Laser Vaginal Rejuvenation Institute of Adelaide

Menstrual Dysfunction

Features of Normal Menstrual Blood Loss

• Regular
• Duration of 4 - 7 days
• Cycle of 28 days (range 26 – 32)
• Not excessively heavy
  • (this can be quite relative as what is considered to be heavy by one woman might be considered to be normal by another).
• ± Passage of small clots

(If postmenopausal there should be no vaginal bleeding, however slight and of any colour whether it be a dark brown stain or a bright loss).

Types of Abnormal Uterine Bleeding

(Most problems with genital bleeding in women are a result of uterine function. Occasionally abnormal bleeding results from problems relating to vaginal, vulval, cervical or Fallopian tube problems)

Menorrhagia

• Heavy ± prolonged, regular menstrual blood loss. The amount of blood loss is a very subjective issue. What one woman finds to be ‘normal’ another may consider to be ‘heavy.’ In technical terms, any blood loss greater than 80ml during any menstrual period would be considered to be abnormally heavy. In clinical practice the volume of menstrual blood loss is rarely measured.

Polymenorrhoea

• Frequent ± prolonged periods where the amount of blood loss is considered to be normal. This usually indicates a cycle length of less than 26 days.

Polymenorrhagia

• Frequent, heavy ± prolonged heavy periods. This usually indicates a cycle length of less than 26 days.

Oligomenorrhoea

• Infrequent ± light menstrual blood loss.

Amenorrhoea

• Complete absence of periods.

Intermenstrual bleeding

• Bleeding that occurs between the normal menstrual periods. The definition does not take into account the degree of blood loss.

Postcoital bleeding

• Bleeding that occurs after intercourse.
  

The Process of Determining the Cause of Problem Genital Tract Bleeding

 

History:

• Cycle duration and length
• Number of pads used
• History of flooding and clots
• Ask specifically about intermenstrual and postcoital bleeding
• Duration of the problem
• Past gynaecological and obstetric history (including timing and results of last cervical smear, method of contraception and last menstrual bleeding)
• Medical, surgical and drug history

Clinical Examination:

• Anaemia
• Goitre
• Presence of abdominal mass?
• Rectal examination
• Genitalia;
  • Quality and oestrogenisation of tissues
  • Evidence of vaginal wall prolapse
  • Cervix (polyps/erosions)
  • Uterine size and mobility

Blood Picture Examination:

• Complete blood picture
• Liver function tests
• Renal function tests
• Thyroid function tests

More specialized tests such as:

• Iron binding studies
• Clotting studies
• Urine tests;
  • Dipstick urine test (Microscopic haematuria)
  • Mid stream specimen of urine (Urinary tract infection)
  • Urine cytology (abnormal bladder cells)
• Histological (tissue specimen) tests
  • Endometrial biopsy
  • Cervical biopsy
• Protoscopy and Sigmoidoscopy
• Cystoscopy
• Laparoscopy
• Hysteroscopy
  • Considered to be the gold standard investigation of the endometrial cavity as it allows for direct visualization which can be followed by target biopsy.

	Endometrial Polyp visualized during hysteroscopy (can sometimes be imaged during an ultrasound assessment of the uterus)
	Endometrial Polyp visualized during hysteroscopy (can sometimes be imaged during an ultrasound assessment of the uterus)
	This atrophic endometrial cavity was noted in a postmenopausal woman who presented with a postmenopausal bleed. The lining was thin and dry with no evidence of endometrial cancer. The appropriate treatment was local oestrogen therapy

 

Radiological Investigations:

• Abdominal and pelvic X-rays
• Ultrasound scan of pelvis, abdomen and renal tract
• CAT scan
• MRI

 

Causes of Abnormal Menstrual Bleeding

 

Hormonal:

• Changes in cycle related to age
• Non specific changes
• Changes related to presence or absence of ovulatory and non-ovulatory cycles

Benign lesions:

• Endometrial polyps
• Cervical polyps
• Adenomyosis
• Pelvic Inflammatory Disease
• Endometriosis
• Fibroids
• Pelvic Inflammatory Disease
• Endometriosis
• Fibroids

Large fibroid filing abdominal cavity removed via open surgery. This uterus has large pedunculated subserosal fibroids as well as intramural fibroids. Submucous fibroids were noted when the uterus was split open after removal

• Submucous
• Subserosal
• Intramural

Uterine abnormalities enlarging the cavity - e.g. A double uterus

Uterus didelphys (double uterus)

 

Cancerous lesions:

• Cervix
• Uterus
• Fallopian tubes
• Ovaries
• Vagina
• Vulva
• Bladder

Drugs:

• The combined oral contraceptive pill
• The progesterone only pill
• Implanted or inserted progesterone only devices
• Anticoagulants such as Warfarin
• Intrauterine contraceptive devices
• Hormone replacement therapy (HRT)
  

Endometrial Ablation

• Mininal invasive technique used to destroy the endometrium (lining of the uterus which is shed during menstruation)
• These techniques are usually done as daycase procedures involving a short general anaesthetic
• No incisions are required and recovery is speedy with a rapid return to normal activities
  
• Outcomes
  
  • 80-90% satisfaction with overall outcome
  • 15-50% having no further menstrual bleeding
  • 60-70% reporting lighter, shorter and more manageable periods
  • 15-35% will undergo a further endometrial ablation or will proceed to hysterectomy

 

• Some endometrial ablation techniques can be repeated if avoidance of hysterectomy is a priority.
• These techniques are only suitable for women who have completed their families as the endometrium is rendered inhospitable to future pregnancy (and hence effective contraception is essential).
• Intercourse should be avoided for 4-6 weeks after surgery.
• Patients can experience lower abdominal cramping discomfort for a few days and some will get a watery per vaginal discharge that can last up to 4 weeks.
• Occasionally some women experience an offensive vaginal discharge which resolves after treatment with antibiotics.
• Endometrial ablation is usually combined with hysteroscopic assessment of the endometrium and endometrial biopsy to exclude non-benign causes of the heavy bleeding and to ensure that there are no lesions within the endometrial cavity that would be a contraindication for performing the endometrial ablation

 

Contraindications to endometrial ablation:

• Uterine malignancy
• Desire for future pregnancy
• Acute pelvic infection
• Excessive endometrial cavity length

Types of endometrial ablation systems:

• First Generation Endometrial Ablation Therapy (FEAT)
  • Transcervical resection of endometrium
  • Rollerball
  • Laser
• Second Generation Endometrial Ablation Therapy (SEAT)
  • Thermal balloons
  • Hot fluid circulation
  • Laser devices
  • Cryosurgery
  • Microwave
  • Monopolar electrical devices
  • Bipolar electrical devices

Hysterectomy

• Involves removal of the uterus
• Does not involve removal of the ovaries unless specified separately
• Does not involve changes to the hormonal profile (unless the ovaries are removed in a woman who has not had her menopause)
• Can bring forward the time of natural cessation of ovarian functions (menopause) by 0 – 18 months depending on the individual woman
• Inpatient stay from 1 - 5 days depending on individual recovery, surgeon and other surgery performed
• Recovery 2-6 weeks depending on technique, individual background health and occupation
• Can be combined with other pelvic/vaginal procedures:
  • Vaginal wall repair
  • Urinary Incontinence surgery
  • Laser Vaginal Rejuvenation
  • Designer Laser Vaginoplasty

Indications:

• Abnormal menstrual bleeding
  • Usually prolong ± heavy bleeding not responsive to conservative measures
• Enlarged uterus
• Uterine prolapse
• Genital tract cancer
  • Cervical
  • Uterine
  • Ovarian
  • Fallopian tube

Types of hysterectomy:

• Total abdominal
  • Removal of uterus and cervix from open surgery
• Subtotal
  • Removal of uterus with preservation of cervix most commonly during open surgery but occasionally during vaginal or laparoscopic surgery
• Total laparoscopic
  • Keyhole surgical removal of uteru (and usually the cervix)
• Laparoscopically assisted
  • Combined laparoscopic and vaginal technique to remove uterus (± cervix)
• Vaginal
  • Vaginal route to remove uterus (± cervix)