Menstrual disorders and HMB

Question 1

What is the length of a normal cycle?

Answer 1

24-32 days

Question 2

What is the average menstrual blood loss?

Answer 2

37-43ml/cycle

Mostly in first 48h

Question 3

Factors affecting MBL

Answer 3

1. Age - heavier post 4th decade of life
2. Genetics - correlation in twins
3. Parity - positive correlation

Question 4

What is the difference between menorrhagia vs. metrorrhagia?

Answer 4

Menorrhagia - heavy regular periods

Metrorrhagia - heavy irregular bleeding

Question 5

Oligomenorrhoea

Answer 5

Infrequent bleeding

Cycle > 35 days but less than 6 months

Question 6

What is DUB?

Answer 6

Dysfunction uterine bleeding

HMB with no recognisable pelvic pathology, pregnancy or general bleeding disorders.

Also known as primary menorrhagia.

Question 7

What is primary amenorrhoea?

Answer 7

No menarche by age 16

Question 8

What is secondary amenorrhoea?

Answer 8

Absent periods for at least 3 months if cycles previously regular

Absent periods for at least 6 months if previously had oligomenorrhoea

Question 9

Causes of oligomenorrhoea?

Answer 9

‘Constitutional’

Anovulation:
PCOS
Thyroid disease
Prolactinoma
CAH

Question 10

Causes of primary amenorrhoea?

Answer 10

Delayed puberty
Imperforate hymen/ transverse septum
Absent vagina
Mullerian agenesis
Gonadal dysgenesis (Turner’s)
PCOS (less common in primary)
CAH

Question 11

Causes of secondary amenorrhoea?

Answer 11

Pregnancy
PCOS
Premature menopause
Prolactinoma
Thyroid disease
Cushing’s
Eating disorder
Exercise induced
Asherman’s syndrome
Sheehan’s syndrome

Question 12

Investigations for primary amenorrhoea?

Answer 12

Question 13

Investigations for secondary amenorrhoea?

Answer 13

Question 14

Physiological causes of amenorrhoea?

Answer 14

Prepubertal
Pregnancy
Menopause

Question 15

Causes of HMB?

Answer 15

Pathology:
Fibroids
Adenomyosis/ endometriosis
IUCD
PID
Polyps

Medical disorders:
Hypothyroidism
Liver disease

Abnormal clotting:
Von Willebrand’s
Thrombocytopenia
Platelet disorders
Coagulation disorders
Leukaemia

Other:
Cancer/ hyperplasia

Question 16

How does IUCD cause HMB?

Answer 16

IUCD causes inflammation in the endometrium due to copper toxicity.

Question 17

How to quantify HMB?

Answer 17

Measure impact on QoL (plus things like anaemia)

Impact on work/social life
Bleeding through clothes/bedding
Disrupted sleep due to heavy bleeding
How many tampons/pads used per day

Question 18

Who is low risk/ high risk with HMB?

Answer 18

Question 19

Medical treatments of HMB:

Answer 19

Symptomatic - tranexamic acid (plus Mefenamic acid - NSAID)

Fibroids - GnRH analogues, Esmya (ulipristal acetate)

Hormonal control (Progesterone only):
POP
LARC - Mirena, Implant, Depo-Provera

Hormonal control (combined):
COCP

Question 20

What is tranexamic acid?

Answer 20

Antifibrinolytic drug (pro-coagulant)

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

Only taken on the days of the heavy period.

SE: Nausea, dizziness, tinnitus, rash, abdo cramps

Question 21

What is Mefenamic acid?

Answer 21

NSAID

Inhibits PG production, and inhibits the binding of PGE2 to its receptor.

SE: GI (usually mild), dizziness, headaches, deranged liver function, asthma, renal disease

Question 22

Surgical treatments of HMB:

Answer 22

Polyps - Myosure (Hysteroscopic removal of polyps)

Fibroids -
Myomectomy for fibroids
Uterine artery embolisation

Family complete (conservative surgery) -
Novasure (endometrial ablation)

Family complete (definitive surgery) -
Hysterectomy

Question 23

Short term emergency control of HMB:

Answer 23

Tranexamic acid

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.

GnRH analogues - Monthly injection to downregulate 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 24

What is PCOS?

Answer 24

Heterogenous endocrine disorder with unknown aetiology. Causes metabolic and reproductive problems in women. Triad: Anovulation Hyperandrogenism Polycystic ovaries on ultrasound.

Question 25

Characteristics of hyperandrogegism?

Answer 25

Acne Hirsutism Obesity

Question 26

Presentation of anovulation?

Answer 26

Oligo/amenorrhoea Multiple ovarian follicules on ultrasound (must be 12 or more in either one or both ovaries) 'string of pearls' Increased ovarian volume > 10cm^3

Question 27

How do you diagnose PCOS?

Answer 27

Rotterdam criteria - at least 2/3 must be present: 1.Clinical/biochemical signs of hyperandrogenism 2. Oligo/amenorrhoea 3. Polycystic ovaries on ultrasound

Question 28

Differential diagnosis for PCOS?

Answer 28

Simple obesity Premature ovarian failure Thyroid disease Hyperprolactinaemia CAH Androgen secreting tumours Cushing's syndrome

Question 29

Investigations for PCOS?

Answer 29

Sex hormone binding globulin (SHBG) Total testosterone Free androgen index (FAI) FSH,LH TFT Prolactin

Question 30

PCOS management

Answer 30

Weight loss is primary prevention Low glycemic index, calorie-controlled diet Exercise Smoking cessation Antihypertensive medications where required Statins where indicated (QRISK >10%) Specific treatment is dependent on patient and their wants/needs: If they want regular periods If they want to conceive If they want treatment for acne and/or hirsutism

Question 31

Management for PCOS patients who want regular periods?

Answer 31

COCP Cyclical progestogens

Question 32

Management for PCOS patients who want to conceive?

Answer 32

Reduce BMI <30 Start folic acid Baseline fertility assessment, incl semen analysis on partner Refer to fertility services May require ovulation induction Metformin (controversial)

Question 33

Management for PCOS patients who want treatment for acne/hirsutism?

Answer 33

COCP Acne treatment - retinoids, abx etc Hair removal methods - waxing, laser treatment

Question 34

Long term complications of PCOS?

Answer 34

Metabolic disorders e.g. impaired glucose tolerance and T2DM CVD Obstructive sleep apnoea Infertility Recurrent miscarriages Pregnancy complications e.g. pre-eclampsia, gestational diabetes Endometrial cancer Psychological disorders e.g. anxiety and depression