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Reproductive Health (Y4) > 1- Menstrual disorders (physiology, history, PMS and menopause) > Flashcards

1- Menstrual disorders (physiology, history, PMS and menopause) Flashcards

1
Q

hormonal production involved in the menstural cycle

A
  • Hypothalamus: GnRH
  • Anterior pituitary: FSH and LH (work on the theca and granulosa cells)
  • Ovaries- progesterone and oestrogen (theca cells (converted from androgen by the granulosa cells)
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2
Q

normal duration of cycle

A

21-35 days (28 day average)

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3
Q

when does ovulation occur within the 28 day cycle

A

day 14
-> variation is due to the length of the follicular phase

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4
Q

the menstrual cycle is ….

A

2 cycles happening in parallel

1) Ovarian cycle
2) Uterine cycle

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5
Q

ovarian cycle summary

A

2 phases
 Pre- ovulation- follicular phase
 Post ovulation- luteal phase

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6
Q

follicular cycle summary

A

2 phases
 Pre-ovulation
* Period
* Proliferative
 Post-ovulation
* Secretory

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7
Q

the hypothalamic-pituitary-gonadal HPG axis

A

The hypothalamus, anterior pituitary gland and gonads (ovaries) work together to regulate the menstrual cycle.

  • GnRH from the hypothalamus stimulates luteinising hormone (LH) and follicular stimulating hormone (FSH) release from the anterior pituitary gland.
  • LH and FSH are gonadotropins that act primarily on the ovaries in the female reproductive tract
    o FSH binds to granulosa cells to stimulate follicle growth and also permits the conversion of androgens produced by the theca cells to oestrogen ->also stimulates inhibin ->which exerts negative feedback on FSH
    o LH binds to theca cells which produces androgens (need converting to oestrogen and progesterone (aromatase produced by granulosa cells)
  • Oestrogen and the HPG axis (levels of LH and FSH)
    o Moderate levels of oestrogen exerts a negative feedback effect on the HPG axis
    o At a high levels of oestrogen, negative feedback is converted to positive feedback to the HPG axis -> leads to surge in LH (not FSH due to inhibin) -> leading to ovulation
  • Oestrogen in the presence of progesterone (i.e. once the follicle is secreting a high level of progesterone in the luteal/ secretory phase) exerts negative feedback on the HPG -> preventing the development of another follicle
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8
Q

the ovarian cycle: follicular phase

A
  • Growth of follicles stimulated by FSH (which is secreted by the AP ->stimulated by GnRH release from hypothalamus (stimulated by activin secreted by granulosa cells))
    -> Primordial follicles ->primary follicles -> secondary follicles -> tertiary follicles
  • One of these follicles then becomes the ‘graafian follicle’ or dominant-> oocyte will be released during ovulation
  • As time goes by FSH levels reduce due to the release of inhibin
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9
Q

the ovarian cycle: ovulation

A
  • 1 day event
  • Due to spike in LH (day 14) ->surge in oestrogen
  • Oocyte bursts out of follicle
  • Level of oestrogen suddenly drops due to disruption in granulosa cell membrane
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10
Q

the ovarian cycle: luteal phase

A
  • empty follicle becomes CL
  • produces oestrogen and progesterone
  • Exerts negative feedback on LH and FSH to the hypothalamus -> prevents another follicle from being stimulated
  • the CL will remain for the rest of the cycle unless fertilised -> then becomes corpus albicans
  • if egg is fertilised it will stay for longer - stimulated by HCG released by embryo- until the placenta can take over the endocrine role
  • cycle restarted if egg is not fertilised and FSH levels will begin to increase again** `
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11
Q

uterine cycle: menstrual phase

A

o When period occurs ->shedding of lining of the endometrium
o When follicles (in ovarian cycle) start to grow)

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12
Q

uterine cycle: proliferative phase

A

mainly oestrogen
o Early proliferative= sparse glands, straight
o Late proliferative – thicker functional layer, glands coiled

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13
Q

uterine phase: secretory phase

A

mainly progesterone
o Secretory-endometrial thickness at maximum, very coiled glands, coiled arterioles
o Day 21-> best time for implantation
o Therefore most fertile time is few days before and after ovulation
o If egg not fertilised, CL degenerates, reduction in O and P -> loss of endometrial lining->menstrual phase

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14
Q

which layer of the ferilised egg releases HCG which prevents the corpus luteum from degenrating

A

syncytiotrophoblast

-> the CL which produces O and P maintains the endometrium -> perfect for implantation

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15
Q

which layer of the ferilised egg releases HCG which prevents the corpus luteum from degenrating

A

syncytiotrophoblast

-> the CL which produces O and P maintains the endometrium -> perfect for implantation

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16
Q

uterine layer histology

A
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17
Q

Steroid hormone action on the endometrium: Oestrogen

A

Highest in Follicular phase
o Thickening of endometrium
o Increases fallopian tube function- cilia which waft oocyte along fallopian tube
o Growth and motility of myometrium
o Produces thin alkaline cervical mucus- for sperm
o Vaginal changes
o Changes skin, hair, metabolism

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18
Q

Steroid hormone action on the endometrium: progesterone

A

Highest in Luteal phase
o Further thickening of endometrium (secretory)
o Thickening of myometrium and reduction of motility- to stop implanted embryo from being expelled
o Thick acidic cervical mucus
o Development of breast tissue
o Increased body temp
o Metabolic changes
o Electrolyte changes

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19
Q

how much blood is lost per cycle

A

MBL (37-43ml/cycle) mostly in first 48h

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20
Q

menstrual history

A

Opening
- Introduce self
- N and DoB
- Explain
- Consent

PC
- What has brought you in today?

HPC
- When was your last period
- Cycle length
- Is it regular
- Heavy or light?
- Any pain? (SOCRATES)
- Smear up to date?
- Sexually active?
- Any chance you could be pregnant?

If painful
- Timing of pain
- Location of pain

If heavy:
- duration of bleeding
- how much of the time it is heavy
- how much blood they think they have lost e.g. how many pads/ tampons
- note length of cycle (duration from the start of one period to the start of the next)
- ask about clots

other symptoms
- anaemia symptoms

PMH
- clotting disorders (easy bleeding gums or bruising)
- thyroid status- hypo especially
- gynaecological history

Ask about associated menstrual problems
- premenstrual syndrome
- intermenstrual bleeding
- postcoital bleeding
- dyspareunia
- pelvic pain

Drug history
- contraception
- pain killers
- blood thinners

Allergies

Social
- how its affecting everyday life e.g. time off work
- smoking
- alcohol
- sexual partners and protection

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21
Q

premenstrual syndrome (PMS)

A

describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.
- impact quality of life

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22
Q

when do the symptoms of PMS resolve

A

once menstruation begins

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23
Q

cause of PMS

A

premenstrual fluctuation in oestrogen and progesterone during menstrual cycle
- may be due to increased sensitivity to progesterone
- or interaction between sex hormoens and serotonin nd GABA

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24
Q

presentation of PMS

A

There is a long list of symptoms that can occur with premenstrual syndrome, and these will vary with the individual. Common symptoms include:
* Low mood
* Anxiety
* Mood swings
* Irritability
* Bloating
* Fatigue
* Headaches
* Breast pain
* Reduced confidence
* Cognitive impairment
* Clumsiness
* Reduced libido

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25
Q

PMS and contraception

A

can still occur in the presence of
- Mirena coil (ovaries continue to function)
- COCP
- cyclical hormone replacement containing progesterone (this is called Progesterone-induced premenstrual disorder)

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26
Q

when symptoms of PMS have a significant effect on quality of life this is called

A

premenstrual dysphoric disorder

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27
Q

Diagnosis of PMS

A

First line:
- Symptom diary spanning two menstrual cycles.
- The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation.

A definitive diagnosis:
- may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.

28
Q

Management of PMS

A
  • General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
  • Combined contraceptive pill (COCP)
  • SSRI antidepressants
  • Cognitive behavioural therapy (CBT)
29
Q

COCP and PMS

A

RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.

30
Q

use of continous transdermal oestrogen patches in PMS

A

Can improve symptoms
Must be used with progesterone to prevent endometrial hyperplasia.

Can be given in the form of
- low dose cyclical progestogens to trigger a withdrawal bleed or
- mirena coil

31
Q

if these first line interventions do not work, what must be considered to treat PMS

A

inducement of menoapuse

32
Q

how can menopause be induced

A
  • GnRH analogues - will need to use HRT to prevent osteoporosis)
  • Hysterectomy and bilateral oophorectomy- will also need HRt
33
Q

management of cyclical breast pain

A

Danazole and tamoxifen

34
Q

management of cyclical breast pain

A

Danazole and tamoxifen

35
Q

spironolactone and PMS

A

may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

36
Q

define menopause

A

permanent end to menstruation
retrospective diagnosis: no periods for 12 months

37
Q

define postmenopause

A

describes the period from 12 months after the final menstrual period onwards.

38
Q

perimenopause

A

Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.

39
Q

premature menopause

A

menopause before the age of 40 years.

It is the result of premature ovarian insufficiency.

40
Q

menopause is caused by

A

lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:

  • Oestrogen and progesterone levels are low
  • LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
41
Q

outline the physiology of menopause

A

Inside the ovaries, the process of primordial follicles maturing into primary and secondary follicles is always occurring, independent of the menstrual cycle. At the start of the menstrual cycle, FSH stimulates further development of the secondary follicles. As the follicles grow, the granulosa cells that surround them secrete increasing amounts of oestrogen.

1) The process of the menopause begins with a decline in the development of the ovarian follicles.
2) Without the growth of follicles, there is reduced production of oestrogen.
- Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced.
3) As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH.

4) The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles.
5) Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea).
6) Lower levels of oestrogen also cause the perimenopausal symptoms.

42
Q

Perimenopausal Symptoms

A

A lack of oestrogen in the perimenopausal period leads to symptoms of:

  • Hot flushes
  • Emotional lability or low mood
  • Premenstrual syndrome
  • Irregular periods
  • Joint pains
  • Heavier or lighter periods
  • Vaginal dryness and atrophy
  • Reduced libido
43
Q

risk of reduced oestrogen after menopause

A
  • Cardiovascular disease and stroke
  • Osteoporosis
  • Pelvic organ prolapse
  • Urinary incontinence
44
Q

blood test results for menopausal women

A
  • Oestrogen and progesterone levels are low
  • LH and FSH levels are high

*FSH is used to help with diagnosis *

45
Q

diagnosis of menopaise

A

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.

46
Q

contraception and the menopause

A

Women need to use effective contraception for:

Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50

47
Q

do contraception affect the menopause

A

no
- may suppress and amsk symptoms

48
Q

Good contraceptive options for women approaching the menopause are:

A

Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation

49
Q

Good contraceptive options for women approaching the menopause are:

A

Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation

50
Q

menopause and COCP

A

can be used up to the age of 50

Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options. *

51
Q

2 key side effects of the progesterone depot injection

A

weight gain and reduced bone mineral density (osteoporosis)

52
Q

Management of Perimenopausal Symptoms

Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include:

A
  • No treatment
  • Hormone replacement therapy (HRT)
  • Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
  • Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
  • Cognitive behavioural therapy (CBT)
  • SSRI antidepressants, such as fluoxetine or citalopram
  • Testosterone can be used to treat reduced libido (usually as a gel or cream)
  • Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
  • Vaginal moisturisers, such as Sylk, Replens and YES
53
Q

clonidone

A

Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.

Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitatio

54
Q

HRT and menopause basics

A

1) Exogenous oestrogen is given to alleviate symptoms
2) Progesterone is giving to prevent endometrial hyperplasia and endometrial cancer (secondary to unopposed oestrogen)

55
Q

risk of HRT

A
  • Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
  • Increased risk of endometrial cancer
  • Increased risk of venous thromboembolism (2 – 3 times the background risk)
  • Increased risk of stroke and coronary artery disease with long term use in older women
  • The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
56
Q

choosing the HRT formulation

A

Step 1: Do they have local or systemic symptoms?

Local symptoms: use topical treatments such as topical oestrogen cream or tablets

Systemic symptoms: use systemic treatment – go to step 2

Step 2: Does the woman have a uterus?

No uterus: use continuous oestrogen-only HRT

Has uterus: add progesterone (combined HRT) – go to step 3

Step 3: Have they had a period in the past 12 months?

Perimenopausal: give cyclical combined HRT
Postmenopausal: (more than 12 months since last period): give continuous combined HRT

57
Q

choosing the HRT formulation

A

Step 1: Do they have local or systemic symptoms?

  • Local symptoms: use topical treatments such as topical oestrogen cream or tablets
  • Systemic symptoms: use systemic treatment – go to step 2

Step 2: Does the woman have a uterus?

  • No uterus: use continuous oestrogen-only HRT
  • Has uterus: add progesterone (combined HRT) – go to step 3

Step 3: Have they had a period in the past 12 months?

  • Perimenopausal: give cyclical combined HRT
  • Postmenopausal (more than 12 months since last period): give continuous combined HRT
58
Q

example regimes for women with no uterus

A

Oestrogen-only pills, for example, Elleste Solo or Premarin
Oestrogen-only patches, for example, Evorel or Estradot

59
Q

example regimes for perimenopausal women with no periods

A
  • Cyclical combined tablets, for example, Elleste-Duet, Clinorette or Femoston
  • Cyclical combined patches, for example, Evorel Sequi or FemSeven Sequi
  • Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
  • Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot
60
Q

example regimes for postmenopausal women with a uterus

A

In a postmenopausal woman with a uterus:

  • Continuous combined tablets, for example, Elleste-Duet Conti, Kliofem or Femoston Conti
  • Continuous combined patches, for example, Evorel-Conti or FemSeven Conti
  • Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
  • Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot
61
Q

two main types of HRT

A

oestrogen only- no uterus (no risk of endometrial hyperplasia)

combine HRT (with progesterone)

62
Q

treatment for women with llow libido due to menopause

A

Tibolone- synthetic steroid hat stimulate oestrogen and porgesterone receptors - weakly stimulates androgen receptors (form of continuous combine HRT

Testosterone- initated and monitored by specialist - transdermal application

63
Q

Contraception with HRT

A

Hormone replacement therapy does not act as contraception. It is important to ensure perimenopausal women have adequate contraception. Common options are:

Mirena coil
* Progesterone only pill, given in addition to HRT

64
Q

Side effects of HRT

A

The oestrogen and progesterone components of HRT cause different side effects.

Oestrogenic side effects:

  • Nausea and bloating
  • Breast swelling
  • Breast tenderness
  • Headaches
  • Leg cramps

Progestogenic side effects:

  • Mood swings
  • Bloating
  • Fluid retention
  • Weight gain
  • Acne and greasy skin
65
Q

contraindication to HRT

A

Pregnancy.
Untreated hypertension.
Active liver disease with abnormal liver function tests.
Active or recent arterial thromboembolic disease.
Previous or current venous thromboembolism unless the women is on anticoagulation treatment.
Undiagnosed vaginal bleeding or untreated endometrial hyperplasia.

Reproductive Health (Y4) (34 decks)

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