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Year 4 - O&G > O&G - Menstrual Dysfunction > Flashcards

O&G - Menstrual Dysfunction Flashcards

(37 cards)

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1
Q

What is a Hysteroscopy?

A

Endoscopic examination of the uterine cavity

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2
Q

When should you do a coagulation screen for women with Heavy Menstrual Bleeding (HMB)?

A
  1. They have had HMB since period began
  2. Hx or FHx suggesting coagulation disorder
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3
Q

What blood tests might you do for a woman with HMB?

A

FBC!!

  • Coagulation screen - not routine, ony if indicated
  • Ferritin - not routine, only if indicated
  • TFT - not routine, only if symptoms suggest thyroid disease
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4
Q

Women with HMB should be offered hysteroscopy if … ?

A

Hx suggests:

  1. Submucosal fibroids or polyps
    • symptoms such as persistent intermenstrual bleeding
  2. Endometrial pathology
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5
Q

What are some risk factors for endometrial pathology?

A
  1. Persistent intermenstrual / persistent irregular bleeding
  2. Infrequent HMB + obese or PCOS
  3. Tamoxifen (SERM - selective oestrogen receptor modulator - acts as oestrogen receptor antagonist + partial agonist –> uses in oestrogen receptord +ve breast Ca)
  4. Treatment for HMB has been unsuccessful previously
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6
Q

If a pt doesn’t want hysteroscopy, what other investigation can be offered?

A

Pelvic ultrasound

  • Not as good as hysteroscopy for identifying uterine causes of HMB
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7
Q

If a pt declines a hysteroscopy under normal analgesia (OTC painkillers prior to procedure) - what can be offered?

A

Hyteroscopy under GA or local anaesthesia

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8
Q

What test might be done during hysteroscopy if pt is at high-risk of endometrial pathology?

A

Endometrial biopsy

Following are risk factors that put a pt at ‘high-risk’ of endometrial pathology:

  1. Persistent intermenstrual / persistent irregular bleeding
  2. Infrequent HMB + obese or PCOS
  3. Tamoxifen (SERM - selective oestrogen receptor modulator - acts as oestrogen receptor antagonist + partial agonist –> uses in oestrogen receptord +ve breast Ca)
  4. Treatment for HMB has been unsuccessful previously
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9
Q

When should a pelvic ultrasound be offered to women with HMB?

A

Offer pelvic ultrasound if pt has HMB + any of:

  1. Uterus is palpable abdominally
  2. Hx or examination suggests pelvic mass
  3. Examination inconclusive or difficulty e.g. obese
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10
Q

What is Adenomyosis?

A

Adenomyosis - characterised by presence of ectopic endometrial tissue

in the myometrium

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11
Q

What are the features of Adenomyosis?

A

Features of Adenoymosis:

  1. Dysmenorrhoea (painful menstruation) - can worsen to chronic pain
  2. Menorrhagia i.e. HMB –> can cause anaemia
  3. Tender (not always), enlarged, boggy uterus
  4. Often occurs after pregnancy - particularly C-section or TOP (can breach endometrial/myometrial junction)
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12
Q

How is Adenomyosis managed?

A

Woman NOT finished with childbearing –> symptom management:

  • 1st line = IUS i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen ↓ menstrual blood loss by ~ 90%
  • 2nd line - consider:
    1. Tranexamic acid
    2. NSAIDs
    3. COCP
  • 3rd line = Oral or IM progesterone treatments - may suppress menstruation
  • 4th line = surgery
    • Endometrial ablation
    • Hysterectomy - only definitive treatment

Woman finished with childbearing:

  • Endometrial ablation
  • Hysterectomy - only definitive treatment
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13
Q

What investigation should be suggested to women with HMB + features suggesting Adenomyosis?

  • Dysmenorrhoea
  • HMB
  • Tender, bulky uterus on examination
A

Transvaginal ultrasound

(in preference to transabdominal US or MRI - but offer these if transvaginal is declined)

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14
Q

What is Endometrial ablation?

A

Destruction of endometrium down to basalis layer (various methods) often using heat based technique

  • Advise:
    • Avoid subsequent pregnancy + contraception
  • 20% of women need repeat by 5-yrs
  • 30% become amenorrhoeic
  • Can be done under GA but often under short anaesthetic as day-case or local anaesthesia as outpatient
  • Risks:
    1. Haemorrhage
    2. Infection
    3. Uterine perforation
    4. Failed procedure
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15
Q

What are Uterine Fibroids?

A

Fibroids - are benign tumours arising from the myometrium of the uterus (often composed of smooth muscle but can contain fibrous tissue)

  • Common! 1 in 3 women develop fibroids during their life
  • Often asymptomatic
  • Most common in 30-50 yrs
  • Develop in response to oestrogen (thus don’t progress post-menopause)
  • More common in Afro-Caribbean women & obese women
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16
Q

Who are fibroids more common in?

Study These Flashcards
A

Black Afro-Caribbean

(occur ~20% of white and ~50% black in later reproductive years)

17
Q

What are the features of Fibroids?

Study These Flashcards
A

May be Asymptomatic !!

  1. menorrhagia (HMB)
  2. dysmenorrhoea - lower abdo pain, cramping during menstruation
    • can have lower back pain
  3. bloating
  4. urinary symptoms (larger fibroids) - e.g. frequency
  5. constipation
  6. pain/discomfort during sex
  7. subfertility
  8. hard, irregular uterine mass palpable on examination
18
Q

How can fibroids complicate pregnancy?

Study These Flashcards
A
  1. Pain - due to degeneration
  2. Abnormal lie of fetus
  3. Obstruction (if cervical fibroid)
  4. Difficult C-section
19
Q

What are the different types of Fibroids?

Study These Flashcards
A
  • Submucous: > 50% of fibroid mass projects into endometrial cavity
  • Intramural: located in myometrium
  • Subserous: > 50% of fibroid mass extends outside uterine border
  • Cervical: (uncommon)
  • Peduncalated: mobile & prone to torsion
  • IV leiomyomatosis: (very rare) fibroid enters circulation via pelvic veins, then to vena cava and causing complications in heart
20
Q

What is the investigation of choice in suspected Uterine Fibroids?

Study These Flashcards
A

Ultrasound

Transvaginal > trans-abdominal

21
Q

How are Uterine Fibroids managed?

Study These Flashcards
A

If symptoms minimal –> no treatment

  1. GnRH anologues (Gonadotropin-releasing hormone) - shrink fibroids (only used prior to surgery)
  2. Myomectomy - surgical resection of uterine fibroids (fertility maintained)
    • Can be done: open, laproscopically or hysteroscopically (depends on location of fibroid)
  3. Hysterectomy - if > 45-yrs or women who no longer want fertility
  4. Uterine artery embolization - artery is catheterized using polyvinyl alcohol powder or gelatin sponge
22
Q

What are endometrial polyps?

Study These Flashcards
A

Endometrial Polyps (adenoma) - are focal overgrowth of endometrium

  • Malignant in < 1%
  • Commoner > 40-yrs
  • Management:
    • Resection during hysteroscopy
    • Histological assessment of resected polyp
23
Q

How are Fibroids < 3cm in diamater managed?

Note: Fibroids < 3cm, Adenomyosis and women with no identifiable pathology have their HMB managed the same way

Study These Flashcards
A

Woman NOT finished with childbearing –> symptom management:

  • 1st line = IUS i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen ↓ menstrual blood loss by ~ 90%
  • 2nd line - consider:
    1. Tranexamic acid
    2. NSAIDs
    3. COCP
  • 3rd line = Oral or IM progesterone treatments - may suppress menstruation
  • 4th line = surgery
    • Endometrial ablation
    • Hysterectomy - only definitive treatment

Woman finished with childbearing:

  • Endometrial ablation
  • Hysterectomy - only definitive treatment
24
Q

How are fibroids > 3cm in diameter managed?

Study These Flashcards
A

Pharmacological:

  • Non-hormonal:
    1. NSAIDs
    2. Tranexamic acid - antifibrinolytic
  • Hormonal:
    1. Ulipristal acetate (used at lower dose than for emergency contraception)
    2. IUS i.e. Mirena (levonorgestrel)
    3. COCP
    4. Progesterone-only contraceptives

Surgical:

  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
25
A pt is takeing Ulipristal acetate for management of symptoms of uterine fibroids. What rare but serious side effect can occur? How is this monitored?
SE: **liver injury** (cases have been severe enough to require liver transplant) Monitoring: **LFTs** **before starting** & **every month** during first 2 treatment courses
26
How do you manage a pt with symptomatic fibroids \> 3cm who is not eligble for surgery?
Offer **ulipristal acetate 5 mg** (up to 4 courses) IF they meet the following criteria: 1. **HMB** and 2. **Fibroids** **\> 3cm** and 3. **+/- haemaglobin \< 102** g/L
27
How do we define heavy menstrual bleeding?
Not measured via blood loss but **Best measured by impact on woman's life**
28
What is an indicator of excessive blood loss during menstruation?
**Blood clots** in menstruation (also tiredness)
29
What does the term Adnexal refer to? E.g. Adnexal mass
Relating to in or near the uterus, fallopian tubes, ovaries or connecting tissue
30
Describe the possible positions the uterus can lie in.
1. **Anteverted** 2. **Retroverted** 3. **Retroflexed**
31
What is the normal range for endometrial thickness?
Depends on the timing of the ultrasound scan in relation to menstrual cycle! Endometrium is **thickest** during **secretory** **phase** (luteal phase) **~ 16mm**
32
A pt presents with Heavy Menstrual Bleeding. What red-flags would warrant a 2-WW referral?
* Age **\> 45-yrs** * **inter-menstrual** bleeding * **post-menopausal** bleeding * **post-coital** bleeding * abnormal examination findings e.g. * **pelvic mass** * **lesion on cervix** * treatment failure **after 3-months**
33
What are some indications for hysteroscopy?
1. **Sterility** - inability to conceive 2. **Infertility** - inability to complete a full term healthy pregnancy 3. **Menstrual disorders** 4. Suspicious US **endometrial findings** 5. **Check-ups:** * after intrauterine interventions * after treatment of endometrial hyperplasia with medication 6. **Lost IUD**
34
How is HMB managed in women with no identifiable pathology? (Same as fibroids \< 3cm and adenomyosis)
Woman NOT finished with childbearing --\> **symptom management**: * **1st** line = **IUS** i.e. Mirena coil (Levonorgestrel) - synthetic progestrogen **↓ menstrual blood loss** by **~ 90%** * **​**Advised to try for **at least 6-months** * **2nd** line - consider: 1. **Tranexamic acid** 2. **NSAIDs** 3. **COCP** * **3rd** line = Oral or IM **progesterone** treatments - may suppress menstruation * **4th** line = surgery * **Endometrial ablation** * **Hysterectomy** - only definitive treatment Woman finished with childbearing: * **Endometrial ablation** * **Hysterectomy** - only definitive treatment
35
How long is it recommended that women try non-surgical interventions for their HMB?
**at least 6 months for IUS** (Mirena) and **at least 3-months** for other e.g. NSAIDs, tranexamic acid, COCP and progesterone-only
36
Using the acronym PALM COEIN name causes of HMB.
* P - Polyp * A - Adenomyosis * L - Leimyoma (fibroids) * M - Malignancy * C - Coagulopathy e.g. Von Willebrand's disease * O - Ovarian dysfunction e.g. PCOS * E - Endometrial processes (most controlled by oestrogen) e.g. hypothyroidism * I - Iatrogenic * N - Not yet classified
37
What does this image show?
Uterine fibroids (seen via laproscopic surgery)

Year 4 - O&G (12 decks)

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