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Menstruation Disorders

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Menstruation Disorders

  1. 1. Menstruation Disorders Rupali Shah Medical Student Cardiff University
  2. 2. • What are the 3 phases of the menstrual cycle? • When does ovulation occur if you had a: – 28 day cycle – 35 day cycle
  3. 3. Define the following • Menorrhagia • Amenorrhoea • Oligomenorrhoea • Dysmenorrhoea
  4. 4. Heavy Menstrual Bleeding • Excessive mestrual loss • >80ml lost • Normal blood loss 35ml
  5. 5. Causes of menorraghia • Local – Fibroids – Polyps (uterine & cervical) – Endometriosis – Chronic PID – Cancer • Systemic – Thyroid disease – Coagulopathy (VWD) – Dysfunctional Uterine Bleeding
  6. 6. What would you want to ask patients? • Flooding • Clots (relatively objective measure) • Dysmenorrhoea before period suggests anatomical cause • Also ask about anaemia (breathlessness etc. as many women present with this)
  7. 7. Investigations • Hb • Exclude systemic cause (coag, TFTs) • Exclude organic cause – transvaginal US (rule our endometrial thickness) – Hysteroscopy (get biopsy eg for endometrial cause) • Cervical smear • Pelvic US (if fibroid/mass suspected) • Diagnostic laproscopy • Endometrial biopsy (pipelle) • TFT if indicated
  8. 8. Treatmeant • Medical – Antifibrinolytics (Plasmin inhibitors)- tranexamic acid – NSAIDs-mefanamic acid (contraindicated in asthma and duodenal ulcers) – GnRH agonists  amenorrhea (for temporary use due to severe side effects). – Progesterone impregnated IUD (Mirena) – Contraception(COC, contraindicated when at risk of clotting)
  9. 9. Surgical Treatment • Only when medical therapy has not worked • Hysteroscopic – Endometrial resection / ablation. Heat and laser therapy ablation. Very successful technique with 40% of women having complete amenorrheoa and 40% having reduction in menstrual bleeding. • Hysterectomy
  10. 10. Secondary Amenorrhoea • Cessation of menses >6 months in a woman who has previously menstruated • Can be physiological or pathalogical
  11. 11. Physiological Amenorrhoea • Pregnancy • Puerperium (after child birth) • Lactation • The menopause Pathological Amenorrhoea • Hypothalamic • Pituitary • Ovarian
  12. 12. Amenorhoea causes • Hypothalamic-Pituitary Ovarian Axis Dysfunction – Polycystic ovarian syndrome – Premature ovarian failure(Radiation, Chemotherapy, Autoimmunity) – Pituitary – prolactinoma, antipsychotic drugs, Sheehan’s. – Hypothalamic- Anorexia, stress, Kallman’s. • Thyroid dysfunction • Non-classical congenital adrenal hyperplasia • Outflow Obstruction – Asherman’s syndrome, cervical stenosis • Turners syndrome, Mullerian agenesis and imperforate hymen, are causes of primary amenorrhoea. This is defined as failure to menstruate by the age of 16.
  13. 13. Dysmenorrhoea – Painful periods – Associated with high prostaglandin levels – Due to contraction and uterine ischaemia Primary Dysmenorrhoea •No organic cause detected •Responds to NSAIDs Secondary Dysmenorrhoea • Pain due to pelvic pathology •Relieved by onset of menstruation •Causes include fibroids, adenomyosis, endometriosis PID, ovarian tumours
  14. 14. Post Coital Bleeding • Vaginal bleeding following intercourse that is not menstrual loss • Cervix is more likely to bleed after trauma if it isn’t covered by healthy squamous epithelium • Causes: – Cervical carcinoma – Cervical ectropion – Cervical polyps – Cervicitis, vaginitis
  15. 15. Management of post coital bleeding • inspect • Take smear • Colposcopy may be used to rule out malignant cause
  16. 16. Intermenstrual bleeding • May coexist with menorrhagia • More common at extremes of age • Causes are anovulatory cycles and pelvic pathology
  17. 17. Causes of intermenstrual bleeding • Anovulatory cycle – More common in early and late replroductive years • Pelvic pathology – Non malignant • Fibroids • Polyps (uterine/cervical) • Adenomyosis • Ovarian cycts • Chronic pelvic infection – Malignant • Ovarian • Cervical
  18. 18. Things you would want to know and investigate • Hb (amount lost) • US (mainly in women >35 yo and in younger women who haven’t responded to medication) • Endometrial biopsy (when endometrium is thick)
  19. 19. Management of intermenstrual bleeding • Drugs – No anatomical cause detected – COC – Progestogens (high dose  amenorrhoea) • Surgery – Polyp can be removed  histology
  20. 20. Things I haven’t covered today, but will cover in other presentations • Pre-menstrual syndrome • Post-menopausal bleeding • Oligomenorrhoea

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