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Obs & Gyn > menstrual cycle and abnormalities > Flashcards

menstrual cycle and abnormalities Flashcards

1
Q

define menstruation

A

process of the endometrium being discharged each month if pregnancy fails to occur

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2
Q

basic physiology of menstruation

A

sloughing of the endometrium of pver a period of days

bleeding and subsequent repair so that the uterus is receptive to an implanting embryo in the next cycle

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3
Q

state the phases of the menstural cycle

A

follicular phase

luteal phase

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4
Q

define the follicular phase

A

from start of menstruation to moment of ovulation (first 14 days in 28 day cycle )

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5
Q

define the luteal phase

A

from moment of ovulation to start of mensturation (final 14 days of the cycle)

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6
Q

define the cells that develop into eggs
-what happens to them

A

oocytes
-surounded by granulosa cells foroming structures called follicles

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7
Q

define how a follicle changes during the menstural cycle

A

PRIMORDIAL FOLLICLES mature into primary and secondary follicles
-this is always occurring and happens independently of the menstrual cycle

once they reach the secondary follicle stage they develop FSH receptso

at the start of the menstural cycle FSH stimulates secondary follicles to grow and the granulosa cells surrounding them secrete oestrogen

one of the follicles will develop further than oterhrs and become the dominant follicle

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8
Q

how does oestrogen released from the granulosa cells impact the menstrual cycle

A

oestrogen negatively feedback on FSH and LH in the ant pit gland

also causes cervical mucus to become more permeable-> allows sper to penetrate the cervix at time of ovulation

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9
Q

how does LH affect the menstural cycle

A

LH spikes just before ovulation cuasing the dominant follicle to realse the ovum (unfertilitsed egg) from the ovary
-this happens 14 DAYS BEFORE THE END OF THE MENSTURAL CYCLE

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10
Q

Descibre the intial parts of teh luteal phase

A

follicle that released the ovum collapses and become shte corpus luteum

-this releases high levels of progesterone
-and a small amount od oestrogen

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11
Q

impact of progesterone at the start of the luteal phase

A

maintains the endometrial lingin

also causes cervical mucus to become thick and no longer permeable

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12
Q

what ahppens at fertilitsaiont

A

syncytiotrophoblasts of the embryo secrete hCG

hCG maintains the corpus leuteum
-whitou it the corpus leutuem degenerates

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13
Q

what happens if tehres no fertilisation

A

no production of hCG
corpus leutuem degenerates and stiops producing oestrogen and progesterone

-fall in both causes the endometruium to break down and mensturation occurs

-ve feedback from porgesterone and oestrogen stops and this allows FSH and LH to rise again and the cycle restat

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14
Q

what does the endometrium release when no fertilation occurs

A

stromal cells of the endometrium release rpostaglandins

prostaglainsn encourage the dnometrium to break down and the uterus to contract

mensturation starts on day 1 of the menstural cycle

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15
Q

which parts of the endometrium are involved in menstration

-what else happens

A

superficial and middle layers of the endometrium separate from the basal layer

-tissue is broken down inside the uterus and released via the cervix and vagina

-can last for 1-8 day s

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16
Q

define heavy menstrual bleeding

A

bleeding that has an adverse impact on woman QoL

-commonest causes of IDA in women in affluent world

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17
Q

average age of menarche in uk

A

13 yo

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18
Q

average age of menopause in uk

A

51
ranges from 45-55

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19
Q

on average how much blood do women loose during menstruation

A

40ml

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20
Q

what value of blood loss defines heavy menstural bleeding
-how is this quantified for diagnosis

A

over 80ml (although this is rarely measured)
-based on symptoms
-changing pads every 1-2hours
-bleeding lasting more than 7 days
-passing large clots

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21
Q

how can causes of heavy menstrual bleeding be classified 3

A

uterine pathology

HMB in absence of pathology (previously DUB (dysfunctional uterine bleeding))

medical disorders

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22
Q

uterine pathology that can cause heavy menstrual bleeding 5
-incidence of this type

A

fibroids

endometrial polyps

andeomyosis

pelvic infection

endometrial malignancy

-incidence- common

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23
Q

causes of heavy menstrual bleeding in abscence of pathology 2
-incidnce

A

anovulatory

ovulatory

-incidence - v common

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24
Q

medical disorder causes of heavy menstrual bleeding 1
-incidence 1

A

clotting disorders

-incidence - very rare

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25
Q

investigations for heavy menstrual bleeding 8

A

pelvic examination - with a speculum and bimanual
-assess for fibroids, ascites, cancer

FBC- look for IDA

outpatient hysteroscopy if fibroids, cancer or persistetn intermenstrual bleeding

pelvic an dtransvaginal ultrasound

Swabs

coagulation screen- if FHx

ferritin If clinically anaemic

TFTs if features of hypotrhydoisim

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26
Q

when would a biopsy be used in investigations for heavy menstrual bleeding 3

A

peristent menstural bleeding

women aged over 45

treatment failure or ineffective treatment

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27
Q

how does managemnt of heavy menstrual bleeding differ

A

if patient willing/accepts use of contraception

-* remember to exclude serious underlying patholgies

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28
Q

management of heavy menstrual bleeding if patient denies contraception 2

A

if patient does not want contraception
-transexamic acid - if no assoc pain
-mefenamic acid- if assoc pain

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29
Q

managemnt of heavy menstural bleeding if patient accepts contraception 3

A

if contraception wanted/accepted
-mirea coil- first line
-combined OCP
-cyclical oral progestogens

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30
Q

how doe progesterone receptor modulators work

A

agonist and antagonistic effects of progesterone

-bind to progesterone receptors
-little effect on ovarian function

act directly on endometrium
-induce amenorrhea
-shrink biroids by 20-40%

-well tolerated, oral medication

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31
Q

what is important regarding biospy of the endometrum

A

must indicate time in cycle and any hormonal preparations the patient is taking
-this may influence interpretation by pathologist

32
Q

anotehr name for mirena coil

A

LNG-IUS

33
Q

describe endometrial ablation

A

local or general anaesthetic

-ablation of enodmetirum to border with myometrium

-PREGNANCY CONTRAINDICATED POST PROCEDURE

-must ensure tissue sampling pre procedure

20-50% amenorrhea
70-80% satisfaction

34
Q

assoicated morbiitidy and mortality of hysterectomy

A

mortatlity 1/1000-2000

major complication 3%

minor complciation 15-30%

*-level of satifaction high

amenorrhea guaranteed

35
Q

define amenorrhoea

A

absent menses

36
Q

describe the two types of amenorrhoea

A

primary - fialure to menstruate by age of 15
-may be associated w normal or delayed/absent development of secondary sexual characteristics

secondary
-established menses stop for ≥6mnths in absence of pregnancy

37
Q

define oligomenorrhoea

A

cycle which is persistently greater than 35 days in length

38
Q

how can medical hormonal management of heavy menstrual bleeding be split

A

pseudo-pregnancy

-pesudo-menopause

39
Q

options for psuedo-regnacy medical hormonal management of heavy menstrual bleeding 3

A

COCP

progestogens

local - (coil)

40
Q

what is the pseudo-menopause treatment for medical hormonal management of heavy menstrual bleeding called

A

GnRH analouges

41
Q

how do GnRH analouges work for medical hormonal management of heavy menstrual bleeding

A

pusaltile release fo GnRH from hypothalamus

continous levels ‘switch off’ FSH and LH release form pituitary (FSH and LH become desensitized to GnRH)

useful for short term (6mnths-2yrs)

can shrink fibroids by up to 40%

imrpve haemoglobin

can be combined w HRT

administer by injection

42
Q

describe the two types of hypogonadism

A

hypogonaodotropic hypogonadism -
-deficiency of LH and FSH

hypergonadotropic hypogonadism
-lack of response to LH and FSH by the gonads (testes and ovaries)

43
Q

causes of hypogonadotropic hypogonadism

A

hypopituitarism

damage to hypothalamus or pituitary

significant chronic conditions eg CF or IBD

excesvie ecervise or dieting

consitituaila delay in growth and development

endocrine- hypothryoidm, cushings, hyperprolcatinaemia

kallman syndrome

44
Q

cuases of hpyergonadotropic hypogonadism

A

previous damge to gonads
-torsion, cacner, infections (mumps)

congential absence of the ovaries

turners syndrome (XO)

45
Q

what is kallmans syndrome assocaited with

A

hypogonadotrophic hypogonadism and a reduced or absent sense of smell

46
Q

common causes of primary ammenrorhea 4

A

physiolgoical delay

weight loss/ anorexia/ heavy exercise

polycystic ovaries

imperforate hymen

47
Q

compoents of history for primary amernorhea

A

FHx

weight

excersie

stresss/exams/ family

sexual activity

48
Q

compoentnes of exmaination for primary amenorrhoea 2

A

secondary sexual cahractereitstcs

tanner staging

49
Q

investgations for primary amenroreha 4

A

plasma FSH,LH oestradiol, prolactin, TFTs

karyotype

X-ray for bone age

cranial imaging

50
Q

first line invesitgation in primary amernorrhea if patient has normal secondary sexual characteristics

-what is looked for

A

ultrasound scan

-if uterus is present

51
Q

after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics
-if the uterus is present what happens next

A

check for outflow tract obstruction
-imperforate hymen
-transverse vaginal septum

if normal anatomy-> hormone profile

52
Q

after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics
-if normal hymen and vaginal canal what happens next

A

karyotype

-XX-> MRKH Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that mainly affects the female reproductive system. This condition causes the vagina and uterus to be underdeveloped or absent, although external genitalia are normal. Affected individuals usually do not have menstrual periods due to the absence of a uterus

-XY- >androgen insensitivity

53
Q

common causes of secondary amenorrrhoea 6

A

pregnacy

lactaion

menopause

weight loos/stress/anoerxia

PCOS

surgery -hysterectomy, endometrial ablation, IUD

54
Q

criteria for PCOS diagnosis

A

Rotterdam Criteria for diagnosis
Requires 2 of the 3 features:

Clinical or biochemical evidence of hyperandrogenism (high Free androgen index)

Oligomenorrhoea/amenorrhoea

Ultrasound features of PCO

55
Q

consequences of PCOS 6

A

Reduced fertility

Insulin resistance and diabetes

Hypertension

Endometrial cancer ‘unopposed oestrogen’
Ensure progesterone protection or withdrawal bleeding

Depression and mood swings

Snoring and daytime drowsiness

56
Q

PCOS managemnt 5

A

Education

WEIGHT LOSS AND EXERCISE

Endometrial protection
Progesterone or withdrawal bleed

Fertility assistance

Lifetime awareness +/- screening for complications

57
Q

define the tanner staging criteria for girls regarding pubic hair (works for males aswell)

A

Stage 1: No hair
Stage 2: Downy hair
Stage 3: Scant terminal hair
Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh

58
Q

describe the tanner staging criteria for girls regarding breast development scale

A

Stage 1: No glandular breast tissue palpable
Stage 2: Breast bud palpable under the areola (1st pubertal sign in females)
Stage 3: Breast tissue palpable outside areola; no areolar development
Stage 4: Areola elevated above the contour of the breast, forming a “double scoop” appearance
Stage 5: Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion

59
Q

define dysmenorrohea

A

excessive menstural pain
-usualy involves cramping lower abdo pain that may radiate to lower back and legs

assoc w GI symptoms or malaise
-affects 30-50%

60
Q

split the causes of dysmeorrhoea

A

primary -idiiopathic

secondary - pelvic pathology

61
Q

charactertistics for primary dysmenorrhoea

A

begins w onset of ovaulatory cycles
-usuallyw within first 2 years of menarche

pain most sever on day of or day prior to starting menstruation

62
Q

cuase of primary dysmenorrhoea

A

prostaglandins are involved

PGF2å increases the contractility of the myometrium adn can lead to dysmenorrhoea

63
Q

managment of primary dysmneorrhoea

A

pelvic exam may not be appropriate when dealing with an adolecsent

transandbominal US scna to reveal normal pevlic organs and provide reassurance

discussion and reassurance essential part of management

if dysmenorrhea unresponsive to standard treatment - consider possibility of underlying pathology

64
Q

treatment for primary dysmenorrhea

A

prostaglandin synthesis inhibitors
-NSAIDs reduce uterine production of PGF2å

COC- suppression of ovulation is highly effective

depot progestogens
-injectable progesogen-only contraceptive suppresses ovulation
-

mirena coil

65
Q

what is secondary dysmenorrheoa usually assocaited with 4

A

endometriosis

adenomyosisi

pelvic infection

fibroids

-can also be assoc w precesnce of IUD

66
Q

managemnt of secondary dysmenorrhoea

A

swabs from genital tract to exclude active pevlic infection

if pelvic massess- US

laparoscopy for endometriosis

-treatement dependent on underlying pathology

67
Q

define intrermenstual bleeeding

A

bleeding (incl brown discharge) in between periods

68
Q

define post-coital bleeding

A

bleeding after intercousre

69
Q

define post menopausal bleeding

A

bleeding occuring >12 months after last menstural period

70
Q

some general casues of post-coital, post-menpausal and intermenstrual bleeding 7

A

infection

truama

polyps

cervical ectorpion

neoplasia/cancer

contraception

pregnancy

71
Q

assessemnt and investigations for intermensturl and post coital bleeding 4

A

cervical smear history
-should have had negative smear ≤3yr
-DO NOT TAKE IF NOT DUE A SMEAR

speculum and bimanual examination
-urgent colposcopy if sus of cancer

STD screen + treat

Urine pregnancy test

72
Q

describe the urgetn gynaecologcy referral pathway

A

women OVER 35 w persistent (over 4 weeks) post coital or intermensrual bleeding

73
Q

describe the routine gynaecology referral pathway

A

women UNDER 35 w PCB or intermenstrual bleeding persistenitng over 12 weeks
or

  • singel eheavy episode of postcoital or intermenstual bleeeding AT ANY AGE
74
Q

describe reassurance given for intermenstual or post coital bleeding

A

in women uner 35 w normal findings and results

-most will resolve within 6 months

if on hormonal contraception or coil consider changing or stopping

75
Q

for post menopausal bleedin what is the investigation of choice

-when should it be biopsed

A

transvaginal USS

-Biopsy if ET>3mm (non-HRT and CC-HRT users)
Biopsy if ET>5mm (Sequential HRT users)
Hysteroscopy/biopsy in Tamoxifen users

Obs & Gyn (23 decks)

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