Identifying and managing menstrual symptoms

Question 1

What is an abnormal time for menstruation to occur for?

Answer 1

Over 8 days in length

Question 2

Mennorrhagia

Answer 2

Heavy menstrual bleeding

Question 3

Dysmenorrhoea

Answer 3

Painful menstrual bleeding

Question 4

Oligomennorhoea

Answer 4

Infrequent periods>35 days - 6 months between bleeds

Question 5

Primary amenorrhoea

Answer 5

Periods never start

Question 6

Secondary amenorrhoea

Answer 6

Periods stop for over 6 months (not menopause)

Question 7

Metrorrhagia/irregular bleeding

Answer 7

Periods out-with the range of 23-35 days with a variability of >7 days between shortest and longest cycles

Question 8

Intermenstrual bleeding

Answer 8

Bleeding between periods

Question 9

Post-menopausal bleeding

Answer 9

Bleeding 1 year after menopause

Question 10

Premenstrual syndrome

Answer 10

Psychological and physical symptoms in luteal phase

Question 11

Primary amenorrhoea

Answer 11

Lack of menses at age 15/16 with development of sexual characteristics

Lack of sexual characteristics or menses at 13

Constitutional - delay (temporary delay in skeletal muscle growth with no physical abnormalities causing it)

Female triad - disordered eating, ammenorhia, osteoporosis is athletic triad

Question 12

Secondary amenorrhoea

Answer 12

Absence of periods for >6 months

causes are PCOS, increased prolactin, premature menopause

Question 13

Amenorrhoea management

Answer 13

History
Exam - general, neuro, endocrine, pelvic
Bloods - oestrogeen, FSH, TSH, prolactin, preg test, androgens

Imaging - TVUSS, MRI head

Refer if unsure of pathology
Treat underlying cause
Osteoporosis risk - diet, bit D, Ca, COCP, HRT

Question 14

PCOS

Answer 14

2/3 of following:
12 small follicles
Irregular periods
Hirsitism - clinical +/or biochemical (inc testosterone)

PC - amenorrhoea, oligomenorrhoea, weight gain, hirsutism
FSH increases in ovulation, normal in PCOS,
Testosterone, LH increase in PCOS

Question 15

Complications and red flags of PCOS

Answer 15

Complications - T2DM, subfertiity, gestation diabetes, metabolic syndrome
Endometrial Ca- many years of amenorrhoea, unopposed oestrogen

Red flags - weight loss(reduce hyperinsulinism and hyperandrogenism, reduce risk of CVD and T2DM, restore periods and improve fertility

problems conceiving - refer if not trying to conceive then COCP

Question 16

Menorrhagia definition and aetiology

Answer 16

> 80ml/cycle OR excessive blood loss that interferes with physical, emotional, social and material Q of L, +/- other symptoms

Most - no histological pathology, subtle abnormalities in haemostats/PG secretion
Hypothyroid and coagulopathy are rare

Common - idiopathic, fibroids, polyp (endometrial, cervical), dysfunctional uterine bleeding

Uncommon - hypothyroidism, coagulopathy, adenomyosis, cervical ectropion, endometriosis

Worrying - endometrial hyperplasia, cervical Ca, ovarian Ca, PID, pregnancy associated

Question 17

Investigations in menorrhagia

Answer 17

Bleeding - clots, flooding, protection, other gynaecologist symptoms
Consequences - anaemia - SOB, fatigue, pallor
Systemic - thyroid, coagulopathy
Meds - anti-coagulants, hormonal contraceptives

Exam - speculum and bimanual, fibroids, adenomyosis, systemic disease and complications

Pregnancy test, bloods (Hb, TFTs, clotting), pelvis (TVUSS, endometrial biopsy, hysteroscopy)

Question 18

menorrhagia tx

Answer 18

Intra-uterine system (Mirena coil - progesterone)
Combined pill
NSAIDs (mefenamic acid) and antifibrinolytics (tranexamic acid)
GnRH analogues - chemical menopause
Surgery (fibroids)

Question 19

Fibroids/uterine leiomyomas

Answer 19

most common benign tumours in women
rare before menarche and shrink post-menopause
Asymptomatic but can cause menorrhagia, pelvic pain, dysmenorrhoea, pressure symptoms, subfertility
RFs - black/asian women, hereditary, reproductive years, early menarche, nulliparous

Red flags - acute pain, irregular bleeding, inc size postmenopausal

Question 20

Dysmenorrhoea (primary)

Answer 20

Starts within 2 years of menarche, most severe on day 1 of bleeding/day before bleeding, cramping lower abdominal pain, radiates to lower back and legs, +/- GI nausea, vomiting, fatigue, headache
No pathology - inc PGs in menstrual fluid

NSAIDs to dec PGs, COCP/depot to dec ovulation, minera coil to dec bleeding and pain

Question 21

Dysmenorrhoea (secondary)

Answer 21

Occurs many years after menarche
Cramping lower abdomen pain, radiates to lower back and legs, +/- GI nausea, fatigue, headache, deep dyspareunia, starts in luteal phase and continues throughout menstruation

Associated with pelvic pathology - endometriosis, chronic PID, fibroids, polyps, copper coil

Question 22

Endometriosis aetiology

Answer 22

Retrograde menstruation
Coelomic menstruation - peritoneal mesothelium - glandular epithelium
Lymphatic/circulatory spread
Immune dysfunction
Genetic predisposition

Question 23

Endometriosis presentation

Answer 23

Severe dysmenorrhoea
Chronic pelvic pain
Deep dysparenia
Ovulation pain
Chronic fatigue
Dyschezia
Infertility
Irregular bleeding
PMS
Cyclical rectal bleeding/haematuria

Thickened nodular ligaments, fixed uterus, enlarged ovary, tenderness
Investigation - laparoscopy, TVUSS

Management - analgesia, COCP, POPs, GnRH analogues
Surgical - laparoscopy, hysterectomy
Fertility treatments

Question 24

Intermenstrual and post-coital bleeding

Answer 24

Post-cotal - infection, cervical ectropion, cervical/endometrial polyps, cervical cancer, trauma/sexual abuse, vaginal atrophy

IMB - vaginal atrophy, cervical polyps, fibroids, ovarian Ca, post-smear, missed pill, breakthrough on hormonal contraception

Question 25

Perimenopause

Answer 25

Months/years before menopause
Declining estradiol and progesterone
LH and FSH inc due to dec -ve feedback
Symptoms

Question 26

Menopause

Answer 26

Last MP, supply of oocytes gone

Retrospective diagnosis 12 months after period cessation

Question 27

Post-menopause changes

Answer 27

Reduced circling oestrogen - inc risk of osteoporosis, CVD, vaginal atrophy