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Menstrual Problems Flashcards

1
Q

What is the normal ages for menarche to menopause

A

13-51

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2
Q

What Is the normal cycle pattern of a period?

A

4-5/21-35

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3
Q

What is menstruation triggered by?

A

A fall in progesterone 2 weeks after ovulation if not pregnant

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4
Q

Mean blood loss of a normal period

A

30-40ml

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5
Q

Blood loss per cycle in menorrhagia

A

> 80ml/cycle

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6
Q

Types of dysmenorrhoea

A 
Primary = on first or second day of menstruation 
Secondary = Most commonly seen in pathology e.g. endometriosis - may last the whole time of the period
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7
Q

When is intermenstrual bleeding (IMB) normal?

A

when related to ovulation ONLY

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8
Q

Definition of intermenstrual bleeding (IMB)

A

Bleeding between periods

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9
Q

Definition of post coital bleeding (PCB)

A

Bleeding after intercourse

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10
Q

Causes of post coital bleeding (PCB)

A

chlamydia (esp. < 25 y/o)
Cervical cancer
cervical polyps

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11
Q

Oligomenorrhoea meaning

A

infrequent periods e.g. /45-90 days

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12
Q

Questions to ask in a history about menstrual problems

A 
Subjective - patients perspective 
Clots/flooding/pads/tampons 
Pain (with heavy flow or premenstrual)
Effect of symptoms on life and QoL
Associated symptoms e.g. vomiting
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13
Q

Investigations of heavy periods

A

FBC (anaemic)
TFTs and coagulation if suggestive
Endometrial biopsy (if >45/persistent IMB/obesity)

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14
Q

Key Investigation of intermenstrual bleeding and post coital bleeding in the <25s

A

Chlamydia test

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15
Q

Possible investigations of menstrual problems (depending on patient and symptoms)

A

FBC (anaemic)
TFTs and coagulation if suggested
Endometrial biopsy (if >45/persistent IMB/obesity)
Chlamydia test
Pregnancy test/contraceptive history
Transvaginal USS
Hysteroscopy (persistent IMB/endometrial pathology suspected on USS)

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16
Q

Likely causes of menstrual problems in early teens

A

Anovulatory cycles

  • PHA not established yet so girls dont have a regular cycle
  • Tend to be heavy, infrequent and generally not painful
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17
Q

Likely causes of menstrual problems in teens –> 40

A 
Chlamydia 
Contraception related side effects
Endometriosis/adenomyosis (heavy + painful)
Fibroids (heavy, no pain usually)
endometrial/cervical polyps (IMB/PCB)
Dysfunctional bleeding
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18
Q

How much of the menstrual problems due to contraceptive related side effects settle?

A

80% settle

20% can continue to have irregular bleeding

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19
Q

Likely causes of menstrual problems from 40 –> menopause

A

Perimenopausal anovulation
Endometrial cancer
Warfarin
Thyroid dysfunction

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20
Q

What should always be considered in menstrual problems as a cause?

A

Pregnancy

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21
Q

FIGO classification for the causes of abnormal uterine bleeding - PALM-COEIN

A 
Polyp 
Adenomyosis
Leiomyoma (fibroids)
Malignancy/hyperplasia
Coagulation e.g. VW disease, haemophilia
Ovarian e.g. PCO/anovulatory cycles
Endocrine e.g. Thyroid dysfunction 
Iatrogenic e.g. warfarin 
Not yet classified - haven't found a cause
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22
Q

Definition of dysfunctional uterine bleeding (DUB)

A

Abnormal bleeding but NO structural/endocrine/neoplastic/infectious cause found(yet)

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23
Q

Hormonal and ovarian activity in dysfunctional uterine bleeding can be described as….

A

erratic

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24
Q

Treatment of dysfunctional uterine bleeding (DUB)

A

Reassure no sinister pathology
Non-hormonal
- tranexamic acid (antifibrinolytic) reduces blood loss by 60%
- mefenamic acid (prostaglandin inhibitor) reduces blood loss by 30% and reduces pain
Hormonal
- progesterone only tablets e.g. provera
- injections e.g. depo provera
- levonogestrel intrauterine system (reduces bleeding, may become amenorrhoeic or irregular)
- COCP
Surgical treatment (if family complete)
- Endometrial ablation
- hysterectomy
- Salpingo-oophrectomy

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25
When treating dysfunctional uterine bleeding, who would use non-hormonal treatments?
For those trying to conceive
26
When are non-hormonal treatments for DUB taken?
At the time of the periods and continued through the period but for no longer than 7 days
27
Why would hormonal treatments for Dysfunctional uterine bleeding not be suitable for those trying to conceive?
As the treatments are contraceptive in nature
28
Types of hysterectomy
Total hysterectomy = cervix and uterus removed Subtotal hysterectomy = uterus removed, cervix left Total hysterectomy with bilateral salpingo-oophrectomy Wetheims hysterectomy = through abdomen, removal of uterus, lymphatics and surrounding tissues
29
Risks of hysterectomy
``` Infection DVT Bladder Bowel Vessel injury Altered bladder function Adhesions ```
30
What does a hysterectomy guarantee?
Amenorrhoea
31
When would ovaries be removed along with the uterus?
Endometriosis | Presence of an ovarian pathology
32
What does an oophorectomy immediately cause?
Immediate menopause
33
What is used to treat immediate menopause caused by an oophrectomy?
HRT until 50
34
What does an oophorectomy reduce the risk of?
Subsequent ovarian cancer
35
Common sites for endometriosis
Ovary Pouch of douglas Pelvic peritoneum
36
Presentation of endometriosis
``` Asymptomatic and may be no signs Premenstrual pelvic pain Can sometimes then develop non-cyclic pelvic pain Dysmenorrhoea Deep dyspareunia Subfertility Tender nodules in rectovaginal septum Limited uterine mobility Adnexal mass ```
37
Theories of pathogenesis of endometriosis
Sampsons theory of retrograde menstruation Coelomic metaplasia (common embryonic precursor) Haematogenous spread Direct transplantation
38
Investigations for endometriosis
Laparoscopy (superficial) MRI (deep i.e. stage IV) USS (Endometrioma - chocolate cysts)
39
Sites possible for endometriosis
``` Umbilicus Small bowel Fallopian tube Ureter Ovary (then formation of chocolate cyst) Sigmoid colon Rectovaginal septum and uterosacral ligaments Utereovesical fold Uterine serosa Bladder Appendix Peritoneum Caecum ```
40
Treatment for endometriosis
``` Hormonal treatment and analgesics - Progesterone oral/injection/LNG-IUS - COCP - GnRH analogues (e.g. leuporelin) Surgical - excisions of deposits from peritoneum/ovary - diathermy/laser ablation of deposits - removal of ovaries +/- hysterectomy ```
41
In the treatment of endometriosis, what do GnRH analogues do?
Induce a medical menopause
42
Can disease recur after treatment for endometriosis?
Yes
43
Definition of endometriosis
Endometrial type tissue outside of the uterine cavity
44
Definition of adenomyosis
The presence of endometrial tissue in the myometrium (muscle wall of the uterus)
45
Why can adenomyosis be mistaken for fibroids?
Due to the thickened wall of the uterus
46
At what age does adenomyosis present?
Late 30s/40s
47
Age of presentation of adenomyosis vs endometriosis
Adenomyosis tends to present much later than endometriosis
48
Presentation of adenomyosis
Heavy painful periods Bulky tender uterus Painful intercourse May co-exist with endometriosis
49
Is adenomyosis usually found in non-parous women or parous women?
Parous women
50
Investigations for adenomyosis
MRI | Hysterectomy (histology)
51
Treatment of adenomyosis
No symptoms = No treatment | Treat symptoms of heavy and painful periods with hormonal contraception (mirena (LNG IUS), progesterones, COCP)
52
Another name for fibroids
Leiomyoma
53
Which race have a higher incidence for fibroids?
Afro-carribean women
54
How many 40 y/os have fibroids of varying size?
60%
55
Investigations for fibroids
Abdominal palpation - irregularly enlarged uterus up to 12 weeks USS - transvaginal or if > 16 weeks abdominal Hysteroscopy - if inside uterine cavity
56
Types of fibroids
Submucous Intramural Subserous
57
Where are submucous fibroids?
Protrude into the uterine cavity
58
Where are intramural fibroids?
Within the uterine wall
59
Where are subserous fibroids?
Project out of the uterus into the peritoneal cavity
60
Presentation of fibroids
Usually asymptomatic Large fibroids may present with pressure symptoms depending on their location - pressing bladder - increased frequency - pressing bowel - constipation menorrhagia (enlarge uterine cavity surface area) Inter menstrual bleeding In pregnancy - pain - malpresentation - obstruction of labour (cervical fibroid)
61
What type of fibroid tends to cause heavy bleeding?
Intramural
62
What type of fibroid may cause intermenstrual bleeding?
Submucous or fibroid polyps
63
Treatment of fibroids
No symptoms = No treatment Standard menorrhagia treatment if cavity not too distorted GnRH analogues or ulipristal acetate (to shrink fibroids, usually preoperatively) Submucous fibroids - transcervical resection hysteroscopically Myomectomy Uterine artery embolization Hysterectomy
64
In the treatment of fibroids, in what situation is a myomectomy carried out?
Women who wish to conceive as this preserves the uterus
65
What does the passage of clots represent?
Heavy flow
66
Treatment of menorrhagia
FIRST LINE = LNG-IUS mirena coil (if not trying to conceive) SECOND LINE = tranexamic acid/ COCP THIRD LINE = progesterones e.g. deprovera surgery may be indicated if underlying pathology such as polyps
67
Most common cause of post-coital bleeding in pre-menopausel women
Cervical ectropion
68
Who is cervical ectropion more common in?
Women on the COCP
69
Causes of post coital bleeding in pre-menopausal women
``` Cervical ectropion Infection e.g. cervicitis secondary to chlamydia Cervical or endometrial polyps vaginal cancer cervical cancer Trauma ```
70
When is tranexamic acid used vs mefenamic acid?
Tranexamic acid - heavy menstrual bleeding | Mefenamic acid - dysmenorrhoea
71
Pathology of cervical ectropion
Elevated oestrogen levels result in a larger area of columnar epithelium being present on the ectocervix
72
Causes of cervical ectropion
Ovulatory phase Pregnancy COCP
73
Presentation of cervical ectropion
Vaginal discharge | PCB
74
Treatment of cervical ectropion
Ablative treatment ONLY for troublesome symptoms
75
What long acting method of contraception be used as emergency contraception?
Copper IUD
76
What is pre menstrual syndrome?
The emotional and physical symptoms that women may experience prior to menstruation
77
Presentation of pre menstrual syndrome
``` Depression Bloating Anxiety / stress Mastalgia Mood swings ```
78
Treatment of pre menstrual syndrome
COCP | Conservative
79
What is supportive of PMS?
Abscence of PMS in puberty, pregnancy and after menopause
80
How does the contraceptive patch work?
Wear one patch for a week, then change and wear for 3 weeks in a row 1 week break after 3 weeks
81
Gold standard investigation for endometriosis
Laparoscopy
82
Explain fibroid degeneration
Fibroids are sensitive to oestrogen and so can grow during pregnancy If their growth outstrips their blood supply, they can undergo red or Carneous degeneration
83
Presentation of fibroid degeneration
Low grade fever Pain Vomiting
84
Treatment of fibroid degeneration and how long does it take to resolve?
Rest and analgesia | 4-7 days
85
First line treatment for menorrhagia (if not trying to conceive)
IUS Mirena

Reproduction Pathology (28 decks)

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