Menstrual disorders

Question 1

what is the menstrual cycle defined as?

Answer 1

The menstrual cycle is the time from the first day of a woman’s period to the day before her next period

Question 2

How can the menstrual cycle be disturbed

Answer 2

• Frequency
• Irregularity
• Duration
• Volume

Question 3

What sort of factors to use to assess whether someone is having heavy bleeding?

Answer 3

´Bleeding>8dys menorrhea ml over 7 days, regular cycle
´AND/OR the need to change menstrual products every one to two hours
´AND/OR passage of clots greater than 2.5 cm
´Bleeding through the clothes
´AND/OR ‘very heavy’ periods as reported by the woman/affecting quality of life

Question 4

Aetiology of heavy bleeding?

Answer 4

• Uterine/ ovarian pathologies
• Systemic diseases and disorders
• Iatrogenic causes

Question 5

list some of the uterine and ovarian pathologies which can cause HMB?

Answer 5

´Uterine fibroids 
´Endometrial polyps 
´Endometriosis and adenomyosis 
´Pelvic inflammatory disease and pelvic infection 
´Endometrial hyperplasia or carcinoma 
´Polycystic ovary syndrome

Question 6

List some of the systemic diseases which can lead to HMB?

Answer 6

´Coagulation disorders (for example von Willebrand disease).
´Hypothyroidism
´Liver or renal disease.

Question 7

List some of the iatrogenic disease which can lead to HMB?

Answer 7

´ Anticoagulant treatment.
´ Herbal supplements
´ Intrauterine contraceptive device

Question 8

Investigation

Answer 8

• history
• pelvic examination
• clotting profile
• PUS
• Laparoscopy
• Endometrial biopsy for al women over 44

Question 9

what are fibroids?

Answer 9

´Non cancerous growths made of muscle and fibrous tissue.

Question 10

What are fibroids also known as?

Answer 10

myoma

lieomyoma

Question 11

Symptoms of fibroids?

Answer 11

´	Can be asymptomatic 
´	HMB
´	pelvic pain
´	urinary symptoms
´	pressure symptoms
´	backache 
´	Infertility
´	Miscarriage

Question 12

Management of fibroids?

Answer 12

small: COP, POP, Mirena

large with fertility preservation:

• fibroid embolisation
• myomectomy

Submucosal
-hysteroscopic fibroid resection

Failed medical treatment and no need for fertility preservation:
-Hysterectomy

Question 13

what is endometriosis?

Answer 13

Defined as endometrial tissue present outside the lining of uterus .

During menstruation this ectopic tissue behaves the same as endometrium and bleeds.

Question 14

symptoms of endometriosis?

Answer 14

oPainful menstrual cramps- get worse over time
oLower back pain
oAbnormal bleeding or spotting between menstrual periods
oPain during/after sexual intercourse
oPainful bowel movements or urination
oDiarrhoea/nausea/bloating

Question 15

what can endometriosis cause?

Answer 15

´May present with HMB
´Most often pelvic pain .
´Multi-system involvement .
´ severely affects quality of life -can be devastating.
´in addition to pelvic symptoms , can cause infertility, fatigue and systemic symptoms

Question 16

what is the diagnosis of endometriosis?

Answer 16

o often misdiagnosed : IBS, Period pain, PCOS, Fatigue..
oPelvic examination
oUltrasound scan, Diagnostic laparoscopy

Question 17

stages of endometriosis?

Answer 17

4

Question 18

stage 1 and 2 of endometriosis?

Answer 18

Stage 1: minimal
o small patches/ surface lesions/ inflammation on or around organs in the pelvic cavity

Stage 2: mild
o more widespread
o starts to infiltrate pelvic organs

Question 19

stage 3 and 4 of endometriosis

Answer 19

Stage 3: Moderate
oPeritoneum/ pelvic side walls infiltrated
oSometime with scarring/adhesions

Stage 4: severe
oInfiltrative
oAffects lots of pelvic organs and ovaries
oOften with distorsion of anatomy and adhesions

Question 20

Management of endometriosis?

Answer 20

Medical
o	COCP
o	POP
o	Mirena IUS
o	Depot prover
o	GnRH Analogues

Surgical
o	Ablation
o	Hysterectomy endometrioma excision
o	pelvic clearance
o	Hysterectomy
´	Surgical management may be required as part of fertility treatment.

Question 21

what is adenomyosis?

Answer 21

A condition where endometrium becomes embedded in myometrium .

Question 22

treatment of adenomyosis?

Answer 22

• may respond to hormones?

- hysterectomy

Question 23

what are endometrial polyps?

how are they managed?

Answer 23

Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium

POLYPECTOMY

Question 24

Treatment for menstrual disorders?

Answer 24

o	Observation and monitoring 
o	Hormones 
o	Hormone-containing IUD 
o	Endomyometrial resection 
o	Endometrial ablation : NovaSure
o	Remove fibroids/polyps 
o	Hysterectomy : robotic/laparoscopic

Question 25

Medical treatment

Answer 25

• Tranexamic acid reduces blood loss 60%
• Mefenamic acid reduces blood loss 30% and pain
• Both of them are taken at the time of periods , Do not regulate cycles
• Suitable for those trying to conceive
• Hormonal contraception
• Combined contraceptive pill (COCP) makes periods lighter, regular and less painful
• LNG IUS and Depo-Provera reduces bleeding – may cause irregular bleeding, some women will be amenorrhoeic
• Oral progestogens

Question 26

Surgical treatment

Answer 26

• Endometrial ablation
• Hysterectomy
• Removal of ovaries
• Salpingo-oophorectomy= removal of the tubes and ovaries

Question 27

what is Oligo/amennorea?

Answer 27

´Infrequent, absent or abnormally light menstruation

´Important to check if its normal to a person

Question 28

Aetiology for oligo/amenorroea

Answer 28

➢Life changes:stress, eating disorders/malnourishment, obesity, Intense exercise
➢Hormones:POP, Mirena, depot injection
➢Primary ovarian insufficiency
➢Polycystic ovarian syndrome ,
➢Hyperprolactinemia (elevated levels of prolactin in the blood)
➢Prolactinomas (adenomas on the anterior pituitary gland)
➢Thyroid disorders (Graves’s disease)
➢Obstructions of the uterus, cervix, and/or vagina

Question 29

what is dysfunctional uterine bleeding?

Answer 29

•Dysfunctional uterine bleeding (DUB) is a common disorder of excessive uterine bleeding affecting premenopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases.