Menstruation Flashcards
(23 cards)
Describe normal menstruation
Normal loss: less than 80ml over 7 days (16tsp)
Average loss: 30-40ml (6-8tsp)
Average duration: 2-7days
What are some potential disturbances of menstruation?
Frequency; frequent or infrequent
Irregular or absent
Abnormal duration of flow
Abnormal volume
Describe heavy menstrual bleeding
Difficult to quantify
May include:
- > 80ml over 7 days
- need to change menstrual products every one to two hours
- passage of clots bigger than 2.5cm
- bleeding through clothes
- affecting quality of life
What are some causes of heavy menstrual bleeding?
Uterine and ovarian pathologies i.e. uterine fibroids, endometrial polyps, endometriosis
Systemic diseases and disorders
- coagulation disorders, hypothyroidism, liver or renal disease
Iatrogenic; anticoag treatment, herbal supplements, IUD
Describe fibroids
Non-cancerous growths made of muscle and fibrous tissue
May be asymptomatic or could have HMB, pelvic pain, urinary symptoms, , backache, infertility, miscarriage
Diagnosis: US
Describe fibroid management
Management: Symptom based
- HMB; pill
- large fibroids and fertility desired; embolisation, myomectomy
- submucosal fibroids; hysteroscopic fibroid resection
Declined/failed medical treatment and fertility preservation not required: hysterectomy
Describe endometriosis
Endometrial tissue present outside lining of uterys
May present with HMB, pelvic pain
Multi-system involvement
Severely affects QoL
Can cause infertility, fatigue, systemic symptoms
Severity of deposits may not correspond with symptoms
What are the four stages of endometriosis?
Stage 1 : Minimal
- mall patches, surface lesions or inflammation around organs in pelvic cavity
Stage 2 : Mild
- more widespread and starting to infiltrate pelvic organs
Stage 3 : Moderate
- peritoneum or other structures, sometimes also scarring and adhesions
Stage 4 : Severe
- infiltrative and affecting many pelvic organs and ovaries, often with distortion of anatomy and adhesions
Describe diagnosis and management of Endometriosis
Pelvic examination
US, diagnostic laparoscopy
Management: analgesia, medical, surgical
Medical: COCP, POP, IUS, GnRH analogues
Surgical: ablation, hysterectomy endometrioma excision, pelvic clearance, hysterectomy
Surgical management may be required as part of fertility treatment
Describe adenomyosis
A condition where endometrium becomes embedded in myometrium
heavy menstrual bleed
May have significant dysmenorrhoea
May partially respond to hormones
Definitive treatment is hysterectomy
Describe endometrial polyps
Overgrowth endometrial lining
Mostly benign
Diagnosis by US or hysteroscopy
Management: polypectomy
Management of heavy menstrual bleeding
Thorough history
Pelvic examination
Clotting profile, thyroid function
PUS
Laparoscopy if endometriosis suspected
options depend on
- impact on QoL
- underlying pathology
- desire for fertility
Treatment options in heavy menstrual bleeding
Hormonal
- mirena IUS
- COCP
- POP
- depot provera
NON-hormonal
- mefenamic acid
- tranexamic acid
- GnRH analogues
Surgical
- endometrial ablation
- fibroid embolisation
- hysterectomy
Describe tranexamic acid and mefenamic acid
Tranexamic: antifibrinolytic reduces blood loss 60%
Mefenamic: prostaglandin inhibitor reduces blood loss 30% as well as reducing pain
Describe endometrial ablation
Permanent destruction of endometrium
First generation ablation: under hysteroscopic vision using diathermy
Second generation: thermal balloon, radiofrequency
Pre-requisites;
- uterine cavity length < 11cm
- submucous fibroids <3cm
- previous normal endometrial biopsy
Describe hysterectomy
Surgical removal of uterus
Options are: abdominal, vaginal, laparoscopic
total = cervic and uterus sub-total = uterus removed, cervix lef
t
Describe salpingo-oophorectomy
removal of tubes and ovaries
Ovaries may be removed if endometriosis or ovarian pathology
Disadvantages
- immediate menopause; recommended HRT until 50
Advantages;
- reduces risk of subsequent ovarian cancer
Describe oligo/amenorrhoea
Infrequent, absent or abnormally light menstruation
Important to check if normal for person
Causes
- life changes
- hormones
- primary ovarian insufficiency
- polycystic ovarian syndrome
- hyperprolactinemia
- prolactinomas
- thyroid disorders
- obstructions of uterus, cervix and/or vagina
Describe polycystic ovary syndrome
Metabolic syndrome with diagnosis confirmed if 2 of 3 criteria met
US appearance of ovary
Biochemical hyperandrogenism
Clinical hyperandrogenism
Infertility, obesity assoc.
Management; lifestyle adjustment to achieve normal BMI
symptom based treatment
at least 3 withdrawal bleeds per yr required to prevent hyperplasia
Describe dysfunctional uterine bleeding (DUB)
Common disorder; excess uterine bleeding not due to pregnancy or recognisable uterine or systemic diseases
Exclude common causes - PALM COEIN
Treatment based on severity and patient wishes
What is PALM COEIN?
Pneumonic to explain causes of heavy menstrual bleeding
Polyp
Adenomyosis
Leiomyoma/fibroid
Malignancy
Coagulopathy Ovulation dysfunction Endometrium/hyperplasia Iatrogenic Not yet classified
What are absolute contraindications to the combined oral contraceptive i.e. UKMEC 4?
- > 35 yrs and smoking over 15/day
- migraine with aura
- hx of thromboembolic disease or thrombogenic mutation
- history stroke/ischaemic heart disease
- breast feeding <6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged embolisation
Diabetes mellitus diagnosed >20 yrs ago is a UKMEC 3/4 depending on severity
What is the UKMEC?
UK Medical Eligibility Criteria for contraceptive use
UKMEC 1 - a condition for which there is no contraindication to using combined pill
UKMEC 2 - advantages generally outweigh disadvantages
UKMEC 3 - disadvantages generally outweigh advantages
UKMEC 4 - represents an unacceptable health risk
