Week 6: Womens' health (2) (menstrual problems) Flashcards
menarche
first period
menopasue
end of periods
amenorrhoea
absence of periods
- primary
- secondary
dysmenorrhoea
painful menstruation
menorrhagia
heavy/prolonged menstrual bleeding
oligomenorrhoea
infrequent periods
inter-menstrual bleeding
- Post coital (after sex)
- Breakthrough (irregular bleeding on hormonal contraception)
abnormal uterine bleeding (AUB) covers
- Menorrhagia
- Intermenstrual
- Post coital
- Break through
does not cover amenorrhea
AUB: types of symptoms
- Heavy
- Irregular
- Infrequently
- Frequent
- Shortened
- Postcoital
- Intermenstrual
causes of AUB
- (PALM- COEIN (FIGO))
- Structural
- Polyp
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy/hyperplasia
- Non-structural
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial
- Iatrogenic
- Not yet classified (DUB)
- Structural
with abdominal pain or heavy bleeding always
THINK: DO A PREGNANCY TEST
- DO A URINE PREGNANCY TEST IF IN ANY DOUBT!
Consider the following scenarios, which could all be related to pregnancy but might be interpreted as a new onset ‘period problem’
- Missed period Pregnancy is the most likely cause
- “Painful period” Could she be pregnant and having a miscarriage or ectopic pregnancy?
- “Heavy period” Could she be pregnant and having a miscarriage?
menorrhagia
- Abnormal menstrual bleeding (heavy or prolonged)
- Interferes with woman’s physical, emotional and social QoL
- Refers to abnormal uterine bleeding outside of parameters noted below
- duration greater than 8 days
- glow greater than 80mL/cycle or subjective impression of heavier-than-normal flow
- occurs more frequently than every 24 days or less frequently than 38 days
- intermenstrual bleeding or postcoital spotting
clinical diagnosis of menorrhagia
>80 mL/cycle
causes of menorrhagia
- Hypothyroidism
- PID
- Endometriosis
- Idiopathic
- Fibroids (non cancerous growths)
- Blood clotting disorders/ warfarin
- Contraceptive pill
presentation of menorrhagia
- FBC- anaemia
- Endocrine tests
- Bleeding disorders
- US
management of menorrhagia
- First line: Mirena (often not first line in practice due to what women wants)
- Second line: tranexamic acid, NSAIDS such as mefenamic acid or COCP/POP
dysmenorrhoea
- Low anterior pelvic pain which occurs in association with periods
- Primary- period pains since start of period
- Secondary- occurring later, with previously normal periods
causes of dysmenorrhoea
- Excess or imbalance of prostaglandins in menstrual fluid, which causes vasoconstriction in the uterine vessels, causing uttering contractions which produce pain
- Prostaglandins may explain: diarrhoea, nausea, headache etc
- Endometriosis
- PID
- Fibroids
- Copper IUDà may hurt for a few months after fitting
- Childbirth reduces dysmenorrhoea
investigation of dysmenorrhoea
- Good history
- Speculum exam of cervix
- High vaginal swap
- Pelvic/ transvaginal US
resentation of dysmenorrhoea
- 1-2 days before or with onset of menses
- Improves 12-72 h
- Crampy and intermittently intense, or continuous dull ache
- Lower abdomen and suprapubic area
management of dysmenorrhoea
- Lifestyle- stop smoking, exercise
- NSAIDs
- Hormonal treatment
- COCP
- Dep-povera
- Coil
- Surgery
- Laparoscopic uterine nerve ablation
- hysterectomy in rare cases
endometriosis
- Endometrial glands and stroma that occur outside uterine cavity
- 5-10% prevalence
RF for endometriosis
- Nulliparity (a woman has never given birth to a child, or has never carried a pregnancy)
- Early menarche
- Short cycles
- Heavy bleeding
- Low BMI
causes of endometriosis
- Not really sure
- Oestrogen dependent, benign inflammatory disease
- Responds to cyclical hormonal changes
- Can cause dysmenorrhea, dyspareunia (recurring pain in genital area), chronic pain and infertility
- Multifactorial pathogenesis- retrograde menstruation??
Most common sites of endometriosis
Adenomyosis: endometrial tissue found deep within myometrium
- Ovaries
- Endometrioma= chocolate cyst
- Bladder
- Rectum
- Peritoneal lining and pelvic side walls
oligomenorrhoea
- Infrequent menstrual periods (fewer than 6 to eight periods per year)
amenorrhoea: primary
- refers to absence of menstrual periods
- Primary (when menstrual periods have not started by age 15)
amenorrhoea: secondary
absence for more than 3 to 6 months in a women who has previously had periods
causes of amenorrhoea: primary
- Genitourinary malformation (imperforate hymen, vaginal septum, absent vagina, absent uterus)
- Chromosomal disorder (turners syndrome 45XO)
- Endocrine disorder (hypothalamic pituitary dysfunction)
- Complete androgen insensitivity disorder
- Isolated GnRH deficiency
causes of amenorrhoea: secondary
- PCOS (usually oligomenorrhea)
- hypothalamic amenorrhea (e.g. body weight too low)
- prolactinoma
- pituitary necrosis – Sheehan’s syndrome- when women loses a lot of blood during birth
- hyper/hypothyroidism
- scarring e.g. cervical stenosis, intrauterine adhesion
- primary ovarian deficiency
compelte androgen insensitivity disorder
Isolated GnRH deficiency
classification of cervical cancer
Then can become invasive where it breaches the epithelial basement membrane
resentation of cervical cancer
- Abnormal vaginal bleeding
- Vaginal discharge
- Vaginal discomfort/urinary symptoms
- Late symptoms
- Painless haematuria
- Painless fresh rectal bleeding
- Altered bowel habit
- Leg oedema
- Signs on exam
- White or red patches on cervix
- Rectal exam may reveal a mass or bleeding
presentation of vulval cancer
- Vulval lump, bleeding, pruritus or pain
- Delayed onset
- Differential : lichen planus
