menstrual disorders

Question 1

what is the normal cycle

Answer 1

24-32 days

Question 2

what is regularity

Answer 2

best between 20-40y longer after menarche

okay to have a fluctuation

shorter in pre-menopause

Question 3

mean blood loss

Answer 3

37-43ml/ per period mostly in first 48h

top 10% lose more than 80ml blood per period

3/4 are anaemic

Question 4

factors affecting mean blood loss

Answer 4

age - as you get older you bleed more 40s ealy 50s have heavy periods

genetics - monozygotic twins heavy periods

parity - more children you have the heavier your period

Question 5

Heavy irregular bleeding (metrorrhagia)

Answer 5

no pattern can bleed anytume anyday

Question 6

define absent periods - amenorrhoea

Answer 6

no period 6 months or more

Question 7

what is dysfunctional uterine bleeding

Answer 7

DUB (60%) = primary menorrhagia

Heavy menstrual bleeding with no recognizable pelvic pathology, pregnancy or general bleeding disorders

have to exclude other causes

Question 8

pathology for abnormal uterine bleed (AUB)/ heavy menstrual bleed (HMB)

Answer 8

• Fibroids
• Adenomyosis / endometriosis
  dysfucntional uterine bleeding
• hypothyroidism
• IUCD - copper coils the copper toxicity cause inflammation
• endometrial carcinoma
• clotting abnormalities - von Willebrand’s, thrombocytopenia, platelet disorders, coagulation disorders
• leukaemia.
• polyps
• cervical cancer

Question 9

what qs to ask during clinical assessment for heavy bleeding

Answer 9

the nature of the bleeding

related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms, that might suggest uterine cavity abnormality, histological abnormality, adenomyosis or fibroids

impact on her quality of life

other factors that may affect treatment options (such as comorbidities or previous treatment for heavy menstrual bleeding).

Impact on work/social life - do they miss work

bleeding through clothing - how many pads they change

bed soiling or disrupted
sleep due to heavy bleeding

Question 10

low risk patient wi heavy period

Answer 10

Age <45
No IMB
No risk factors for endometrial cancer
normal BMI 
may jave contraceptional needs

Question 11

low risk clinical assessment

Answer 11

history

examination

1st Ix - FBC

Question 12

who is high risk patient w heavy period

Answer 12

Age >45IMB
Suspected pathology - ie fibroids

Risk factors for endometrial

• diabetes
• obesity
• PCOS
• strong FH of breast cancer or breast syndromes

cancer

Question 13

high risk pt assessment for heavy periods w suspected submucosal fibroids, polyps or endometrial pathology

Answer 13

History
Examination
FBC

High risk
hysteroscopy - biopsy
1) they have symptoms such as persistent intermenstrual bleeding or

2) they have risk factors for endometrial pathology (see below).

if hysteroscopy rejected suggest under anaesthaseia if still rejected suggest pelvic US

Question 14

symptomatic treatment for regular heavy periods not hormonal

the treatment for no identified pathology, fibroids less than 3cm or suspected or diagnosed adenomyosis

Answer 14

tranexamic acid - procoagulant - only take it when period is heavy

plus mefenamic acid - non steroidal inhibits PG synthesis, analgesic, anitimflammatory agent

GIVE BOTH

Question 15

hormonal treatment for heavy periods

the treatment for no identified pathology, fibroids less than 3cm or suspected or diagnosed adenomyosis

Answer 15

FIRST LINE
Mirena system (progestogen laden IUS) - BEST ONE 

Progestogen Only Pill (POP)

LARC (long acting reversible contraceptives) such as:

Implant

Depo-Provera - 3 monthly injection

Question 16

If they want regular bleeding but treat the heavy bleeding

Answer 16

COCP

Question 17

if fribroids are diagnosed what medical treatment can u suggest

Answer 17

GnRH analogues - downregulate the ovaries put women in temp medical menopause

Question 18

if polyps are diagnosed causing the heavy bleed Mx

Answer 18

Hysteroscopic removal of polyps (MYOSURE) - endometrium and uterine cavity intact

Question 19

if fibroids are diagnosed causing the heavy bleed more than 3cm

Answer 19

Myomectomy for fibroids - can still have children BUT depends on clincial circumstances

fibroid/Uterine artery embolization - not suitable for women who wants to have children

Question 20

heavy bleeding but family complete CONSERVATIVE SURGERY

Answer 20

endometrial ablation (NOVASURE)

Question 21

family complete definitiv surgery heavy bleed

Answer 21

Hysterectomy (laparoscopic or open)

Question 22

Excessively heavy menstrual bleeding may be controlled in the short term using the following medications:

Answer 22

tranxemaic acid - bridge

Norethisterone: 5mg po tds for up to 7 days. Can be used in a 3-weeks-on, 1-week-off pattern for 3-4 months to temporise, for example where patient is on waiting list for treatment.

GnRH analogues: Monthly (or quarterly, depending on preparation) injection to downregulate the cycle and induce temporary ‘medical menopause’. Often used to stop very heavy periods in the presence of fibroids, to allow for correction of anaemia and iron stores in preparation for another intervention.

Question 23

role of tranexamic acid

Answer 23

Inhibit plasminogen activation (inhibit tPA, and uPA), thus reduce fibrinolysis

Reduces MBL by 50%

Question 24

SEs of tranexamic acid

Answer 24

Nausea, dizziness, tinnitus, rash, abdominal cramp

Question 25

NSAID role

Answer 25

Inhibit the production of PG and inhibit the binding of PGE2 to its receptor Reduces MBL by 20-44.5%

Question 26

SEs of NSAID

Answer 26

gastrointestinal (50%) usually mild. Dizziness and headaches 20%, deranged liver function, asthma, renal disease.

Question 27

when should testing for coagulation disorders in HMB women should be considered

Answer 27

have had heavy menstrual bleeding since their periods started and have a personal or family history suggesting a coagulation disorder.

Question 28

when to consider endometrial biopsy at the time of hysteroscopy

Answer 28

women with persistent intermenstrual or persistent irregular bleeding, and women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome women taking tamoxifen women for whom treatment for heavy menstrual bleeding has been unsuccessful.

Question 29

when to offer pelvic US w heavy menstrual bleeding

Answer 29

their uterus is palpable abdominally history or examination suggests a pelvic mass examination is inconclusive or difficult, for example in women who are obese.

Question 30

when to offer transvaginal US w heavy bleeding

Answer 30

significant dysmenorrhoea (period pain) or a bulky, tender uterus on examination that suggests adenomyosis.

Question 31

what do u do if a woman declines transvaginal US

Answer 31

transabdominal US or MRI

Question 32

pharmacological hormonal non-hormonal surgical treatment IF FIBROIDS ARE MORE THAN 3 CM

Answer 32

pharmacological: non-hormonal: tranexamic acid NSAIDs ``` hormonal: LNG-IUS combined hormonal contraception cyclical oral progestogens uterine artery embolisation ``` surgical: uterine artery embolisation myomectomy ONLY MX TO IMPROVE FERTILTY hysterectomy.

Question 33

signs of anaemia

Answer 33

``` pale conjunctiva glossitis - inflammation of the tongue koilonychia pale mucous membranes sores in the corner of the mouth ```

Question 34

role of oestrogen during the follicular phase

Answer 34

thins the cervical mucus | thickens the endometrium

Question 35

during menstruation which layer is shed

Answer 35

only the functional layer the basal layer stays intact

Question 36

role of progestrone what produces before implanatation where is it produced in the later stages of pregnancy

Answer 36

progestrone allow endometrium to become receptive to implantation of a balstocyst and prevents menstruation occuring - inhibits LH and FSH production - initiation of the secretory phase of the endometrium - increase in basal body temperature placenta

Question 37

which Sx are present in a woman whos about to ovulate

Answer 37

increase in basal body temperature thinning of cervical mucous

Question 38

what is the proliferative phase and when does it occur

Answer 38

days 1 - 5 | increased levels of oestrogen driving repair and growth of the functional endometrial layer

Question 39

what is the secretory phase and when does it occur

Answer 39

begins after ovulation when the ruptured graafian follicle develops into the corpus luteum. days 14-28

Question 40

Role of LH

Answer 40

formation and maintenance of the corpus luteum thinning of the Graafian follicles membrane

Question 41

what is endometriosis

Answer 41

chronic oestrogen-dependent condition growth of ectopic endometrial tissue outside of the uterine cavity

Question 42

clinical features of endometriosis

Answer 42

- chronic pelvic pain - worse at the time if menstruation or just prior to it - dysmenorrhoea - pain often starts days before bleeding - deep dyspareunia - subfertility - non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) - on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be see

Question 43

Ix for endometriosis

Answer 43

GOLD STANDARD - laparoscopy

Question 44

Mx for endometriosis

Answer 44

FIRST LINE - NASIDs and/or paracetamol COCP or POP tried if analgesia/hormonal Mx fails or fertility is a priority do SURGERY GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 45

routes of administration for HRT

Answer 45

oral - low dose oestrogen ``` transdermal - gel (oestrogen only) - patch (oestrogen/combined oestrogen and progestrone - spray orestrogen only ``` - injected beneath the skin Sequential HRT- starting within 12 months of the last period to minimise the risk of irregular bleeding patterns. Continuous Combined HRT (cc-HRT)- not had a period for 12 months. women can experience some irregular bleeding in the first 3 months of treatment. Tibolone - is its own class of HRT. It's risk profile is broadly the same as ccHRT. Vaginal Oestrogen – Vaginal pessaries or creams can help with vaginal and urinary symptoms

Question 46

types of regimen for combined HRT

Answer 46

1. Monthly cyclical regimen — oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days. 2. Three-monthly cyclical regimen — oestrogen is taken daily and progestogen is given for 14 days every 13 weeks. 3. Continuous combined regimen — oestrogen and progestogen are taken daily.

Question 47

oestrogen related adverse effects

Answer 47

Fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, and dyspepsia.

Question 48

progestrone related adverse effects

Answer 48

Fluid retention, breast tenderness, headaches or migraine, mood swings, premenstrual syndrome-like symptoms, depression, acne vulgaris, lower abdominal pain, and back pain. They tend to occur in a cyclical pattern during the progestogen phase of cyclical HRT.

Question 49

2 main hormones used in HRT

Answer 49

oestrogen – types used include estradiol, estrone and estriol progestogen – a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel

Question 50

define menopause

Answer 50

Menopause is defined when a woman aged 45 or over has amenorrhoea for at least 12 months. Her last period naturally. Ovaries are removed at surgery Radiotherapy Chemotherapy

Question 51

sx of menopause

Answer 51

- menstrual irregularity - hot flushes - sweats - vaginal dryness - dyspareunia, recurrent UTIs mood changes - - irritable - loss of concentration - anxiety - low mood - depression - sleep disturbance, - loss of libido - joint and muscle ache pain

Question 52

diagnosis of menopause

Answer 52

clinical * No blood test is needed after 45 years of age but just treat symptoms only * Could be done between 40 and 45 years of age - if have irregular periods or considering preg-nancy * The test should be done for anyone before the age of 40 with perimenopausal symptoms * This is confirmed when serum FSH levels are more than 40 MIU/ML at least twice 4-6 weeks apart - then can say woman has menopause FSH levels - high FBC TFT Glucose

Question 53

what conditions may be associated with menopause

Answer 53

``` CVS disease osteoporosis urogenital atrophy redistribution of body fat alzheimers ```

Question 54

Mx of vasomotor symptoms short term

Answer 54

HRT upto 5 years

Question 55

what does the oestrogen do in the HRT and in who can we use it

Answer 55

- relieves hot flushes - prevents vaginal Sx - maintains bone strength

Question 56

what does combined HRT do and in who do we use it

Answer 56

women who have nod had a hysterectomy oestrogen can stimulate the endometrium leading to cancer maybe progesterone counteract the effects of oestrogen by shedding the endometrium and protect the endometrium

Question 57

which HRT may result in a bit of bleed

Answer 57

sequential HRT - monthly bleeds 14 days every 13 weeks - bleeds every 3 months continuous - no bleeds

Question 58

what is tibolone

Answer 58

oestrogen progestrone testosterone | - relieves menopausal symptoms, prevents bone loss and may improve interest in sex

Question 59

SEs ass w HRT

Answer 59

``` breast tenderness leg cramps nausea bloatedness irritability depression irregular bleeding/spotting ```

Question 60

diagnosis of premature ovarian insuffieciency

Answer 60

- no periods or infrequent ones AND elevated FSH levels on 2 blood samples take 4-6 weeks apart

Question 61

Mx of premature ovarian insufficiency

Answer 61

hormonal treatment w HRT or a combine hormonal contraceptive

Question 62

what are endometrial polyps made of

Answer 62

- benign lesions of surface endometrium - appear at any age - subfertility fibrous tissue covered by columnar epithelium glands

Question 63

Sx Ix Mx of endometrial polyps

Answer 63

asymptomatic - abnormal uterine bleeding - intermenstrual/HMB/PMB - US scan -> best detected in the secretory phase of the menstrual cycle Mx - dilatation and curretage

Question 64

Types of fibroids and ass sx Ix

Answer 64

submucosal - distort the pelvic organs/ HMB/infertility subserosal - pressure on adjacent organs and cause bowel and bladder symptoms intramural US of abdomen hysteroscopy laparoscopy

Question 65

fibroids are more common in who

Answer 65

``` most common in 30-50 afro carribean ethnicity obesity nulliparous (PCOS) diabetes hypertension FH of fibroids. Pregnancy causes enlargement and the menopause is associated with involution. age ```

Question 66

what is 'red degeneration' fibroids

Answer 66

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply >5cm fibroids occur in pregnancy, after mx with embolisation severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.

Question 67

Sx and signs of fibroids

Answer 67

abnormal uterine bleeding pelvic pain -> acute - torsion or prolapse dysparaeunia abdominal pain worse during mens bloating/feeling full in the abdomen pressure - palpable in abdomen, bladder, rectum - increased urinary frequency, tenesmus - change in bowel habit complciations of pregnancy -> recurrent miscarriage SUBMUCOUS fibroids, obstruct PPH preterm labour perinatal morbidity infertility

Question 68

what is adenomyosis

Answer 68

characterized by the invasion of endometrial glands and stroma into myometrium with surrounding smooth muscle hyperplasia. pelvic pain and heavy bleeding during menstruation presence of endometrial tissue in the myometrium

Question 69

Ix for adenomyosis

Answer 69

transvaginal US even if pelvis looks normal if contradicted do transabdominal US histological assessment from hysterctomy

Question 70

clinical presentation of endometriosis/adenomyosis

Answer 70

parous women - dysmenorrhea - HMB - Painful intercourse (dyspareunia), - Painful defecation (dyschezia) and - Painful urination (dysuria) - Heavy periods - Lower abdominal pain persistent - IMB and PCB - Epistaxes , rectal bleeding - Little correlation between symptom severity and disease severity

Question 71

microscopic appearance of adenomyosis

Answer 71

whorl-like trabeculated appearance -> dark haemorrhagic spots

Question 72

PMDD

Answer 72

very severe form of premenstrual syndrome (PMS), which can cause many emotional and physical symptoms every month during the week or two before you start your period. It is sometimes referred to as 'severe PMS'. make it difficult to work, socialise and have healthy relationships. In some cases, it can also lead to suicidal thoughts. ``` mood swings feeling upset or tearful feeling angry or irritable feelings of anxiety feeling hopeless feelings of tension or being on edge difficulty concentrating feeling overwhelmed lack of energy less interest in activities you normally enjoy suicidal feelings ```

Question 73

Complications of fibroids

Answer 73

Heavy menstrual bleeding, often with iron deficiency anaemia Reduced fertility Pregnancy complications, such as miscarriages, premature labour and obstructive delivery Constipation Urinary outflow obstruction and urinary tract infections Red degeneration of the fibroid Torsion of the fibroid, usually affecting pedunculated fibroids Malignant change to a leiomyosarcoma is very rare

Question 74

what is primary dysmenorrhoea

Answer 74

no underlying pelvic pathology Excessive endometrial prostaglandin production is thought to be partially responsible. Features pain typically starts just before or within a few hours of the period starting suprapubic cramping pains which may radiate to the back or down the thigh Management NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production combined oral contraceptive pills are used second line

Question 75

secondary dysmenorrhoea

Answer 75

``` underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include: endometriosis adenomyosis pelvic inflammatory disease intrauterine devices* fibroids ```

Question 76

what is premenstrual syndrome

Answer 76

describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle. presence of ovulatory menstrual cycles ``` Emotional symptoms include: anxiety stress fatigue mood swings ``` Physical symptoms bloating breast pain

Question 77

Mx of Premenstrual syndrome

Answer 77

1. mild symptoms can be managed with lifestyle advice - apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates 2. moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP) examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg) 3. severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI) this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)

Question 78

conservative Mx of menopause

Answer 78

- Exercises - Running, Swimming and Yoga are highly recommended - Smoking cessation - Reduced alcohol and coffee intake also helps with symptoms of hot flushes and night sweats. Mediterranean style diet Bio-identical hormones herbal meds vaginal lubricants acupuncture/homeopathy psych Mx - CBT has been proven to elevate the low mood or anxiety

Question 79

Benefits of HRT when is it CI in a pt

Answer 79

most effective Mx for hot flushes and low mood - increase libido - reduce vaginal dryness - prevents osteoporosis - reduce urinary sx oestrogen only increases risk of endometrial combined increases risk of breast Hx of thromboembolism Hx of breast cancer Hx of migraines