Gynaecology: Menstruation Flashcards
When do the following typically start:
- Thelarach
- Adrenarch
- Menstruation
- 9-11 years (breast)
- 11-12 years (pubes)
- <16 yo typically 13 years
How long is the menstruation cycle?
23-35 days
What are the phases of the menstruation cycle?
Menstruation (day 1-4)
Proliferating phase (day 5-13)
Luteal and secretory phase (day 14-28)
What is the function of oestrogen during menstruation?
Oestrogen (oestradiol)
- acts as -ve feedback for FSH - ensures only one folic matures at a time
- acts as +ve feedback for LH to cause surge leading to release of oocyte from follicle
- promotes thickening of endometrium
What is the function progesterone during menstruation?
Progesterone
- Produced by corpus luteum
- Increase stromal cells, glands and blood flow to the endometrium
What is the definition of:
- Abnormal uterine bleeding
- Intermenstrual bleeding
- Post-coital bleeding
- Dyspareunia
- Post-menopausal bleeding
- Primary amenorrhoea
- Secondary amenorrhoea
- Oligomenorrhoea
- Dysmenorrhoea
- Irregular periods
- Any bleeding that is abnormal in frequency, quantity or timing
- Bleeding that occurs between period cycles
- Bleeding that occurs after sex
- Pain that occurs during sex
- Bleeding that occurs 1 year after menopause
- Delay in menstruation in a child > 16 years
- Cessation of previously achieved menstruation for ≥ 6 months
- Menstruation that occurs at infrequent periods - 35d- 6 months
- Pain that occurs during menstruation
- Menstruation that occurs outside of the normal cycle 23-35 days, with variability >7d between shortest & longest cycle.
What is the surgical treatment options for Menorrhagia (heavy menstrual bleeding)
Hysteroscopy
- Polyp or Fibroid resection
- Endometrial ablation
- resection or destruction of endometrium
- causes amenorrhoea or light periods
- useful for post-menopausal women - ## Trans-cervical resection of Fibroid
Radical
- Myomectomy
- Ovarian a embolisation
- treats HMB secondary to fibroids - Hysterectomy
What is the surgical treatment options for Menorrhagia (heavy menstrual bleeding)
Hysteroscopy
- Polyp resection
- Endometrial ablation
- resection or destruction of endometrium
- causes amenorrhoea or light periods
- useful for post-menopausal women - ## Trans-cervical resection of Fibroid (TCRF)
Radical
- Myomectomy
- Ovarian a embolisation
- treats HMB secondary to fibroids - Hysterectomy
What is the treatment for irregular or inter-menstrual bleeding?
1st line
- IUS i.e. Mirena coil - reduces blood flow > 90%
- COCP - regular, lighter periods
2nd line
- Progestogen - causes amenorrhoea
What are the causes of irregular or inter-menstrual bleeding
Polyps
Adenomyosis
Leiomyoma (fibroid)
Malignancy
Coagulopathy Ovulatory dysfunction (anovulation) Endometriosis or Ectropion Iatrogenic No cause
What are the investigations for irregular or inter-menstrual bleeding?
- Bloods - Hb
- Speculum - visualise any polyps
- Cervical smear - identify abnormal cells
- TV USS
- for women > 35; or <35 w/ failed response to tx - Endometrial biopsy
- endocervical thickening, age > 40yo, polyp suspected, surgery
What are the physiological reasons for Oligomenorrhoea or Amenorrhoea?
During pregnancy, lactation, menopause or hereditary delays
What are the pathological causes for Oligomenorrhoea or Amenorrhoea?
- Hypothalamic
- Hypothalamic hypogonadism caused by psychiatric disorder such as anorexia nervosa, excessive exercise, low weight
- Treat with COCP or HRT - Pituitary
- Hyperprolactinaemia caused by pituitary hyperplasia or benign adenoma
- Treat with Bromocriptine or Carbogeline - Thyroid
- Increase or decrease, typically hyperthyroidism causes hyperprolactinaemia –> amenorrhoea - Adrenal
- Congenital adrenal hyperplasia - Ovary
- Anovulation due to PCOS, early menopause - Ouflow
- imperforate hymen, transverse vaginal septum, Asherman’s syndrome
What is Asherman’s syndrome?
Intrauterine adhesions which prevent menstruation
What is Mullerian agenesis?
Congenital malformation
Mullerian ducts fail to form –> absence of uterus and also vaginal abnormalities
What is Sheehan’s syndrome?
Hypo-pituitarism due to ischaemic necrosis secondary to blood loss
What is Sheehan’s syndrome?
Hypo-pituitarism due to ischaemic necrosis secondary to blood loss
What are the three causes you must consider for post-coital bleeding? How would you investigate or treat these?
Post-coital bleeding is ALWAYS abnormal!
- Cervical ectropion
- columnar epithelium of cervical os is exposed to the vagina, therefore more prone to bleeding
- common in younger patients or pregnancy
- Investigate via speculum (appears red), smear test (detect columnar cells), Colposcopy (visualise redness of columnar cells more)
- Treat with Cryotherapy - Benign cervical polyp
- Investigate with speculum
- Tx - polypectomy - Invasive cervical carcinoma (must exclude)
What are the three causes you must consider for post-coital bleeding? How would you investigate or treat these?
Post-coital bleeding is ALWAYS abnormal!
- Cervical ectropion
- columnar epithelium of cervical os is exposed to the vagina, therefore more prone to bleeding
- common in younger patients or pregnancy
- Investigate via speculum (appears red), smear test (detect columnar cells), Colposcopy (visualise redness of columnar cells more)
- Treat with Cryotherapy - Benign cervical polyp
- Investigate with speculum
- Tx - polypectomy - Invasive cervical carcinoma (must exclude)
What are the symptoms, cause of and treatment of primary dysmenorrhoea?
Idiopathic - no cause found, but common in women at start of menstruation
Symptoms
- Pain precedes period (hrs) –> cramping epigastric pain radiates to back/thigh
Treatment
- 1st line = NSAIDs (mefanemic acid or ibuprofen) - inhibits PG synth
- 2nd line = COCP
- IUS i.e. Mirena Coil
- if treatment fails consider secondary dysmenorrhea due to pelvic pathology
What is the cause, symptoms and treatment of secondary dysmenorrhoea?
Typically due to pelvic pathology - fibroids, adenomyosis, endometriosis, PID, ovarian tumours, Asherman’s syndrome
Symptoms:
- Pain precedes period (3-4d)
- Pain relieved by period
- Dyspareunia, menorrhagia, irregular menstruation
Refer
What is the pathophysiology behind dysmenorrhoea?
Painful menstruation due to increased prostaglandin synthesis in endometrium and painful uterine contractions
What is the definition of and what are the symptoms of pre-menstrual syndrome (PMS)?
Emotional, behavioural and physical symptoms that occur during luteal phase of the menstrual cycle - typically resolve at the end of menstruation
Behavioural:
- irritable, aggressive, labile, depressed, neurosis
Physical:
- bloating, abdominal discomfort, headache, cyclical weight gain, breast pain (mastalgia)
What is the treatment for PMS?
- SSRIs
- COCP - Yasmin most effective (contains anti-mineralocorticoid and anti-androgen progestogens)
- Transdermal oestrogen patch (HRT)
- GnRH agonist (stops ovarian activity, very effective short term)
Others
- Primrose oil - helps with breast pain
- B6 - mild PMS
- Mg - useful for anxiety
