Menstrual Cycle

Question 1

Define:

• Primary amenorrhea
• Secondary amenorrhea
• Oligomenorrhea
• Dysmenorrhea
• Menorrhagia

Answer 1

1. Primary amenorrhea = period never starts
2. Secondary amenorrhea = period stops > 6 months
3. Oligomenorrhea = infrequent periods
4. Dysmenorrhea = painful periods
5. Menorrhagia = heavy menstrual bleeding

Question 2

Normal/Abnormal Menstruation Definitions:

• Ages for menarche
• Age for menopause
• Duration of menstruation
• Blood loss
• Cycle length

Answer 2

1. Menarche should start before 16 years and after 10 years
2. Menopause = average age 51. Before 40 is abnormal
3. Duration of menstruation should be less than 8 days
4. Greater than 80mls of blood loss is objectively menorrhagia
5. Normal cycle length = 23-35 days

Question 3

Describe the aetiology of menorrhagia

Answer 3

1. Majority have no histological abnormality
2. Fibroids (30%) and polyps (10%) are most common underlying pathology
3. Rarer causes = clotting issues, malignancy, thyroid problems

Question 4

What are the clinical features of menorrhagia

Answer 4

1. Signs & Symptoms of anaemia:
   - Fatigue
   - Pallor
   - SoB
   - Poor exercise tolerance
2. Disruption to daily life
   - Frequent sanitary product changes
   - Leaking
3. Examination findings consistent with fibroids or polyps

Question 5

What are the primary investigations for menorrhagia

Answer 5

1. Assess anaemia
   - FBC
   - Iron/Ferritin
2. Assess for clotting and thyroid disorders
   - Clotting bloods
   - TFTs
3. Assess for local causes
   - TVUSS to assess for endometrial thickness, masses (fibroids, polyps, tumours)
   - Endometrial biopsy
   - Hysteroscopy

Question 6

What are the main treatments for menorrhagia?

Answer 6

1st line = IUD (Mirena coil)
2nd line = TXA, mefanamic acid, COCP
3rd line = Progestogens, GrNH Agonists
4th line = Hysteroscopy treatment, endometrial ablation, Uterine Artery Embolisation, Myomectomy
5th line = Hysterectomy

Question 7

What are the main causes of irregular/intermenstrual bleeding?

Answer 7

• Anovulatory cycles
• Fibroids
• Uterine/Cervical polyps
• Adenomyosis
• Ovarian cysts
• PID
• Malignancy

Question 8

What are the main treatments of irregular/intermenstrual bleeding?

Answer 8

Anovulatory cycles = IUD or COCP, Progestogens

Cervical/Uterine polyps = polypectomy

Question 9

What are the main investigations for irregular/intermenstrual bleeding?

Answer 9

1. Assess anaemia
   - FBC
   - Iron/Ferritin
2. Exclude malignancy
   - Cervical smears
   - Endometrial biopsy
3. USS
4. Hysteroscopy

Question 10

Causes of amenorrhea/oligomenorrhea

Answer 10

1. Physiological:
   - Pregnancy
   - Lactation
   - Menopause
   - Low body fat % (Eating disorders, elite athletes)
2. Pathological:
   - PCOS
   - HPA axis issues (hyperprolactinaemia, hypothalamus hypogonadism, hypothyroidism, congenital adrenal hyperplasia)
   - Congenital (Turners Syndrome, Gonadal dysgenesis, Androgen insensitivity)
3. Anatomical:
   - Imperforate hymen
   - Transverse vaginal septum
   - Cervical stenosis
   - FGM

Question 11

Causes of post-coital bleeding

Answer 11

1. Cervical ectropion
2. Vaginal atrophy
3. Cervical cancer