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Menstrual disturbance

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Peter Neil

on 11 February 2013

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Transcript of Menstrual disturbance

Menstrual Disturbance throughout the ages 15 year old with heavy menses ever since menarche at age 12 What investigations are warranted?

What are some possible treatments? Hormonal/Anovulatory
Clotting Disorders
Pregnancy Complications

Uterine Disorders
Foreign Body Differential Diagnosis Investigations Full Blood Count +/- Fe studies
Coagulation studies +/- including VW factor
Pregnancy test
Chlamydia/Gonorrhoea PCR
Ultrasound - not often indicated in the first instance unless you have no other leads Management Iron
OCP may be the easiest treatment for anovulatory bleeding - continuous
Tranexamic Acid, Mefenamic Acid... Continuous OCP
The Great Debate Pros Cons Less Periods - pain, PMS etc...
Less Bleeding - less anaemia
Better Contraception
Less endometriosis Breakthrough Bleeding
Don't feel normal
Don't feel fertile
Takes time to educate Evidence Continuous OCP leads to
Fewer bleeding days
Better quality of life in PMS
Breakthrough bleeding reduces over time
Similar effect on Endometriosis pain as GnRH
No increase in post OCP infertility A 25 year old in complaining about intermenstrual bleeding. What else would you like to know? Postcoital bleeding
Last Pap smear On OCP Regular cycles STI risk Causes Cervical
OCP, Implanon
IUD 35 year old G0P0 with regular cycles has menorrhagia - considering pregnancy 61 year old with single postmenopausal bleed 47 year old G3P3 with perimenopausal irregular heavy very PV bleeding. The ultrasound shows a thickened endometrium of 18mm. 45 year old G3P3 with menorrhagia and a bulky uterus Causes Regular periods
Endometrial polyp
Irregular periods
Dysfunctional Uterine Bleeding
Endometrial hyperplasia/cancer Irregular Cycles (<24 or >35 days) Causes of anovulation
Age related
Thyroid Dysfunction
Hyper or Hypo
Androgenising conditions
Decreased ovarian reserve Investigations FSH/LH
raised will imply peri/premature menopausal
Raised LH:FSH - PCOS
Free Androgen Index?? Treatment Among other things
Progesterone How do you investigate and manage? Bloods
Fe studies
Anovulatory bloods not warranted
Ultrasound Treatment - If normal scan Tranexamic acid (Fe and folate) Acts within 2-3 hours of administration
Reduces blood loss by 50% (BJOG 1996)
More effective than luteal phase progesterones
More effective than NSAIDs - mefenamic acid

Side Effects
Nausea, vomiting, diarrhoea
No significant increase in DVT
Contraindicated if high risk of DVT Uterine Haemorrhage Investigations Hb, Fe
Ultrasound +/- endometrial sampling if >15mm ET Fibroids 3 main problems
mass effects
infertility Treatment Myomectomy
laparoscopic Hysterectomy
robotic Other Treatments Embolisation Can cause pain and bleeding
Not safe prepregnancy
Day stay - although 50% require admission for analgesia MRgFUS Dr Andrew Dobrotwir - Radiologist RWH Causes
Endometrial hyperplasia
Endometrial cancer
Dysfunctional uterine bleeding
Causes of anovulation
Structural Causes Treatment - Medical
OCP, Cyclical progesterone
Non Hormonal
Tranexamic Acid
Mefenamic Acid Mirena -IUD Mirena - the blight of registrar training!

Has halved the hysterectomy rate
Has decimated the easy hysterectomy rate
Reduces bleeding by 80% in the first year
Increasing to 95% reduction in the next two years

Also useful in
simple endometrial hyperplasia
contraception with CV RFs
medical comorbidities - DVT... Can easily be placed at the diagnostic procedure Needs Hysteroscopy D+C Endometrial Ablation Useful next step when Mirena fails or is poorly tolerated Reduction in bleeding in 90% of cases Pros Cons Requires other contraception, and may cause problems if pregnancy results 20% will require further procedure Day stay with quick recovery - may avoid hysterectomy Technique Rollerball Diathermy
Non-disposable - cheaper
Tends to be done in public
Can remove submucous fibroids at the same time Novasure - impedence diathermy
Good burn Novasure Happy Ultrasound - 4mm endometrium 10% will be endometrial cancer Mostly atrophy - 60% Polyps - 10%
HRT - 10%
Hyperplasia - 10%
Cervical Ca
sarcoma Approach History Examination Pap - bimodal distribution High risk
Obesity, Diabetes, Tamoxifen, recurrent bleed
Low risk
Vaginal dryness, post-coital, dyspareunia
Recent menopause Source U/S < 4mm
Bleed not ongoing
No major risk factors
Does not need hysteroscopy sampling

Office endometrial sampling still preferable >4 mm
Recurrent bleeding
OR - a couple of...
Obese, Tamoxifen, Diabetes
>70 years old Hysteroscopy D+C Doctor I have been bleeding heavily all day and have soaked a dozen pads!! If hypovolaemic - hospital
Rule out pregnancy
Confirm uterine source and rule out masses/obvious pathology

Try and ascertain if this is ovulatory or anovulatory

If anovulatory - oral progesterone
Norethisterone (primolut) - 5-10mg qid until settles then 5mg bd for two weeks
Medroxyprogesterone Acetate (Provera) - 10mg qid until settles then bd for two weeks
Will have a withdrawal bleed after discontinuation If ovulatory
Tranexamic acid 1g qid until bleeding settles Then Investigate
Treat Anaemia Menorrhagia Defined as >80ml blood loss per cycle Practical definition - heavy or problem bleeding that leads to anaemia or significant impact on quality of life Broadly speaking - can be anovulatory (hormonal) or ovulatory (structural) Anovulatory 6 cases Twins Clinic Very High Risk Pregnancy Clinic Menstrual Management Clinic Gynaecology List - DDH Training Supervisor Private Obstetrician and Gynaecologist Periods every 6-8 weeks Floods and clots and occ embarrassing accidents Has been sexually active Normal examination Examination normal
Pap Normal
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