P year‎ > ‎Obstetrics & Gynaecology‎ > ‎

13.06.07 Menstrual abnormalities

Menorrhagia
  • Prevalence
    • 5% of women 30-49 years consult GP
    • 12% of gynae referrals
  • Causes
    • Ovulatory DUB
    • Fibroids
    • Adenomyosis
    • Coagulation disorders
    • Anovulatoy DUB
      • Teenagers
      • Perimenopausal
      • PCO
    • Hyperplasia/malignancy
    • Endocrine disorders (thyroid)
  • Investigations
    • History
    • Abdo/pelvis exam
    • Smear
    • FBC +/- clotting
    • Transvaginal USS
    • Pipelle biopsy
    • Hysteroscopy is gold standard
  • Stepwise management
    • Mefenamic acid / tranexamic acid 
      • Synergistic
      • Only need to take during period
    • COCP
    • Progestogens
      • => Weight gain
      • Androgenic side effects
    • Mirena
      • Irregularity / spotting for up to 6 months
      • Increased risk of ectopics (as a %)
      • Risk of early infection
      • Subsequent protection from infection (thickened mucous plug), but don't tell them
    • Endometrial ablation 
      • e.g. Novasure
      • Lasts 3 years, but only use if family complete
    • Uterine artery embolisation
      • For fibroids
    • Myomectomy
      • For fibroids
      • More risky than hysterectomy, but preserves fertility
    • Hysterectomy 

Dysmenorrhoea
  • Causes
    • 35% no cause found
    • 33% endometriosis
      • Laproscopic diagnosis
      • Triad of: Dysmenorrhoea, Deep dyspareunia, Pelvic pain
    • 24% adhesions
    • 5% chronic PID
    • 3% ovarian cyst
      • But surgeons always refer as this
    • 1% pelvic varicosities
      • AKA Pelvic congestion syndrome
      • Varicose veins in lower abdomen
    • 1% fibroids
  • Management
    • NSAIDs (mefenamic acid, ibuprofen)
    • COCP (no cycle => no pain)

Amenorrhoea + oligomenorrhoea
  • Definitions
    • Primary amenorrhoea = No menses by 14 plus no secondary sexual characteristics
    • Primary amenorrhoea = No menses by 16 regardless of secondary sexual characteristics
    • Secondary amenorrhoea = Absence cycles for 6 consecutive months when previously menstruating
    • Oligomenorrhoea = More than 35 days between periods
  • Causes
    • Hypothalamic (weight loss, anorexia, bulimia, exercise)
    • Pituitary (prolactinoma, stalk compression, Sheehan's)
    • Ovarian (Turners, premature ovarian failure, PCOS)
    • Outflow (Ashermans, Mullerian abnormalities, AIS, imperforate hymen)
  • Management
    • Depends on cause
    • Beware sequelae e.g. Bone mineral loss in POF

Intermenstrual / postcoital bleeding
  • Think cervix
    • Ectropion
    • Polyps
    • Malignancy
  • Midcycle bleeding from physiological oestrogen surge
  • Chlamydia in young women

Notes
  • Menstruation = "Shedding of superficial layers of endometrium after withdrawal of ovarian hormones due to failure of implantation"
  • Pipelle biopsy
  • PCOS diagnosis: 2 out of:
    • Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3))
    • Oligo- or anovulation
    • Clinical and/or biochemical signs of hyperandrogenism
  • Nicole Kidman = AIS
  • 50% of female prisoners were premenopausal when they committed their crime
  • GnRH analogues + add-back HRT for premenstrual syndrome
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