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