Hormonal Disorders

Question 1

A/Oligomenorrhoea causes

Answer 1

Low BMI - lifestyle
Hypothalamic lesion(glioma) - 
  surgery
Hyperprolactinaemia - dopamine agonist (cabergoline)
POF - HRT/COCP
PCOS - COCP, clomiphene
Ashermans - ahesiolysis + IUD
Cervical Stenosis - hysteroscopy and dilation

Question 2

Ix Secondary Amenorrhoea

Answer 2

Urine serum hCG (exclude pregnancy(
Gonadtrophins (low = hypothalamus high = ovarian)
Prolactin
Androgen (high in PCOS)
Oestradiol
TFTs

Question 3

Rotterdam Criteria for PCOS

Answer 3

At least 2:
Oligo/anovuation >2y
Clinical/biochem hyperandrogeny
Polycystic ovaries on USS(>12 in one ovary 2-9mm)

Question 4

Sex Hormone profile for PCOS

Answer 4

oestrogen, 
mid luteal progesterone, 
FSH + LH (d2-5),
 free testosterone
LH:FSH greater than 1:1

Question 5

Non-sex hormone Ix in PCOS

Answer 5

Prolactin
TFTs
Cortisol
OGTT (1/yr if PCOS and obese)
TVUSS - find PCO
BMI

Question 6

Mx Menstrual issues in PCOS

Answer 6

COCP - inc. sex hormone binding globulin (relieves androgenic sx), regulate withdrawal bleed (every 3-4mo)
OR Cyclical oral progesterone

Question 7

Mx sub-fertility in PCOS

Answer 7

1 Wt loss
2 Clomiphene - SERM (1st line normal BMI, up to 6mo course, add metformin after 3 failed cycles, induce ovulation if req.) inc. multiple preg
3. Laparoscopic ovarian drilling (destroys stroma to prompt cycles)

Question 8

Mx Complications of PCOS

Answer 8

• Lifestyle (avoid T2DM, risk of CVD)
• Hirsuitism + acne:
  co-cyprindol (dianette)
  topical elfornithine
  cyproterone aceteate (anto-androgen)
  metformin
  GnRH analogues if intolerant of other mx
• Endometrial hyperplasia
  norethistrone for period every 3/12
• Surgical: laser/electrolysis

Question 9

Cx of PCOS

Answer 9

Metabolic syndrome (DM/CVD)
Sleep apnoea
Endometrial ca. 
  withdrawal bleed 3-4mo
  endomet. >7mm refer for 
  biopsy

Question 10

Explain PCOS to Pt

Answer 10

RF: FHx, Obesity
Dx: no clear cause, abnormal hormone levels
v. common 1/10
Cx: oligomen., subfert., VCD, acne
Tailor to conerns:
- Fertility: wt loss, clomiphene +/- metformin -> LOD
- Periods: COCP or progestogens (3/4 yr)
- Metabolic syn.: DM, cholesterol, lifestyle advise

Question 11

Premenstrual syndrome Dx

Answer 11

symptom diary 2 cycles

Question 12

Conservative measures for PMS

Answer 12

Stress reduction
Alcohol/caffeine limit
exercise
Alternative: SJW, vitamins

Question 13

PMS Grading

Answer 13

Mild (no impact on life) - lifestyle advise
Moderate (some impact) - COCP, Paracetamol/NSAID, CBT referral
Severe (prevents normal function): Same + SSRI (3 mo trial)
Alternative: GnRH analogue, transdermal oestrogen, surg

Question 14

HMB Ix

Answer 14

1. FBC in all with HMB
2. Coag. screen if primary menorrhagia or FHx bleeding disorder
3. Bimanual (adnexal mass/bulkt uterus)
4. Speculum (ectropion/polyp)
5. TVUSS

Question 15

Suspected submucosal fibroid, polyp or endometrial path

Answer 15

• Offer OP hysteroscopy
• Consider biopsy if high risk
• If declined pelvic USS

Question 16

> 45 HMB and suspected IU pathology

Answer 16

pipelle biopsy

Question 17

Acute Mx of HMB

Answer 17

ABCDE
Fluid resus, IV colloid, blood 
Correct coagulopathy
Treat cause
Ferrous sulphate

Question 18

Mx HMB of no identified path, fibroids <3cm, or adenomyosis

Answer 18

First line: LNG-IUS
Second line non hormonal:
  Tranexamic (1g TDS when 
   bleeding CI: renal 
   impairment, thrombotic dx)
  NAIDS (mefenamic acid)
Second line hormonal
  COCP
  Cyclical oral progestogens
      Norethistrone 5mg TDS 
      stops accute bleed
   When stopped cause heavy bleed
Surgical: endometrial ablation (will still require contraception), hysterectomy

Question 19

Mx HMB w/fibroids >3cm diameter

Answer 19

Non-hormonal: 
  TXA, NSAIDs
Hormonal
  LNG-IUS (if possible w/ large 
  fibroid)
  COCP
  Cyc. oral progestogens
  Ulipristil acetate (pre-op 
  6mo. to stop bleed and 
  reduce size, long term use -> 
  liver injury)
Surgical:
  TCRF
  Myomectomy (hysteroscopic 
  for submucosal)
  Hysterectomy
  NB consider GnRH 
  analogues 
  if fibroid distorting anatomy
Other:
  Uterine art. ablation
  Endom. ablation (if family 
  comlete)
  MRgFUS

Question 20

GnRH analgue side effects

Answer 20

think menopause:
hot flush
vaginal dryness
muscle stiffness
osteoporosis

Question 21

PACES Counselling Fibroids

Answer 21

RF: age up to menopause, early puberty, obesity, black, FHx
Dx: common, smooth muscle mass can -> HMB and subfertility
20-50% of women >30
Mx:
- HMB: LNG-IUS, COCP
- Fertility: surg, TXA
- Symptoms: TXA

Question 22

Dysmenorrhoea Ix

Answer 22

1. Bimanual (bulk)
2. Speculum (infection)
3. STI screen (PID)
4. TVUSS (fibroid, adeno., endmetriosis
5. MRI (adenomyosis)
6. Diagnostic laparoscopy (endometriosis - see and treat)

Question 23

Dysmenorrhoea Rx

Answer 23

1st Line: NSAIDs
2nd Line: COCP
  Prevents ovulation
  Progestogens can also -> 
  amenorrhoea

LNG-IUS (underlying cause if AM/EM)
Lifestyle
Warmth
GnRH analogues
Surgery