Gynecology 5th year, 4th lecture (Dr. Sindus)

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The lecture has been given on Dec. 8th, 2010 by Dr. Sindus.

Published in: Health & Medicine

Gynecology 5th year, 4th lecture (Dr. Sindus)

  1. 1. Disorders of the menstrual cycle
  2. 2. <ul><li>Disorders of the menstrual cycle are one of the most common reasons for women to attend their general practitioner and, subsequently, a gynaecologist. Although rarely life threatening, menstrual disorders lead to major social and occupational disruption, and can also affect </li></ul><ul><li>psychological well-being. </li></ul><ul><li>Menstrual disorder include : </li></ul><ul><li>1 – menorrhagia. </li></ul><ul><li>2 – dysmenorrhoea. </li></ul><ul><li>3 – amenorrhoea/oligomenorrhoea. </li></ul><ul><li>4 – PCOD. </li></ul><ul><li>5 – postmenopausal bleeding. </li></ul><ul><li>6 – premenstrual syndrome. </li></ul>
  3. 3. <ul><li>There are many Latin words to describe abnormal vaginal bleeding. It is better to use Anglo-Saxon and describe the symptoms as heavy periods or prolonged periods but the classic terms are still in use and need definition. </li></ul><ul><li>• Menorrhagia is an excessive loss of blood (>80ml) with regular menstruation. </li></ul><ul><li>• Metrorrhagia is prolonged bleeding from the uterus. </li></ul><ul><li>• Metro-menorrhagia is heavy and prolonged periods. </li></ul><ul><li>• Polymenorrhoea is frequent menstruation. </li></ul>
  4. 4. <ul><li>These may be associated with </li></ul><ul><li>1 Complications of early and undiagnosed pregnancy. </li></ul><ul><li>• Miscarriage. </li></ul><ul><li>• Ectopic pregnancy. </li></ul><ul><li>• Hydatidiform mole. </li></ul><ul><li>2 Foreign bodies in the uterus—intrauterine contraceptives. </li></ul><ul><li>3 Treatment with hormones especially in menopausal and postmenopausal women. Breakthrough bleeding may occur with synthetic progestogens given for oral contraception or for treatment of pelvic disorders. </li></ul><ul><li>4 Psychosomatic causes, for example a severe emotional </li></ul><ul><li>shock, may induce irregular bleeding. </li></ul><ul><li>5 An abnormal bleeding tendency may be present </li></ul><ul><li>such as leukaemia or Hodgkin’s disease. </li></ul><ul><li>6 Hyper- or hypothyroidism may be associated with </li></ul><ul><li>menorrhagia or irregular bleeding. </li></ul>
  5. 5. <ul><li>MENORRHAGIA </li></ul><ul><li>Definition: The average menstrual period lasts for 3-7 days, with </li></ul><ul><li>a mean blood loss of 35 mL. </li></ul><ul><li>Menorrhagia ('heavy periods') is defined as a blood loss of greater than 80 mL per period. This definition is rather arbitrary, but represents the level of blood loss at which a fall in haemoglobin and haematocrit concentration commonly occurs. </li></ul><ul><li>Prevalence : Menorrhagia is extremely common. Indeed, each </li></ul><ul><li>year in the UK, 5 per cent of women between the ages of 30 and 49 consult their general practitioner with this complaint . </li></ul>
  6. 6. <ul><li>Classification: </li></ul><ul><li>Menorrhagia can be classified as: </li></ul><ul><li>• idiopathic, where no organic pathology can be found: idiopathic menorrhagia is otherwise known as dysfunctional uterine bleeding-(DUB). </li></ul><ul><li>The majority of women who present with menorrhagia will have DUB, </li></ul><ul><li>• secondary to an organic cause, such as fibroids. </li></ul><ul><li>Aetiology: Despite extensive research, the aetiology of DUB remains unclear . Disordered endometrial prostaglandin production has been implicated in the aetiology of this condition, as have abnormalities of endometrial vascular development. </li></ul><ul><li>With decreasing family size, women now experience many more menstrual cycles. Additionally, the changing role of women in society and more liberated attitudes to the discussion of sexual and reproductive health mean that women are now much less likely to tolerate menstrual loss that they consider to be excessive. </li></ul>
  7. 7. <ul><li>Other physiology: </li></ul><ul><li>Menorrhagia is a feature of a number of organic conditions, which should be considered in the differential diagnosis. These include: </li></ul><ul><li>• von Willebrand's disease, </li></ul><ul><li>• other bleeding diatheses, </li></ul><ul><li>• fibroid uterus, </li></ul><ul><li>• endometrial polyp, </li></ul><ul><li>• thyroid disease, </li></ul><ul><li>• drug therapy, including intrauterine contraceptive devices (IUCDs), </li></ul><ul><li>• bleeding in pregnancy. </li></ul><ul><li>Clinical features: </li></ul><ul><li>History: The hallmark of menorrhagia is the complaint of regular 'excessive' menstrual loss occurring over several consecutive cycles. This is largely a subjective definition and it can be hard for the woman to communicate in words how much blood she is losing . </li></ul>
  8. 8. <ul><li>Discussion of the number of towels and tampons used per day may be useful - perhaps accompanied by a menstrual pictogram in selected cases. Of perhaps greater relevance is to determine the impact of the condition on the patient's lifestyle and quality of life. For example, the patient whose menorrhagia is so severe that she does not leave the house during her period clearly has a much greater problem (and may wish to pursue treatment further) than one to whom menorrhagia is a minor inconvenience. </li></ul><ul><li>It is also important to determine the duration of the current problem, and any other symptoms or factors of potential importance. The following symptoms should be enquired about specifically, as they may suggest a diagnosis other than DUB: </li></ul><ul><li>irregular, intermenstrual or postcoital bleeding, a sudden change in symptoms, dyspareunia, pelvic pain or premenstrual pain, and excessive bleeding from other sites or in other situations (e.g. after tooth extraction). </li></ul>
  9. 9. <ul><li>Clinical examination: </li></ul><ul><li>Unless specific factors in the history alert the clinician to the presence of organic disease, clinical examination of women presenting with menorrhagia usually fails to reveal any significant signs. Despite this, it is important to perform a physical examination, including an abdominal and bimanual pelvic examination, in all women complaining of menorrhagia. A cervical smear should be performed if one is due. </li></ul><ul><li>Abnormalities on clinical examination require further investigation. Depending on their nature, they may either suggest an organic cause for the menorrhagia (e.g. an enlarged uterus might suggest a diagnosis of </li></ul><ul><li>uterine fibroids), or may point to other (coincident) pathology entirely. </li></ul>
  10. 10. <ul><li>Initial investigations: </li></ul><ul><li>Full blood count </li></ul><ul><li>A full blood count (FBC) is done to ascertain the need for iron therapy. </li></ul><ul><li>In women in whom menorrhagia is the only relevant symptom, and in whom examination reveals no abnormalities (other than perhaps a slightly enlarged uterus, no greater than 10 weeks' gestation in size), further extensive investigation is not needed. Specifically, tests of thyroid function and endometrial assessment are not required routinely. </li></ul><ul><li>Investigations in women who fail to respond to treatment after 3 : months </li></ul><ul><li>• Transvaginal ultrasound, to look at the myometrium, endometrium and ovaries . </li></ul><ul><li>• Endometrial thickness should be less than 12mm in perimenopausal women. </li></ul><ul><li>• 5mm in postmenopausal women. </li></ul><ul><li>• Endometrial polyps. </li></ul><ul><li>• Fibroids. </li></ul><ul><li>• Ovarian pathology in women with PCOS. </li></ul><ul><li>• Endometrial biopsy (with hysteroscopy if transvaginal ultrasound is abnormal). </li></ul>
  11. 11. <ul><li>i.E We need biopsy in the following: (a) Women over 40. </li></ul><ul><li>(b) Those with abnormal endometrial thickness. </li></ul><ul><li>(c) Those with endometrial polyps. </li></ul><ul><li>Treatments: There is a host of different treatments for menorrhagia, all of which have different efficacies and side effects. </li></ul><ul><li>Each treatment option is associated with a different array of side </li></ul><ul><li>effects, which may be acceptable to some women but not others. For these reasons, and since menorrhagia is rarely life threatening but has an adverse impact on the woman's quality of life, it is essential that the treatment plan is determined in collaboration with the patient. </li></ul><ul><li>Medical treatments for menorrhagia: </li></ul><ul><li>Drugs that are compatible with ongoing attempts at conception </li></ul><ul><li>• Mefenamic acid and other non-steroidal, anti-inflammatory drugs (NSAIDs) </li></ul><ul><li>• Tranexamic acid </li></ul>
  12. 12. <ul><li>Drugs that are incompatible with ongoing attempts at conception but not licensed for use as contraceptives </li></ul><ul><li>• Danazol </li></ul><ul><li>• 200mg daily continuously for three to six months </li></ul><ul><li>• Derivative of testosterone so anti-oestrogenic at hypothalamus and at endometrium. </li></ul><ul><li>Drugs licensed for use as contraceptives that are effective in the treatment of menorrhagia </li></ul><ul><li>• Combined oral contraceptive pill </li></ul><ul><li>• LNG-IUS </li></ul><ul><li>Second-line drugs with few advantages over the forgoing, and whose side effects limit long-term use </li></ul><ul><li>• Danazol </li></ul><ul><li>• Gestrinone </li></ul><ul><li>• Gonadotrophin-releasing hormone analogues. </li></ul>
  13. 13. <ul><li>Drugs compatible (with caution) with ongoing attempts at conception </li></ul><ul><li>Mefenamic acid and other non-steroidal anti-inflammatory drugs </li></ul><ul><li>(500mg six-hourly during menstruation Avoid if peptic ulceration) .These agents are associated with a reduction in mean menstrual blood loss (MBL) of about 35 mL. This may be sufficient in some women to restore menstrual blood loss either to normal or to a level that is compatible with normal life. Their mode of action is probably in restoring imbalanced endometrial prostaglandin synthesis. An added benefit of these drugs is their pain relieving properties; thus they are useful alone or in combination for women who complain of both menorrhagia and dysmenorrhoea. </li></ul><ul><li>Tranexamic acid </li></ul><ul><li>(1 g six-hourly during menstruation). This agent is associated with a mean reduction in MBL of about 50-100 mL. Its mode of action is by inhibiting fibrinolysis (clot breakdown) in the endometrium. In view of this, theoretical concerns have been raised that tranexamic acid may be associated with an increased risk of venous thrombosis. </li></ul>
  14. 14. <ul><li>Drugs incompatible with ongo ing attempts at conception but not licensed for use as contraceptives </li></ul><ul><li>Danazol </li></ul><ul><li>Treatment with danazol for 2-3 months is associated with a mean reduction in MBL in the order of 100 mL. However, danazol is associated with androgenic side effects such as weight gain, acne, hirsutism and voice changes. Although the majority of these (with the exception of voice changes) are reversible on cessation of treatment, the fact that they can occur is enough to prevent most women with menorrhagia from opting for danazol treatment . </li></ul><ul><li>Drugs licensed for use as contraceptives that are effective in the treatment of menorrhagia </li></ul><ul><li>Combined oral contraceptive pill : </li></ul><ul><li>The combined oral contraceptive pill (COCP) is widely used for the treatment of menorrhagia, particularly by women who require contraception, and is believed to be effective. </li></ul>
  15. 15. <ul><li>COCP demonstrate a mean reduction in MBL of around 50 per ,cent. The side effects of the combined contraceptive pill are well known and, although no worse than the alternatives, many women are reluctant </li></ul><ul><li>to take the COCP for non-contraceptive uses because of the potential adverse effects. </li></ul><ul><li>LNG-IUS </li></ul><ul><li>It is no exaggeration to say that the LNG-IUS has revolutionized the treatment of menorrhagia. For the first time, the LNG-IUS provides a highly effective alternative to surgical treatment for menorrhagia, with few side effects. </li></ul><ul><li>Mean reductions in MBL of around 95 per cent by 1 year after LNG-IUS insertion have been demonstrated. These results are similar to those for the surgical procedure endometrial resection, and the patient satisfaction rates for the two treatments were found to be similar . Notwithstanding, the side effect of irregular menses for the first 3-6 months after insertion should be discussed in detail with the patient. Around 30 per cent of women with the LNG-IUS are amenorrhoeic by 1 year after insertion.. </li></ul>
  16. 16. <ul><li>Second-line drugs with few advantages over the forgoing and whose side effects limit long- term use </li></ul><ul><li>• Danazol </li></ul><ul><li>• Gestrinone </li></ul><ul><li>• Gonadotrophin- releasing hormone (GnRH) analogues. </li></ul><ul><li>Medical and surgical treatments that ai'e not effective in the treatment of menorrhagia: </li></ul><ul><li>• Ethamsylate </li></ul><ul><li>• Luteal phase progestogens </li></ul><ul><li>• Uterine curettage. </li></ul><ul><li>Surgical treatments for menorrhagia: </li></ul><ul><li>Surgical treatment is normally restricted to women for whom medical treatments have failed. </li></ul><ul><li>Womem contemplating surgical treatment for menorrhagia should be certain that their family is complete. </li></ul>
  17. 17. <ul><li>Women wishing to preserve their fertility for future attempts at childbearing should therefore be advised to have the LNG-IUS rather than endometrial ablation or hysterectomy. </li></ul><ul><li>Endometrial ablation </li></ul><ul><li>All endometrial destructive procedures employ the principle that ablation of the endometrial lining of the uterus to sufficient depth prevents regeneration of the endometrium. During normal menstruation, the upper functional layer of the endometrium is shed, whilst the basal 3 mm of the endometrium is retained. </li></ul><ul><li>In endometrial ablation, the basal endometrium is destroyed, and thus there is little or no remaining endometrium from which functional endometrium can regenerate. </li></ul><ul><li>There is a variety of methods by which endometrial ablation can be achieved, including the following. </li></ul>
  18. 18. <ul><li>Methods performed under direct visualization at hysteroscopy: </li></ul><ul><li>• Laser </li></ul><ul><li>• Diathermy </li></ul><ul><li>• Transcervical endometrial resection. </li></ul><ul><li>Methods performed non-hysteroscopically (i.e. without direct visualization of the endometrial cavity at the time of the procedure) </li></ul><ul><li>• Thermal uterine balloon therapy </li></ul><ul><li>• Microwave ablation </li></ul><ul><li>• Heated saline. </li></ul><ul><li>All the above operations are performed through the uterine cervix. Most take around 30-45 minutes to perform, and in the majority of cases the patient can return home that evening. The mean reduction in MBL associated with endometrial ablation is around </li></ul><ul><li>90 per cent. </li></ul>
  19. 19. <ul><li>The complications associated with endometrial ablation include uterine perforation, haemorrhage and fluid overload. Around 4 per cent of women have some sort of immediate complication. In 1 per cent of women, the complications arising during the procedure are sufficiently serious to prompt either laparotomy or another unplanned surgical procedure. </li></ul><ul><li>Hysterectomy </li></ul><ul><li>Hysterectomy involves the removal of the uterus. It is an extremely common surgical procedure. </li></ul><ul><li>Hysterectomy can be 'total', in which the uterine cervix is also removed, or 'subtotal', in which the cervix is retained. Hysterectomy is often accompanied by bilateral oophorectomy (removal of both ovaries). </li></ul><ul><li>The precise choice of operation should be determined after detailed discussion between the doctor and patient. In terms of the treatment of menorrhagia, it is removal of the uterus that effects a cure, and '-thus removal of the cervix and/ or ovaries is an 'optional extra'. </li></ul>
  20. 20. <ul><li>The main perceived advantage of oophorectomy is a reduced risk of ovarian cancer. Additionally, women with pelvic pain and/or severe premenstrual syndrome in addition to their menorrhagia may find that hysterectomy and bilateral salpingo-oophorectomy is more effective at treating their symptoms than hysterectomy alone. </li></ul><ul><li>These advantages have to be set against the adverse effects of oestrogen loss on bone density for women who do not take hormone replacement therapy (HRT) after oophorectomy. </li></ul><ul><li>Mode of hysterectomy </li></ul><ul><li>Total hysterectomy may be achieved using three main techniques: </li></ul><ul><li>• abdominal hysterectomy </li></ul><ul><li>• vaginal hysterectomy </li></ul><ul><li>• laparoscopically assisted hysterectomy. </li></ul>

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