Menstrual Problems

Question 1

What is normal with menstruation?

Answer 1

• 28 day cycle
• Ovulation occurs at 14 days roughly
• First 2-7 days is shedding of the lining of the endometrium
• Mean blood loss is 30-40ml
• Age 13-51 yrs menarche-menopause

Question 2

What does oligomenorrhea mean? Dysmenorrhoea?

Answer 2

Infrequent periods

Painful periods

Question 3

What needs to be questioned when taking a period history?

Answer 3

• Patients perception of how it differs from normal
• Clots/bleeding/how many pads needed/bleed through clothes
• Pain (with heavy flow or premenstrual)
• Ask about effect of symptoms on lifestyle and quality of life

Question 4

What needs examined when there is issues with menstruation?

Answer 4

• General / abdominal / speculum / bimanual

Question 5

Why do we investigate FBC in someone who has menorrhagia?

Answer 5

• To check if they are becoming anaemic

Question 6

What clinical indications would cause you to check there thyroid function? (women having period problems)

Answer 6

Consider thyroid if very tired and gaining weight

Question 7

What other investigations may be necessary in menstrual problems and why?

Answer 7

• Pregnancy test
• Transvaginal ultrasound scan
• Hysteroscopy: Persistent IMB, suspected endometrial pathology on ultrasound

Question 8

What is an anovulatory cycle?

Answer 8

When ovulation is skipped/period missed.

Question 9

What menstrual problems are early teens likely to come across?

Answer 9

• Anovulatory cycles
• Coagulation problems

Question 10

What problems are likely to occur to teens-40?

Answer 10

• Chlamydia
• Contraception related
• Endometriosis
• Fibroids
• Endometrial/cervical polyps
• Dysfunctional bleeding

Question 11

What menstrual problems are likely to occur to age 40-menopause?

Answer 11

• Perimenopausal anovulation
• Endometrial cancer
• Warfarin
• Thyroid dysfunction

Question 12

What is the FIGO classification of abnormal uterine bleeding?

Answer 12

PALM-COEIN

P- polyp

A- adenomyosis
L- leiomyoma
M- malignancy
C- coagulation
O-ovarian, PCOS
E- endocrine
I- iatrogenic
N- not yet classified

Question 13

What is dysfunctional uterine bleeding? (DUB)

Answer 13

• Abnormal bleeding but no structural/endocrine/neoplastic/infectious cause found
• 50% of hystorectomies for menorrhagia are for DUB

Question 14

What is endometriosis? Where does it normally present?

Answer 14

• Endometrial type tissue found outwith the uterine cavity
• An oestrogen dependent chronic condition
• Usually presents in the pouch of douglas (because blood gravitates there), ovary and pelvic perineum

Question 15

What is the cause of endometriosis?

Answer 15

Retrograde menstruation is the most suspected cause

Question 16

Symptoms of endometriosis?

Answer 16

• Premenstrual pelvic pain
• Dysmenorrhoea
• Deep dyspareunia
• Subfertility

Question 17

Signs of endometriosis?

Answer 17

• Potentially none
• Tender nodules in the rectovaginal septum
• Limited uterine mobility
• Adnexal mass

Question 18

How to diagnose endometriosis?

Answer 18

• Gold Standard: laparoscopy - clear, red, bluish black or white lesions
• MRI for deep endometriosis
• Ultrasound can diagnose endometrioma (chocolate cyst)

Question 19

What is the treatment of endometriosis?

Answer 19

Medical

• Progesterone: oral/injected
• Combined oral contraceptive pill
• GnRH analogues

Surgical

• Excision of deposits from peritoneum/ovary
• Diathermy/laser ablation of deposits
• Removal of ovaries with or without hystorectomy

Question 20

What is adenomyosis?

Answer 20

‘Cousin of endometriosis’

• Endometrium cells migrate to the muscle cell wall of the uterus (presence of endometrial cells in te myometrium)

Question 21

Signs and Symptoms of adenomysis?

Answer 21

• Heavy painful periods
• Bulky tender uterus
• Usually in parous women
• May co-exist with endometriosis

Question 22

How do we diagnose adenomyosis?

Answer 22

• MRI may suggest diagnosis but limited availability
• histology of uterine muscle – generally post hysterectomy

Question 23

Management of adenomyosis?

Answer 23

Treat symptoms of heavy and painful periods with hormonal contraception

Question 24

What are fibroids? Features?

Answer 24

Smooth muscle growths also known as leiomyoma.

Common and usually asymptomatic: Up to 60% of 40 year olds have fibroids of varying size

Question 25

How is a diagnosis of fibroids made?

Answer 25

* clinical exam – irregularly enlarged uterus * ultrasound * Hysteroscopy (if inside uterine cavity)

Question 26

What are the three types of fibroids?

Answer 26

* Sub-mucous: Protrude into uterine cavity * Intramural: within uterine wall * Sub-serous: project out of uterus into peritoneal cavity

Question 27

Symptoms of fibroids?

Answer 27

* Large fibroids may cause pressure symptoms * Menorrhagia: enlarge the uterine cavity surface area * Submucous or fibroid polyps may cause intermenstrual bleeding * May be asymptomatic

Question 28

Management of fibroids?

Answer 28

[only if symptomatic] * Standard menorrhagia treatment if cavity not too distorted * GnRH analogues or Ulipristal acetate may be used temporarily to shrink the fibroids – usually preoperatively * Submucous fibroids: Transcervical resection hysteroscopically * Myomectomy * Uterine artery embolisation * Hysterectomy

Question 29

Management of DUB?

Answer 29

* May just need reassurance that there is no sinister pathology Medical * Non hormonal: Tranexamic acid or Mefanamic acid * Hormonal: Progestogen only tablets, injections (Depo Provera), Levonorgesterel Intrauterine System, Combined pill Surgical * Endometrial ablation * Hysterectomy

Question 30

What is tranexamic acid and how does it function?

Answer 30

* Antifibrinolytic * Reduces blood loss by 60%

Question 31

What is Mefenamic acid and how does it work?

Answer 31

* Prostaglandin inhibitor * Reduces blood loss by 30% and pain

Question 32

What is salpingo-oophorectomy?

Answer 32

Removal tubes + ovaries