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