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GYNAECOLOGY > IRREGULAR VAGINAL BLEEDING > Flashcards

IRREGULAR VAGINAL BLEEDING Flashcards

1
Q

What is primary amenorrhoea?

A

Failure to establish menstruation by 15 years in girls with normal secondary sexual characteristics, or by 13 years if age in girls with no secondary sexual characteristics

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2
Q

What is secondary amenorrhoea?

A

Cessation of menstruation for 3-6 months in women with previously normal or regular menses, or 6-12 months in women with previous oligomenorrhoea

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3
Q

What can cause primary amenorrhoea?

A

Gonadal dysgenesis - tuner’s syndrome - most common
Testicular feminisation/andorgen insensitivity syndrome
Congenital malformations of genital tract - imperforate hymen
Functional hypothalamic amenorrhoea e.g. anorexia
Congenital adrenal hyperplasia

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4
Q

Investigations for amenorrhoea?

A

Urinary or serum beta HCG to exclude pregnancy
FBC, U&Es, coeliac screen, TFTs
Gonadotrophins
Prolactin
Androgen levels
USS if PCOS suspected

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5
Q

What does raised gonadotrophins in a pt with amenorrhoea indicate?

A

Ovarian issue or gonadal dysgenesis

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6
Q

What could amenorrhoea and raised testosterone indicate?

A

PCOS

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7
Q

When should you consider osteoporosis prophylaxis in women with amenorrhoea?

A

If amenorrhoea lasts >12 months

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8
Q

How can we improve fertility in pt with amenorrhoea?

A

Clomifene
Metformin
IVF

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9
Q

Complications of amenorrhoea?

A

Osteoporosis
CVD
Infertility
Psychoglocial distress

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10
Q

Why might the risk of osteoporosis secondary to amenorrhoea persist even if normal menses is resumed?

A

As they may not attain a desirable peak bone mass

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11
Q

What is gonadal dysgenesis?

A

A congenital developmental disorder of the reproductive system which causes atypical development of the gonads

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12
Q

What is complete gonadal dysgenesis?

A

Swyer syndrome
Female/ambiguous genitalia but streak gonads (i,e not functioning).
46XY - phenotypically female but genotypically male

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13
Q

What is the issue with streak gonads?

A

High risk of malignancy

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14
Q

What is Turner’s syndrome?

A

45X0
Underdeveloped or missing ovaries resulting in primary amenorrhoea, infertility and certain physical characteristics
(Short stature, shield chest, webbed neck, cardiac issues, kidney issues, short 4th metacarpal)

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15
Q

What is androgen insensitivy syndrome?

A

Testicular feminisation
An X-linked recessive condition causing genotypically male children to have a female phenotype
There is an absent response to testosterone and conversion of the additional androgens to oestrogens resulting in a female phenotype externally.
Internally there will be no female organs as the testes produce anti-mullerian hormone.
It causes primary amenorrhoea, littl/no axillary and pubic hair, groin swellings from undescended testes, breast development and a female whos slightly taller than average
Pt are infertile

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16
Q

What is the hymen?

A

A thin membrane of stratified squamous epithelium that circumscribes the vaginal introitus and should spontaneously rupture during neonatal development

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17
Q

What is an imperforate hymen? Symptoms? Risks?

A

When the hymen doesnt spontaneously rupture during neonatal development so it blocks the vagina
This can cause cyclical pelvic pain, primary amenorrhoea, acute urinary retention
If not treated before puberty it can lead to peritonitis, or endometriosis due to retrograde bleeding

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18
Q

What is a transverse vaginal septae?

A

When a septum forms transversely across the vagina in development
It can be perforate or imperforate

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19
Q

What is Mayer-Rokitansky-Kuster-Hauser syndrome?

A

A congenital disrder causing mullerian agenesis or vaginal agenesis but with a normal 46XX Karyotype
This causes congenital absence of uterus and upper 2/3rds of the vagina
They typically have normal external genitalia and normal secondary sexual characteristics and functioning ovaries
Causes primary amenohorrea

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20
Q

What is a bicornucate uterus?

A

When there are 2 horns to the uterus giving it a heart-shaped appearance
May be associated with adverse pregnancy outcomes but it is mostly successful

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21
Q

What is Ashermann syndrome? cause? Presentation? Tx?

A

Damage to thw basal layer of the endometrium which causes it to heal abnormally creating adhesions connecting areas of the uterus, potentially sealing it shut
It occurs secondary to instrumentation of the uterus e.g. following surgical management of miscarriages or after a dilatation and curettage procedure
Presents with secondary amenorrhoea, significantly lighter periods, dysmenorrhoea or infertility
Tx is dissection of adhesions during hysterescopy
(Recurrence is common)

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22
Q

What is functional hypothalamic amenorrhoea?

A

This is when high levels of exercise, energy deficit in the body, increased levels of cortisol in the body from stress or chronic illness can signal the body to conserve energy, causing a reduction in GnRH

23
Q

What is the female athlete triad?

A

Low energy availability with or without an ED
Menstrual dysfunction
Low bone density

24
Q

What is congenital adrenal hyperplasia? How does it present?

A

Autosomal recessive condition caused by a 21 hydroxylase deficiency which causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth

Causes early development of pubic hair, amenorrhoea or oligomenorrhoea, hirsutism, acne. In severe cases it can present with ambiguous genitalia and an enlarged clitoris due to high testosterone

25
Q

Why can PCOS cause amenorrhoea?

A

There are chronically elevated LH levels so no LH surge to trigger the dominant follicle to break away i.e. no ovulation
This along with high levels of androgens

26
Q

What inhibits prolactin secretion?

A

Dopamine

27
Q

Where is prolactin released from and what are its actions?

A

Anterior pituitary
Stimulates breast development and milk production
Decreases GnRH pulsatility
Blocks the action of LH on ovaries and testes

28
Q

Outline how hyperprolactinemia can cause amenorrhoea?

A

High levels of prolactin suppress GnRH pulsatility which causes anovulation and can lead to amenorrhoea and galactorrhoea

29
Q

What can cause hyperprolactinaemia?

A

Prolactinomas
Other pituitary tumours
Drugs - anti-psychotics, methyldopa, opioids, TCAs, SSRIs, verapamil
Physiological - pregnancy, nipple stimulation, stress, excessive exercise
Hypothyroidism

30
Q

What is premature ovarian failure? What is it characterised by?

A

The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40
Characterised by hypergonadotropic hypogonadism - hypogonadism causes a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotrophins

31
Q

What can cause premature ovarian failure?

A

• idiopathic ~50% of cases
• Bilateral oophorectomy
• Radiotherapy
• Chemotherapy
• Infections e.g mumps, TB, CMV
• Autoimmune disorders - coeliac, adrenal insufficiency, type 1 diabetes, thyroid
• Resistant ovary syndrome - disturbance of gonadotropin receptors in ovarian follicles

32
Q

What are the features of premature ovarian failure?

A

• climacteric symptoms e.g. hot flushes and night sweats
• Infertility
• Secondary amenorrhoea

33
Q

What are levels of FSH, LH and oestradiol like in premature ovarian failure?

A

Raised FSH and LH (hypergonadotropic)
Low oestradiol <100pmol/l (hypogonadism)

34
Q

Tx of premature ovarian failure?

A

HRT or COCP until the average age of menopause

35
Q

Average age of menopause

A

51

36
Q

How can hyperthyroidism cause amenorrhoea?

A

High thyroid hormones -> increases levels of sex hormone binding globulins and prolactin -> inhibits GnRH release

37
Q

What is sheehans syndrome?

A

Postpartum pituitary necrosis second to massive obstetric haemorrhage. This causes Hypopituitarism = low gonadotropins

38
Q

What is Kallmann syndrome? feature?

A

An x-linked recessive condition caused by the failure of GnRH-secreting neurones to migrate to the hypothalamus causing hypogonadotropic hypogonadism
More common in males as x-linked recessive

Delayed puberty, hypogonadism, anosmia, sex hormones low, FSH/LH low/norm

39
Q

What is post-contraception amenorrhoea?

A

Prolonged use of contraception can cause long term down regulation of the pituitary gland and irregular/absent periods/lack of ovulation

Post-pill amenorrhoea = failure to resume menstruation within 6 months after discontinuation of oral contraceptives

40
Q

What is post-contraception amenorrhoea most commonly seen with?

A

Depo-provera - it can take up to 18 months for menses to resume

41
Q

What is oligomenorrhoea?

A

Irregular periods with intervals between menstrual cycles >35 days or <9 periods a year

42
Q

Most common causes of oligomenorrhoea?

A

PCOS
Contraceptive or hormonal Tx
Perimenopause
Thyroid disease or diabetes
EDs or excessive exercising
Meds - anti-epileptics or anti-psychotics

43
Q

What is dysmenorrhoea?

A

Crampy lower abdominal pain during the menstrual period

44
Q

What causes primary dysmenorrhoea?

A

Excessive release of prostaglandins by endometrial cells after decline in progesterone in the menstrual cycle. This causes spiral artery vasospasm and increased myometrial contractions

45
Q

What is primary dysmenorrhoea?
How common?
When does it typically start?

A

Painful periods with no underlying pelvic pathology
Affects 50% of menstruating women
Starts within 1-2 years of menarche

46
Q

How can we manage primary dysmenorrhoea?

A

NSAIDs - mefanamic acid and ibuprofen which inhibit prostaglandin production
COCP second line

(Non-pharm - application of heat)

47
Q

What is secondary dysmenorrhoea?
When does it start?

A

Painful periods that are as a result of underlyign pathology
Develops many years after the menarche

48
Q

Primary vs secondary dysmenorrhoea?

A

Primary - pain occurs within a few hours of the period starting and lasts 4-48 hours
Secondary - may last up to 5 days, much worse, may be associated with other symptoms of causes such as menorrhagia

49
Q

Causes of secondary dysmenorrhoea?

A

Endometriosis
Adenomyosis
PID
Intrauterine copper coil
Fibroids

50
Q

What is pre-menstrual syndrome?

A

The emotional and physical symptoms a woman may experience in the luteal phase of the normal menstrual cycle
Symptoms are severe enough to affect family functioning and interfere with work, school, performance or interpersonal relationships

51
Q

What type of symptoms may occur during the pre-menstrual syndrome?

A

Anxiety
Stress
Mood swings
Fatigue
Bloating
Breast pain

52
Q

What is pre-menstrual dysphoric disorder?

A

When features of PMS are very severe e.g. anxiety and depression and have a significant effect on the quality of life

53
Q

How do we diagnose PMS?

A

Use a symptom diary for at least 2 menstrual cycles
Definitive diagnosis can be made by administering GnRH analogues e.g. goserelin to halt the menstrual cycle and temporarily induce menopause to see if symptoms resolve

54
Q

How do we manage PMS?

A

Mild - lifestyle, regular 203 hourly small balanced meals rich in complex carbs, simple analgesia
Moderate - new generation COCP - continuous use of Yasmin pill
Severe - SSRI taken continuously or just during the luteal phase of the menstrual cycle

GYNAECOLOGY (9 decks)

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