History, Exam and Menstruation

Question 0

Menstruation questions

Answer 0

How often do you menstruate and how long does it last e.g. 4/28.

Regular or irregular, any pain, discharge, abnormal bleeding.

Question 1

PC and HPC

Answer 1

How long has the problem been present and how does it affect the patient. Rate complaints in order of severity and effect on life.

Question 2

Sexual health and contraception questions

Answer 2

Is the patient sexually active, is it painful (dyspareunia), and what type of contraception is being used at the moment?

Question 3

Cervical smear questions

Answer 3

When was the last one done and has it ever been abnormal. If yes what was done about it?

Should be every 3 years 25-49 and every 5 years 50-64 years.

Question 4

Urinary and prolapse questions

Answer 4

Any dysuria, haematuria, frequency, nocturia, urgency, enuresis or leaking of urine. Is there ever a dragging sensation or mass felt in the vagina.

Question 5

Past medical and obstetric history

Answer 5

Any previous gynaecological operations.

Have you ever been pregnant - when, weight and complications.

Question 6

Drug history and allergies

Answer 6

Regular medication including oral contraceptives.

Question 7

Family history

Answer 7

Especially of breast or ovarian carcinoma.

Question 8

Social history

Answer 8

Ask about smoking and alcohol habits.

Also enquire about living arrangements.

Question 9

General examination

Answer 9

General observations and weight.

Anaemia, lymphadenopathy and jaundice should be checked for.

Question 10

Breast and axillary examination

Answer 10

Only routinely performed if examining for a potentially malignant pelvic mass. All 4 quadrants should be examined.

Question 11

Abdominal examination

Answer 11

Inspect for scars, distribution of body hair, striae and hernias.

Palpate from the umbilicus to the pubic symphysis feeling for masses or tenderness.

Percuss for dullness associated with potential pelvic masses.

Question 12

Vaginal inspection

Answer 12

The vulva and vagina are inspected for discolouration, ulcers, lumps or a prolapse.

Question 13

Digital bimanual examination

Answer 13

Left hand on pubic symphysis and right hand examines

Cervix - the first part of the uterus - hard or irregular?

Uterus - size and shape of a small pear - size, consistency, regularity, mobility, anteversion or retroversion and tenderness.

Adnexa - lateral to the uterus containing Fallopian tubes and the ovaries - size, tenderness, consistency and masses?

Pouch of Douglas - behind the cervix - irregular or a mass?

Question 14

Cusco’s speculum examination

Answer 14

Insert with blades closed and parallel to the labia.

Rotate 90 degrees, insert further and then open the blades.

Inspect for ulceration, spontaneous bleeding or irregularities.

Slowly close blades, rotate 90 degrees and withdraw speculum.

Question 15

Sims speculum examination

Answer 15

Allow better inspection of the vaginal walls and a prolapse.

Patient to lie in lateral position. Press against posterior wall t view anterior wall and vice versa. Ask the patient to bear down.

Question 16

Rectal examination

Answer 16

Appropriate if there is a posterior wall prolapse to distinguish between an enterocoele and a rectocoele or in assessing malignant cervical disease.

Question 17

Puberty physiology

Answer 17

At 8 years of ages pulses of GNRH increase in amplitude and frequency. This causes LH and FSH release from the pituitary which leads to oestrogen release from the ovaries.

Oestrogen is responsible for 2ndary sex characteristics- thelarche (breast development) at 9-11 years, adrenarche (pubic hair growth) at 11-13 years and menarche at 13 years of age.

Question 18

The menstrual cycle - definition

Answer 18

The hormonal changes in the menstrual cycle cause ovulation and induce changes in the endometrium that prepare it for implantation should fertilisation occur.

Question 19

The menstrual cycle - days 1-4

Answer 19

Menstruation - the endometrium is shed as hormonal support is withdrawn. Myometrial contractions occur and can cause pain.

Question 20

The menstrual cycle - days 5-13

Answer 20

Proliferation phase - pulses of GNRH stimulate LH and FSH release to induce follicular growth. Follicles produce oestrodiol and inhibit which suppress FSH secretion so only one follicle and oocyte develop.

Oestrodiol levels continue to rise and when they reach a max cause an LH surge and ovulation 36 hours later.

Oestrodiol also causes stroma cell proliferation causing thickening of the endometrium.

Question 21

The menstrual cycle - days 14-28

Answer 21

The luteal or secretory phase - the follicle from which the egg is released becomes the corpus luteum which produces progesterone causing secretory changes to the endometrium.

The corpus luteum starts to fail if the egg is not fertilised so oestrogen and progesterone levels fall. Continuous administration of progesterone (eg OCP) can delay menstruation.

Question 22

Menorrhagia

Answer 22

Excessive bleeding in an otherwise normal menstrual cycle but this is subjective. Clinically it is bleeding that interferes with the women’s physical, social and emotional well being. A value of >80ml blood loss per cycle is the max that can be lost before iron deficiency anaemia occurs.

Question 23

Menorrhagia - Causes

Answer 23

Uterine fibroids (30%) and uterine polyps (10%) are the most common causes. Hypothyroidism, haemostatic disorders or anti coagulation therapy are rarer causes.

Chronic pelvic infection and malignancy can cause menorrhagia but are more likely to cause irregular bleeding.

Question 24

Menorrhagia - Investigations

Answer 24

Clinical examination (signs of anaemia or irregular enlargement of the uterus), bloods (especially Hb, coagulation screen and thyroid function), transvaginal ultrasound (for fibroids, polyps or ovarian mass), biopsy (if features of malignancy) or hysteroscopy.

Question 25

Menorrhagia - Medical Treatment

Answer 25

1st line - progesterone impregnated intrauterine device - a coil can reduce menstrual flow by up to 90% with relatively few side effects. (Note that a copper coil can increase menstrual loss).

2nd line - antifibrinolytics e.g. Tranexamic acid increase fibrin and clotting. They should be taken during menstruation and reduce blood loss by 50%. NSAIDs e.g. Mefanamic acid inhibit prostaglandin synthesis and reduce blood loss by up to 30% and can help treat dysmenorrhea.

Question 26

Menorrhagia - hysteroscopic surgical treatment

Answer 26

Polyp removal, endometrial ablation therapy (with microwave probe or thermal balloon), transcevical resection of fibroids, uterine artery embolisation (for women with fibroids who want to avoid surgery), myomectomy (if <8cm) or hysterectomy is a last resort.

Question 27

Irregular menstruation - causes

Answer 27

Anovulatory cycles pelvic pathology which can benign (fibroids, uterine or cervical polyps, adenomyosis, ovarian cysts or chronic pelvic infection) or malignant (especially in older women).

Question 28

Irregular bleeding - investigations

Answer 28

Bloods (for Hb), speculum (cervical polyp) and smear (for CIN or malignancy), transvaginal ultrasound in all women >35 years and if medical treatment has failed (fibroids or mass) or endometrial biopsy if suspicious.

Question 29

Irregular bleeding - management

Answer 29

Medical - intrauterine device or combined OCP are first line where no anatomical cause is found. HRT can help regulate erratic bleeding in the peri-menopausal period.

Surgical - as for menorrhagia but endometrial ablation is less helpful as some endometrium will remain and continue to bleed.

Question 30

Amenorrhoea and Oligomenorrhoea - Causes

Answer 30

Physiological - pregnancy, post-menopause, during lactation, with antipsychotics (increase prolactin) or in constitutional delay.

Hypothalamus - hypothalamic hypogonadism is common and caused by low weight, psychological factors or excessive exercise. GNRH, LH, FSH and oestrodiol are reduced and oestrogen and progesterone replacement is required - combined OCP or HRT.

Pituitary - hyperprolactinaemia (increases dopamine which inhibits GNRH) in pituitary hyperplasia or benign adenomas.

Thyroid - both hyper and hypothyroidism can cause amenorrhea.

Ovary - congenital in Turners syndrome or acquired in PCOS.

Outflow obstruction - congenital in imperforate hymen or transverse vaginal septum lead to haemotocolpos (vagina) or haematometra (uterus). Acquired in cervical stenosis or Ashermans syndrome (excessive curettage during evacuation of retained products of conception).

Question 31

Postcoital bleeding

Answer 31

Causes - when the cervix is not covered in healthy squamous endometrium e.g. cervical ectropion (columnar epithelium protrudes through external os), polyps, malignancy or cervicitis.

Management - polyp removal or smear followed by cryotherapy or colposcopy to exclude malignancy.

Question 32

Dysmemorrhoea

Answer 32

Primary - occurs in 50% of women and usually responds to NSAIDs or ovulation suppression e.g. with OCP.

Secondary - due to pelvic pathology e.g. fibroids, adenomyosis, endometriosis, pelvic inflammatory disease or ovarian tumours.

Question 33

Precocious puberty

Answer 33

Menarche before the age of 10 or development of secondary sex characteristics before 8 must be investigated as final height is affected due to early fusion of the epiphysis. GNRH agonists can cause regression of characteristics and cessation of menstruation.

Central causes - increased GNRH secretion in hypocephalus, CNS tumour, meningitis, encephalitis or hypothyroidism.

Ovarian or adrenal causes - increased oestrogen secretion in hormone producing tumours.

Central causes -

Question 34

Premenstrual syndrome

Answer 34

Occurs in the luteal phase in 95% of women - tension, irritability, depression, bloating, minor gastrointestinal upset or breast pain.

Management - continuous OCP or HRT, continuous or intermittent SSRIs to reduce hormone fluctuations or in severe cases GNRH agonists with add back oestrogen therapy can be used to induce a peri-menopause or bilateral oophorectomy as a last resort.