

Side effects and mechanism of mirena

5 years
Low dose progestogen
Thins endometrium
94% reduction MBL after 3 month

SE:
PV spotting, weight gain, breast tenderness,
expulsion of devices, increased ovarian cysts
formation

13

Following up patient with menorrhagia

2 weeks->review results
Remind to have routine pap smear
If iron deficient->oral iron supplements until heavy bleeding controlled
Review again in 3 months unless problems

14

Requirements for normal menstruation

Hypothalmic function
Pituitary function
Ovarian function
Endometrial function
Patent cervix and vagina

15

Etiology of dysfunctional uterine bleeding

Anovulatory cycles->
Functional ovarian tumor
PCOS
Obesity
Malnutrition
Systemic illness
Thyroid
Adrenal

Other->
OCP
Post/perimenopausal changes

16

Mechanism of DUB

+estrogen proliferation w/o progesterone countering effect
inadequate luteal phase->low progesterone, early menses

17

Pathophysiology of amenorrhea in hypothyroidism

+TRH--> +prolactin=
inhibition of LH/FSH=
anovulation

also +SHBG,
+Testosterone
-ve clearance of estrogen

18

Is a vaginal examination performed on a virgin

No- an abdominal examination is all that is required

19

Managing menorrhagia in adolescent patient

1. Iron-folate supplementation 2-3 months
2. 50ug ethynyl estradiol COCP->be sure to check BP, ask about migraines with aura, history of VE/family
3. Pill has other roles other than contraception
4. Initial SE of N, headache- will generally resolve with continued use
5. Must take every day, same time, pissed pill will lead to breakthrough bleeding
6. Also helpful with menstrual pain, can add mefenamic acid/NSAIDs
7. Other alternative is tranexamic acid, but OCP is easiest. Takes 2-3 cycles to judge effectiveness
8. Review in 3 months. Can continue on the pill until want to have a baby. When becomes sexual active should return to understand contraceptive effects

20

Define primary and secondary dysmenorrhea

Primary->not associated with pelvic patholgy
Secondary->due to pelvic pathology

21

Presentation of primary dysmenorrhea

6-12 months post menarche
Lower abdominal, cramping, ay radiate to back/inner thigh
8-72 hours
Can be associated with nausea, vomiting, diarrhea, fatigue and headache
Usually subsides once menses commences

22

Presentation of secondary dysmenorrhea

Years after menstruation, new complaint in 30s and 40s.
Not always with menstruation alone
May worsen as menses progresses
May be accompanied by irregular heavy bleeding, discharge and dysparaneuria

23

Etiology of secondary dysmenorrhea

Endometriosis
Chronic PID
Polyps
Fibroids
IUCD

Congenital uterine abnormalities
Cervical stenosis
Ovarian pathology

24

History in dysmenorrhea

Age of menarche
Onset
Characetristics
Timing/duration
Associated->fatigue, irritability, dizziness, HA, MV
Exacerbating/relieving->secondary more commonly resistant to NSAIDs
Severity, interference with daily activity
Menstrual history
Post-coital, intermenstrual, vaginal discharge
Sexual history
Obstetric history
Medical, family, social

25

Examination in dysmenorrhea

General inspection
Abdominal
Pelvic
Speculum
Bimanual

Not necessary in young when most likely primary

26

Investigations in dysmenorrhea

Primary->nil required
TVUS
Chlamydia/gonorrhea swabs/serology
FBC
Pregnancy test
Laparoscopy->PID, endometriosus, adhesions
Ca-125 if ovarian mass
MRI/CT if USS equivocal
Hysteroscopy
Pipelle biopsy

27

Red flags in dysmenorrhea

PID
Ovarian cyst with hemorrhage
Ovarian torsion

28

Management of primary dysmenorrhea

1. Reduce risk->smoking cessation, reduce alcohol, maintain healthy weight
2. Ensure not to see menstruation in negative light
3. NSAIDs->naproxen, mefenamic acid or ibuprofen: start day before menses, continue for 48-72 hours
4. COCP->ethinylestradiol30ug COCP
5. Heat packs

29

Pathogenesis of primary dysmenorrhea

Prostaglandins released by endometrial cells at the start of menstruation cause vasoconstriction, muscle contraction and compression of the spiral arteries, leading to myometrial ischaemia. The severity of primary dysmenorrhoea is directly related to the prostaglandin concentration in the menstrual fluid.

30

Dosing of NSAID in primary dysmenorrhea

Ibuprofen->200-400mg PO 3-4 times daily. Max 1600g

Mefenamic acid 500mg tds

Naproxen 500mg PO initial, then 250mg every 6-8 hours

31

Risk factors for primary dysmenorrhea

Early menarche
Prolonged menstrual flow
Smoking
Alcohol
Obesity