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Page 1 of 2

  • Chapter 1 - Revision Guide Part 1 MRCOG
  • from 1 - Introduction
  • Edited by Alison Fiander, Cardiff University, Baskaran Thilaganathan
  • Book: MRCOG Part One
  • Published online: 27 January 2017
  • Print publication: 13 October 2016, pp 3-4
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Menstrual Problems for the MRCOG and Beyond
  • Menstrual Problems for the MRCOG and Beyond
  • 2nd edition
  • Mary Ann Lumsden, Margaret Rees
  • Published online: 05 June 2014
  • Print publication: 27 February 2014
  • View description
    Menstrual problems are among the most common reasons for primary care and specialist referral. Therefore, it is important for all gynaecologists and primary care practitioners to have a basic understanding of menstrual reproductive physiology to enable them to counsel women safely and accurately. This second edition has been comprehensively updated to reflect current clinical practice and new research. The contents cover the diagnosis, management and treatment - both medical and surgical - of a wide range of menstrual disorders, including excessive menstrual loss; fibroids; dysmenorrhoea; endometriosis; chronic pelvic pain; delayed menarche; premature ovarian failure; polycystic ovary syndrome; and premenstrual syndrome. This is a perfect introduction for any gynaecologist who needs an accessible and concise introduction to modern management of menstrual problems. It also acts as an ideal revision guide for candidates preparing for the Part 2 MRCOG examination, fully covering the RCOG curriculum for menstrual problems.
  • 7 - Dysmenorrhoea
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 83-90
  • View extract

    Summary

    Dysmenorrhoea is common and many women consider it to be a normal part of menstruation. For a teenager, congenital uterine abnormalities may present with dysmenorrhoea. Endometriosis is the most common identifiable pathology associated with dysmenorrhoea. At the initial consultation an assessment should be made of the severity of pain and the level of disruption caused. Dysmenorrhoea may begin a few hours before the onset of bleeding, but should tail away as the bleeding ends, or before. Contraception may be required in addition to treatment of the dysmenorrhoea. The combined oestrogen-containing pill offers good contraception and substantial reduction in dysmenorrhoea. The pill may be particularly helpful if the menstrual cycle is chaotic due to anovulatory cycles. If symptoms are particularly troublesome and the woman wishes to stop the bleeding all together, she may choose high-dose progestogens or a GnRH analogue.
  • 4 - Medical management of excessive menstrual bleeding
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 37-46
  • View extract

    Summary

    Management of excessive menstrual bleeding has changed over the past two decades with the promotion of effective medical treatments and in particular the use of the levonorgestrel-releasing intrauterine device. The aims of therapy are to reduce blood loss, reduce the risk of anaemia and improve quality of life. Non-hormonal treatment options for excessive menstrual bleeding are non-steroidal anti-inflammatory drugs, antifibrinolytics, and etamsylate. Intrauterine administration of levonorgestrel, oral and intramuscular progestogens, oestrogen/progestogen combinations, and antiprogestogens are used as hormonal treatments for excessive menstrual bleeding. Plasminogen activator inhibitors have been promoted as a treatment for excessive menstrual bleeding because of increased endometrial fibrinolytic activity in women. The use of progestogens is based on the erroneous concept that women with excessive menstrual bleeding principally have anovulatory cycles and require progestogen supplementation. From clinical experience, combined oral contraceptives (COCs) are generally considered to be effective in the management of dysfunctional menstrual bleeding.
  • 5 - Surgical management of menstrual problems
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 47-68
  • View extract

    Summary

    The surgical options for the management of menstrual problems are chiefly endometrial ablation as a uterine conserving procedure and either total or subtotal hysterectomy, which can be performed by a number of routes. Endometrial ablation represents the most thoroughly evaluated surgical treatment to date. Endometrial techniques are divided into first generation and second generation techniques. First generation techniques include transcervical resection of the endometrium (TCRE), rollerball endometrial ablation (RBEA), and endometrial laser ablation (ELA). They offer the benefit of direct vision and require a fluid distension media. Second generation techniques are: thermal balloon ablation, microwave endometrial ablation (MEA), NovaSure, Hydro ThermAblator, and cryosurgical ablation. Second-generation ablative techniques have been evolved to simplify the technique and ideally place endometrial ablation safely in the hands of all gynaecologists. Total hysterectomy is the only surgical treatment for menstrual problems that guarantees amenorrhoea. Satisfaction with hysterectomy is higher than that with ablation.
  • 13 - Premenstrual syndrome
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 139-146
  • View abstract

    Summary

    The surgical options for the management of menstrual problems are chiefly endometrial ablation as a uterine conserving procedure and either total or subtotal hysterectomy, which can be performed by a number of routes. Endometrial ablation represents the most thoroughly evaluated surgical treatment to date. Endometrial techniques are divided into first generation and second generation techniques. First generation techniques include transcervical resection of the endometrium (TCRE), rollerball endometrial ablation (RBEA), and endometrial laser ablation (ELA). They offer the benefit of direct vision and require a fluid distension media. Second generation techniques are: thermal balloon ablation, microwave endometrial ablation (MEA), NovaSure, Hydro ThermAblator, and cryosurgical ablation. Second-generation ablative techniques have been evolved to simplify the technique and ideally place endometrial ablation safely in the hands of all gynaecologists. Total hysterectomy is the only surgical treatment for menstrual problems that guarantees amenorrhoea. Satisfaction with hysterectomy is higher than that with ablation.
  • 3 - Investigation
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 17-36
  • View extract

    Summary

    The purpose of uterine cavity evaluation is to make an accurate diagnosis of the cause of abnormal uterine bleeding, in order that therapy can be appropriately tailored to the woman. This chapter reviews the accuracy and efficacy of currently available tests used to evaluate the uterine cavity. Uterine size can be assessed on bimanual examination; if the uterus is greater in size than 12 weeks of gestation, it may be palpable abdominally. Women with amenorrhoea (no menstrual bleeding for 6 months) should have a full history and examination. Dilatation and curettage (D&C) used to be the method of choice for assessing the uterine cavity. Other methods for assessing the uterine cavity include hysteroscopy, ultrasound, Doppler ultrasound, and outpatient endometrial biopsy. Women presenting with postmenopausal bleeding require urgent referral for pelvic ultrasound and further testing, with endometrial biopsy and/or hysteroscopy undertaken depending on the initial ultrasound result.
  • 12 - Polycystic ovary syndrome
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 129-138
  • View abstract

    Summary

    Management of excessive menstrual bleeding has changed over the past two decades with the promotion of effective medical treatments and in particular the use of the levonorgestrel-releasing intrauterine device. The aims of therapy are to reduce blood loss, reduce the risk of anaemia and improve quality of life. Non-hormonal treatment options for excessive menstrual bleeding are non-steroidal anti-inflammatory drugs, antifibrinolytics, and etamsylate. Intrauterine administration of levonorgestrel, oral and intramuscular progestogens, oestrogen/progestogen combinations, and antiprogestogens are used as hormonal treatments for excessive menstrual bleeding. Plasminogen activator inhibitors have been promoted as a treatment for excessive menstrual bleeding because of increased endometrial fibrinolytic activity in women. The use of progestogens is based on the erroneous concept that women with excessive menstrual bleeding principally have anovulatory cycles and require progestogen supplementation. From clinical experience, combined oral contraceptives (COCs) are generally considered to be effective in the management of dysfunctional menstrual bleeding.
  • 2 - Excessive menstrual bleeding
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 7-16
  • View extract

    Summary

    Excessive menstrual bleeding describes the clinical problems of heavy menstrual blood loss together with frequent or irregular menstruation. This chapter addresses endometrial morphology, the mechanism of menstruation and the aetiology and management of menstrual problems. A very common cause relates to ovulatory dysfunction, which typically leads to a combination of irregular bleeding and a variable volume of menstrual flow, which can lead to heavy menstrual bleeding (HMB). Clotting disorders such as von Willebrand's disease are another cause of HMB. Reduced clotting is a known feature at the time of menstruation. Pelvic pathologies such as fibroids are common, affecting between 20 and 25% of women. It is reported that around a third of women with fibroids complain of heavy menstrual blood loss. There are a number of terminologies to describe menstrual complaints such as menorrhagia, polymenorrhoea, oligomenorrhoea, polymenorrhagia and metrorrhagia.
  • 9 - Chronic pelvic pain
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 103-114
  • View abstract

    Summary

    This introduction discusses the aetiology of menstrual problems, their presentation and investigation as well as medical and surgical management. Specific problems such as fibroid-associated bleeding, adolescent and perimenopausal bleeding and breakthrough bleeding are covered, as are other critically important problems such as premenstrual disorders, pelvic pain and dysmenorrhoea. The most common presenting menstrual problem is heavy menstrual bleeding (HMB). A woman's approach to her periods will vary through her reproductive life. After childbearing is completed, the view of the menses will alter dramatically. The longest intermenstrual interval occurs at the menarche. Menstrual irregularity is most likely to occur at the extremes of reproductive life, the incidence of anovulation increasing as the menopause approaches. Classical primary spasmodic dysmenorrhoea occurs at the onset of the menses and gets better after 1 or 2 days, whereas secondary dysmenorrhoea tends to start prior to the menses and worsens as it proceeds.
  • 10 - Delayed menarche
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 115-118
  • View abstract

    Summary

    Excessive menstrual bleeding describes the clinical problems of heavy menstrual blood loss together with frequent or irregular menstruation. This chapter addresses endometrial morphology, the mechanism of menstruation and the aetiology and management of menstrual problems. A very common cause relates to ovulatory dysfunction, which typically leads to a combination of irregular bleeding and a variable volume of menstrual flow, which can lead to heavy menstrual bleeding (HMB). Clotting disorders such as von Willebrand's disease are another cause of HMB. Reduced clotting is a known feature at the time of menstruation. Pelvic pathologies such as fibroids are common, affecting between 20 and 25% of women. It is reported that around a third of women with fibroids complain of heavy menstrual blood loss. There are a number of terminologies to describe menstrual complaints such as menorrhagia, polymenorrhoea, oligomenorrhoea, polymenorrhagia and metrorrhagia.
  • 6 - Uterine fibroids and heavy menstrual bleeding
  • Mary Ann Lumsden, University of Glasgow, Margaret Rees, University of Oxford
  • Book: Menstrual Problems for the MRCOG and Beyond
  • Published online: 05 June 2014
  • Print publication: 27 February 2014, pp 69-82
  • View extract

    Summary

    Uterine fibroids are the most common tumour of the female reproductive tract and occur in approximately 25% of women of reproductive age. Diagnosis of fibroids is made by imaging, either ultrasound or magnetic resonance imaging (MRI). Oestrogen is essential for fibroid growth. Gonadotrophin-releasing hormone (GnRH) agonists downregulate the pituitary with the subsequent decrease in estradiol levels leading to fibroid shrinkage. Standard treatment of fibroids consists of hysterectomy and myomectomy, the former being appropriate for those women who have completed their families and the latter for those who wish to retain their uterus. Uterine artery embolization (UAE) has been carried out for the treatment of uterine fibroids since 1995. UAE is successful in decreasing menstrual blood loss. The objective of UAE is to completely infarct all the fibroid tissue while preserving the uterus, ovaries and surrounding pelvic tissues.

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