3.2

Question 1

Define amenorrhoea

Answer 1

Absence of periods for at least 6 months.

Question 2

What is primary amenorrhoea?

Answer 2

Never had a period
Absence of menses by age 14 with absence of secondary sexual characteristics.
OR
Absence of menses by 16 with normal secondary sexual characteristic development.

Question 3

What is secondary amenorrhoea?

Answer 3

Established menstruation has ceased for three months in a woman with a history of regular cyclic bleeding or nine months in a woman with a history of irregular periods.
Normally in women aged 40-55.

Question 4

Define menorrhagia.

Answer 4

Heavy periods

Excessive (>80ml), prolonged (>7 days) regular uterine bleeding.

Question 5

Define Dysmenorrhoea

Answer 5

Painful periods

Question 6

Define oligomenorrhoea

Answer 6

Infrequent periods occurring at intervals of 35 days - 6 months.

Question 7

Define cryptomenorrhoea

Answer 7

Periods occur but not visible due to obstruction in outflow tract.

Question 8

Define Dysfunctional Uterine Bleeding

Answer 8

Abnormal bleeding
Excessively heavy, prolonged or frequent
Origin that is not due to pregnancy, pelvic or systemic disease.

Question 9

What are anovulatory cycles?

Answer 9

No ovulation/luteal phase

Olio/amenorrhoea +/- menorrhagia

Question 10

What are ovulatory cycles?

Answer 10

Normal menstrual cycles + Dysmenorrhoea and mastalgia (sore breasts)

Question 11

What are the origins of amenorrhoea?

Answer 11

Hypothalamic/pituitary
Ovarian/gonadal
Outflow tract (uterus, cervix, vagina)

Question 12

How can primary/secondary outflow tract amenorrhoea be caused? What is the FSH level?

Answer 12

Outflow tract origin
HPO axis is functional so FSH is normal?

Primary:
Uterine - Mullerian agenesis
Vaginal - vaginal atresia, cryptomenorrhoa, imperforacte hymen
Stenosed cervix

Secondary:
Intrauterine adhesions (Asherman's syndrome)

Question 13

Describe gonadal/end organ amenorrhoea. Primary and secondary causes? FSH levels?

Answer 13

Ovary does not respond to pituitary stimulation.
Low oestrogen levels.
Lack of negative feedback –> High FSH (hypergonadotrophic amenorrhoea).

Primary:
Gonadal dysgenesis (Turner's)
Androgen insensitivity syndrome
Receptor abnormality for FSH/LH
Congenital adrenal hyperplasia

Secondary:
Pregnancy
Anovulation
MEnopause
Polcystic ovarian syndrome
Drug induced

Question 14

What is hypothalamic/pituitary amenorrhoea? FSH levels?

Answer 14

Inadequate FSH levels lead to inadequately stimulated ovaries, which then fail to produce enough oestrogen to stimulate the endometrium of the uterus –> amenorrhoea.
(Hypogonadotrophic)

Question 15

Describe causes of primary and secondary hypothalamic amenorrhoea.

Answer 15

Primary hypothalamic:
Kallmann Sydrome - inability to produce GnRH (therefore FSH)

Secondary hypothalamic:
Exercise amenorrhoea
Stress
Eating disorder and weight loss (below 47kg menses cease).

Secondary pituitary
Sheehan syndrome - hypopituitarism
Hyperprolactinaemia
Hypo/hyperthyroidism

Question 16

How to evaluate secondary amenorrhoea?

Answer 16

Menstrual history - regularity?
Contraception
Pregnancy
Surgery
Medication
Weight change
Chronic disease
Stress
Diet
Family history
- Thyroid, age at menopause, diabetes
Physical exam 
- BMI, hair (PCOS), thyroid, breast discharge (hyperprolactinaemia)

Question 17

How is amenorrhoea managed?

Answer 17

Hormone replacement if due to hormonal insuffieciey
Lifestyle changes
Laser ablation of endometrium - destroy endometrial basalis layer - renders woman incapable of producing endometrium.

Question 18

Describe dysfunctional uterine bleeding

Answer 18

Excessive heavy, prolonged or frequent bleeding of uterine origin, not due to pregnancy, pelvic or systemic disease.

Question 19

When does DUB occur?

Answer 19

Usually Anovulatory
90% when ovulation is not occurring.
Corpus luteum des not form to release progesterone
Oestrogen is produced continuously causing uterine overgrowth.

10% occurs when ovulation is occurring
Progesterone secretion is prolonged because oestrogen is low.
Irregular shedding and erratic bleeding

Question 20

how DUB diagnosed?

Answer 20

Exclusion
hCG, TSH - Exclude pregnancy and thyroid
Smear to exclude cancer
Sample endometrium

Question 21

Management of DUB?

Answer 21

Oestrogen therapy followed by progesterone.

Question 22

What is menorrhagia? When does it occur? Causes?

Answer 22

Heavy vaginal bleeding that is not DUB.
Secondary to distortion of the uterine cavity, leaving the uterus unable to contract down on open venous sinuses in the zone basal is.

Usually ovulatory

Causes:
Organic, endocrine, haemostatic, iatrogenic

Question 23

What are fibroids and how are they diagnosed?

Answer 23

Benign tumours of myometrium
Increased blood supply and neovascularisation
Diagnosed:
Bimanual examination
Ulatrsound
Hysteroscopy - into womb via vagina
Laparoscopy - into womb via abdominal incision
Bopsy

Question 24

How is menorrhagia assessed?

Answer 24

FBC - Hb
Pictoral blood loss assessment - pad/tampon counts
>80ml for >7days excessive and prolonged

Question 25

How is menorrhagia managed?

Answer 25

Progesterone

Hysterectomy/endometrial resection

Question 26

What are the advantages of removing ovaries in hysterectomy? Disadvantages?

Answer 26

Reduced risk of ovarian and breast cancer

Ovaries produce female hormones that play a part in osteoporosis protection, sexual desire and pleasure.
Sudden onset of menopause

Question 27

How can normal menstrual cycle be disrupted?

Answer 27

Contraception
O/P imbalance
PCOS
Pregnancy
EArly micarriage

Question 28

What causes period pain?

Answer 28

Muscular wall of womb contracts and presses against nearby blood vessels, briefly cutting off oxygen supply to the womb.