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1

Week 204 - Gynaecology: Give a definition of menorrhagia and give the objective definition.

• Excessive loss of blood during menstruation.
• >80ml

2

Week 204 - Gynaecology: Give a definition of dysmenorrhea.

Painful menstrual periods.

3

Week 204 - Gynaecology: What is primary and secondary dysmenorrhea?

• Primary - no associated with organic disease or psychological cause.
• Secondary - A cause can be found (e.g. endometriosis, PID)

4

Week 204 - Gynaecology: What is Dyspareunia?

Pain during sexual intercourse.

5

Week 204 - Gynaecology: What are the three differentials for menorrhagia?

• Dysfunctional uterine bleeding.
• Uterine leiomyomas (Fibroids).
• Endometriosis or Adenomyosis.

6

Week 204 - Gynaecology: What is the common name for uterine leiomyomas?

• Fibroids

7

Week 204 - Gynaecology: What is dysfunctional uterine bleeding?

This is heavy menstrual bleeding that is not associated with organic disease of the genital tract.

8

Week 204 - Gynaecology: What are fibroids? What is the medical term for them?

• Uterine Leiomyomas.
• Benign growths in the uterus which can cause heavy menstrual bleeding.

9

Week 204 - Gynaecology: What is endometriosis?

This is where endometrial tissue is found outside of the uterus. It can cause heavy bleeding, persistent pain and infertility.

10

Week 204 - Gynaecology: What is adenomyosis?

This is where endometrial tissue grows within the myometrium.

11

Week 204 - Gynaecology: What key feature of examination is used to distinguish between fibroids and dysfunctional uterine bleeding?

• The size of the uterus.
• DUB will typically be a normal sized uterus whilst fibroids will lead to an enlarged uterus.

12

Week 204 - Gynaecology: On examination you feel an enlarged uterus, what is your initial investigation?

• USS, this is to determine whether there are fibroids or an ovarian cyst.

13

Week 204 - Gynaecology: A 25yr olf lady presents with heavy menstrual bleeding? Is an endometrial biopsy required? When is a biopsy indicated?

No, this is normally only performed in patients over 40, since the risk of endometrial cancer increases after 40. It may indicated in a younger woman if she fails to respond to treatment.

14

Week 204 - Gynaecology: What initial investigation should be offered to women who experience heavy menstrual bleeding?

FBC - to identify anaemia.

15

Week 204 - Gynaecology: What are the five medical treatments for menorrhagia?

• Tranexamic Acid
• Mefenamic Acid
• Combined Oral Contraceptive Pill
• Oral Progesterones.
• Mirena IUS

16

Week 204 - Gynaecology: What is the role of Tranexamic acid in the treatment of menorrhagia?

• Antifibrinolytic.
• Taken during menstruation and can reduce blood loss by 50%.

17

Week 204 - Gynaecology: What is the role of Mefenamic Acid in the treatment of menorrhagia?

• NSAID
• Useful for dysmenorrhoea and also reduces blood loss.
• Can be used in conjuction with Tranexamic acid.

18

Week 204 - Gynaecology: What is the role of the oral contraceptive pill in the treatment of menorrhagia?

Reduces blood loss by 10-20%, and also helps with dysmenorrhoea.

19

Week 204 - Gynaecology: What impact does the Mirena IUS have on menorrhagia?

• Reduces blood loss by 90% and at 1 year 30% are amenorrhoeic.

20

Week 204 - Gynaecology: In patients who are very anaemic or constantly bleeding what is the treatment aim? And what treatments are used?

• To achieve Amenorrhoea rapidly.
• GnRHa - Inhibits release of Gonadotrophins so inhibits the release of oestrogen and androgen.
• High dose progesterones.

21

Week 204 - Gynaecology: When is the use of surgery indicated in the treatment of menorrhagia and what are the options?

• Failure of medical treatment and when family is complete.
• Endometrial ablation - destruction of endometrium.
• Hysterectomy.

22

Week 204 - Gynaecology: Where are the six locations for an ectopic pregnancy and which is the most common?

• Interstitial/Cornual
• Isthmic Tubal
• Infundibular Tubal
• Ovarian
• Abdomial
• Ampullar Tubal (Most common, due to narrowing of fallopian tube).

23

Week 204 - Gynaecology: What are the risk factors for developing fibroids?

• Age (Later reproductive years)
• Menarche (Early onset)
• Race (African)
• Hypertension / CV risk
• Family History
• Obesity
• Tamoxifen

24

Week 204 - Gynaecology: Which drug, used in the treatment of breast cancer, is a risk factor for developing fibroids?

Tamoxifen

25

Week 204 - Gynaecology: What are the five locations of fibroids? Give a brief description of each.

• Intramural - This is completely enclosed in the endometrium.
• Submucosal - This is where it protrudes into the uterus but is covered by a layer of mucosa.
• Subserosal - Opposite of a submucosal, protrudes out the external wall of the uterus, but it covered by serosa.
• Pedunculated - Both subserosal and submucosal. Look like pendulums.

26

Week 204 - Gynaecology: What are the symptoms of fibroids?

• Asymptomatic - 50%
• Heavy menstrual bleeding.
• Haematological disorders.
• Dysmenorrhoea.
• Infertility.

27

Week 204 - Gynaecology: What investigations should be performed for suspected fibroids?

• FBC - Hb
• Tumour Markers - Ca125, CEA
• USS
• Endometrial biopsy (Women over 40)
• Hysteroscopy/Laparoscopy

28

Week 204 - Gynaecology: What are the medical treatments available for fibroids?

• Esmya
• GnRH agonists. - Shrink fibroid and reduce vascularity.
• Mirena IUS

29

Week 204 - Gynaecology: How does Esmya treat fibroids?

Three modes of action-
• Acts on the fibroid by reducing progesterone receptors which reduces cell proliferation and induces apoptosis.
• Acts on the pituitary to reduce Gonadotrophin secretion..
• Acts on the endometrium to have a direct affect to reduce bleeding.

30

Week 204 - Gynaecology: What are the surgical options for the treatment of fibroids?

• Myomectomy - Surgical removal of fibroids.
• Hysterectomy
• Uterine Artery Embolisation - cut's off blood supply to fibroid.