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Menstrual disorders Flashcards

1
Q

What are the possible locations of endometrial foci?

A
  1. Ovary
  2. Rectovaginal pouch
  3. Rectum
  4. Uterosacral ligaments
  5. Umbilicus
  6. Bladder
  7. Vagina
  8. Lower abdominal scars
  9. Lungs
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2
Q

How does endometriosis bring about pain?

A

Foci bleed during menstruation, the blood causing irritation, provoking fibrosis, adhesions and subfertility

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3
Q

What are the possible causes of endometriosis?

A
  1. Retrograde menstruation
  2. Genetics
  3. Manual removal of the placenta/failure of proper CCT
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4
Q

Cycles of what length are considered ‘normal’?

A

25-35 days

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5
Q

A normal length of menstruation would be:

A

<8 days

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6
Q

How may an irregular period be defined?

A

Too frequent, or infrequent (less or more than 25-35 days) or of variable length

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7
Q

What are irregular and inter-menstrual bleeding caused by in the absence of pathology?

A

Anovulatory cycles. Treated with COCP or IUS

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8
Q

What are the possible causes of PCB?

A

Vagina causes = vaginitis; carcinoma

Cervical causes = carcinoma; cervicitis; trauma; ectropion; polyps

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9
Q

How is HMB technically defined?

A

> 80ml blood loss per period (i.e. the max a woman can tolerate w/out becoming iron-deficient anaemic)

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10
Q

How should HMB actually be assessed in clinic? (i.e. don’t use the technical definition because menstrual blood loss is rarely measured)

A

Subjectively, based on how the HMB affects her QoL

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11
Q

What proportion of hysterectomies do HMB account for?

A

> 50%

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12
Q

What are the vaginal causes of PCB?

A

Vaginitis and carcinoma

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13
Q

What are the cervical causes of PCB?

A

Carcinoma, cervicitis, trauma, ectropion, polypos

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14
Q

What are the causes of HMB?

A

Systemic causes = hypothyroidism + platelet disorders, e.g. von Willebrand’s

Pelvic causes =

1) Fibroids (30%)
2) Polyps (10%)
3) Endometriosis
4) Adenomyosis
5) Pregnancy/incomplete miscarriage (esp. in young girls and when they present with only one episode)
6) Endometrial cancer

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15
Q

What are the systemic causes of HMB?

A

Hypothyroidism + platelet disorders, e.g. von Willebrand’s

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16
Q

What are the pelvic causes of HMB?

A

1) Fibroids (30%)
2) Polyps (10%)
3) Endometriosis
4) Adenomyosis
5) Pregnancy/incomplete miscarriage (esp. in young girls and when they present with only one episode)
6) Endometrial cancer

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17
Q

When is an endometrial biopsy indicated in HMB?

A

1) Endometrial thickness >10mm (on TVUS)
2) Polyp suspected
3) >40 with recent onset menorrhagia
4) >40 + IMB
5) Not responded to treatment

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18
Q

What is the management for women with HMB who are TRYING TO CONCEIVE?

A

Tranexamic acid + NSAIDs

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19
Q

How does tranexamic acid work?

A

An anti-fibrinolytic, taken during menstruation only, it reduces fibrinolytic activity and can reduce blood loss by >50%

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20
Q

What is the management for women with HMB who are NOT trying to conceive?

A

1st = Progestogen IUS (will both reduce volume loss and regulate the loss)
2nd = Tranexamic acid + NSAIDs / COCP
3rd =Progestogens (high OS dose or IM) / GnRH analogs +/- ‘add-back’ HRT
4th = hysteroscopy (endometrial ablation) /hysterectomy

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21
Q

How may endometriosis present?

A

1) Deep dyspareunia
2) Dysmenorrhoea
3) HMB
4) Asymptomatic - first presentation might be the acute pain of a ruptured chocolate cyst
5) Subfertility
6) Chronic pelvic pain
7) Dysuria at menses
8) Dychezia at menses

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22
Q

How may endometriosis appear on laparoscopy?

A

1) Red dots
2) Black ‘powder-burn’
3) White scarring

Black powder-burn and white scarring indicate less active lesions

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23
Q

What is adenomyosis?

A

Presence of endometrium within the myometrium

24
Q

In whom are fibroids more common?

A

1) Older women
2) Those with a FHx
3) Afro-Carribbean women

25
What are the different classification of fibroids based on site?
1) Intramural 2) Subserosal 3) Submucosal 4) Cervical
26
What drives fibroid growth?
Oestrogen + progesterone (hence repression post-menopause)
27
How may fibroids present?
1) Asymptomatic 2) Menorrhagia 3) Dysmenorrhoea 4) IMB 5) PCB 6) Pain (torsion/red degeneration) 7) Subfertility
28
What type of fibroid might cause IMB?
Submucosal
29
When might fibroids cause pain?
1) Torsion of pedunculate fibroids 2) Red degeneration - that is degeneration of the fibroid due to inadequate blood supply that then causes haemorrhage and necrosis resulting in pain and uterine tenderness
30
How should fibroids be investigated?
USS, laparoscopy or MRI if difficulty in distinguishing them from an ovarian mass or adenomyosis + a FBC
31
What is fibromatous erythrocytosis syndrome?
When fibroids secrete EPO (only occurs in some instances), and this causes polycythaemia
32
What are the complications of fibroids?
1) Calcification post-menopause 2) Torsion 3) Red degeneration 4) Malignant transformation
33
What proportion of fibroids malignantly transform?
0.1% will transform into leiomyosarcoma
34
How can fibroids be managed medically?
GnRH agonists - e.g. goserelin. Shrinks the fibroid
35
How can fibroids be managed surgically?
1. Hysteroscopic resection 2. Hysteroscopic/open myomectomy (if fertility desired) 3. Uterine artery embolization (UAE) 4. Microwave endometrial ablation (MEA) 5. Hysterectomy
36
What should be given with the GnRH agonists for the medical management of fibroids?
Tibolone (HRT) or raloxifene (SERM), because bone demineralisation can occur
37
How long can fibroid be medically managed for?
6-12 months. Therefore, only tend to be used in women whom are peri-/near-menopausal, for pre-op debulk or in those unfit for surgery since upon stopping the medication, the fibroids return
38
What is primary dysmenorrhoea?
Pain during menstruation in the absence of pathology. Therefore tends to be seen in women where the pain begins soon after the onset of menarche, i.e. in adolescence
39
What is secondary dysmenorrhoea?
Pain during menstruation due to pelvic pathology. Therefore tends to be seen in women whom have previously had years of painful periods
40
What are the Sx associated with primary dysmenorrhoea?
Non-gynaecological - e.g. N+V, bloating, migraine
41
What are the Sx associated with secondary dysmenorrhoea?
Gynaecological - e.g. dyspareunia, IMB, HMB
42
What causes should be considered for secondary dysmenorrhoea?
1) Fibroids 2) Endometriosis 3) PID 4) Adenomyosis
43
What is primary amenorrhoea?
Menstruation that has not occurred by age 16 If secondary sexual characteristics have not developed by age 14, cause = likely delayed puberty, but if secondary sexual characteristics have developed cause might be imperforate hymen, transverse vaginal septum, absent vagina or absent/non-functional uterus
44
What is secondary amenorrhoea?
When previously normal menstruation ceases for >6/12
45
What is oligoamenorrhoea?
Menstruation every 35 days to 6 months
46
What are the causes of secondary amenorrhoea?
Non-pathologcial = 1) Pregnancy; 2) Lactation; 3) Menopause; 4) Drugs Pathological = 1) Anorexia; 2) Hyperprolactinaemia; 3) Hypo/hyperthyroidism; 4) Adrenal tumours; 5) PCSO; 6) Premature ovarian failure; 7) Asherman's syndrome; 8) Cervical stenosis
47
What investigations should be carried out to investigate amenorrhoea?
``` Prolactin TFTs FSH Androgens USS Pregnancy test ```
48
What are the diagnostic criteria of PCOS?
2 or more of: 1) Polycystic morphology on USS - multiple (>12), small (2-8mm) follicles in an enlarged ovary (>10ml volume) 2) Irregular periods >5 weeks part 3) Hirsutism
49
What are the reasons a person may be referred for hysteroscopy?
1. PMB 2. Bleeding on tamoxifen 3. Unscheduled bleeding on HRT 4. IMB 5. HMB 6. Subfertility and recurrent miscarriage 7. Insertion/removal of coils + lost coils 8. Assessment/resection of known polyps/fibroids 9. Thickened endometrium 10. Sterilisation 11. Division of adhesions
50
What are the benefits of flexible hysteroscopy?
1) Reduced pain
51
What are the benefits of rigid hysteroscopy?
1) Shorter procedure time 2) Better quality images 3) Cheaper 4) Fewer failure procedures
52
What are the risks of hysteroscopy?
1. Bleeding 2. Fainting 3. N&V (cervical irritation) 4. Uterine/cervical trauma (uterine perforation rate = 0.002-1.7%)
53
How should the cervix be prepared for hysteroscopy?
LA may be used - although it does not appear to reduce the pain associated with the procedure, it does appear to reduce the risk of vasovagal episodes (+ used to 'soften' the cervix'). Alternative cervical softeners (prostaglandins) may be used, but you didn't see that in clinic, even those with very resistant, stenosed cervices
54
What is the most common cause of procedural failure in hysteroscopy?
Cervical stenosis
55
What are the common causes of cervical stenosis?
1) Atrophy 2) Null-parity 3) Prior surgery
56
Whom is most likely to be affected by cervical stenosis?
Post-menopausal women
57
How should the uterus be distended in hysteroscopy?
Normal saline (rather than carbon dioxide) - 1) it appears to reduce the risk of vasovagal episodes, 2) the procedure time is quicker and 3) the images are of better quality

Obstetrics & Gynaecology (14 decks)

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