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Obstetrics & Gynecology > Menstrual Cycle and Abnormalities > Flashcards

Menstrual Cycle and Abnormalities Flashcards

1
Q

What is normal menstruation

A

Process by which the endometrium is discarded each month , if pregnancy fails to occur
- sloughing of the endometrium over a period of days, bleeding and subsequent repair, so that the uterus is ready for receiving an embryo in the next cycle

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2
Q

What are the hormones involved in normal menstruation

A

GnRH
Gonadotropins - LH, FSH
Oestrogen and Progesterone

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3
Q

What happens to oestrogen and progesterone levels during the menstrual cycle

A

Oestrogen rises from day one, peaking just before ovulation (around day 12/13). After this it decreases until the end of the cycle (with a small second peak in mid-luteal phase)
Progesterone remains low until the corpus luteum is created (after ovulation), where it begins to rise. Peaks in mid-luteal phase, from which it decreases until the end of the cycle

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4
Q

What is menarche

A

The first onset of menstruation

  • average age of 13
  • investigate if onset before 8 years, or after 16 years
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5
Q

Definition of heavy menstrual bleeding.

A

Bleeding that is having an effect on the woman’s quality of life
- quantification of blood loss not used clinically
Most common cause of iron deficiency anaemia in women in the developed world

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6
Q

Causes of heavy menstrual bleeding

A 
Uterine pathology 
- fibroids (a.k.a uterine leiomyoma)
- endometrial polyps
- pelvic infection 
- adenomyosis
- endometrial carcinoma 
HMB in absence of pathology (previously called dysfunctional uterine bleeding)
- anovulatory
- ovulatory 
Medical disorders
- clotting disorders (very rare)
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7
Q

How do uterine fibroids cause heavy menstrual bleeding

A

Due to decreased uterine contractility, increased endometrial surface area and dilated vessels overlying the fibroid
Not related to size or location

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8
Q

What investigations are required in ?heavy menstrual bleeding

A 
History and examination (abdominal and bimanual)
Blood tests
- FBC ?anaemia and serum ferritin
- coagulation disorders
- female hormone testing
- thyroid testing
Biopsy
- in women >45 years old with treatment failure OR
- treatment was ineffective
Ultrasound (TV or TA)
- for endometrial thickness
Cervical smear
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9
Q

Management of heavy menstrual bleeding

A 
No treatment 
- for women who just want reassurance
Pharmacological 
- hormonal or non-hormonal 
Surgical management
Endometrial ablation
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10
Q

Describe the non-hormonal pharmacological management of heavy menstrual bleeding

A

Mefenamic acid - NSAID
- prostaglandin synthase inhibitor
Tranexamic acid
- antifibrinolytic

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11
Q

Describe the hormonal pharmacological management of heavy menstrual bleeding

A

Pseudo-pregnancy
- COCP (tricycle packs)
- progesterones (POP, depo-provera, mirena coil)
Pseudo-menopause
- GnRH analogues (continuous release causes LH and FSH ‘switch-off’ at the pituitary)
Progesterone receptor modulators (a.k.a esmya)

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12
Q

What are the benefits of GnRH analogues

A 
Good in the short-term
- combine with HRT add-on for longer term use
Symptom relief 
Fibroid shrinkage 
Given by injection
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13
Q

What are the pros and cons of using the mirena coil

A

Pros
- useful for shrinking small fibroids (<5cm)
- progesterone and oestrogen release also provides contraception
Cons
- may come out during heavy menses

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14
Q

Describe the surgical management of heavy menstrual bleeding

A

Hysterectomy and resection
- can inspect the uterine cavity and sample endometrium
- allows resection of polyps
Myomectomy
- removal of uterine fibroids (fertility sparing)
- pre-op GnRH analogues or esmya required
Uterine artery embolism
- interrupts fibroid blood supply (decreases by roughly 50%)
- also fertility sparing

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15
Q

What are the pros and cons of hysterectomy for the management of heavy menstrual bleeding

A 
Pros 
- amenorrhoea guaranteed 
- high satisfaction levels 
Cons 
- influenced by age and fertility
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16
Q

What is endometrial ablation

A

Ablation performed until the border with the myometrium
Pregnancy is contraindicated post-procedure
Tissue sampling mandatory post-procedure

17
Q

Define amenorrhoea, primary and secondary

A

Amenorrhoea is absent menses
Primary
- failure to menstruate by 16 years
- with/without delayed development of secondary sexual characteristics
Secondary
- established menses stop for 6 months or more in the absence of menses

18
Q

Define oligomenorrhea

A

A cycle of menses that is persistently 35 days or longer

19
Q

What are the causes of primary amenorrhoea

A

Hypothalamic (causes decrease in GnRH release)
- physiological delay
- weight loss/anorexia/exercise
Ovarian
- polycystic ovaries (causes decreased oestrogen and progesterone release)
Vaginal
- imperforate hymen (HPO-axis intact)

20
Q

What are the causes of secondary amenorrhoea

A 
Physiological (normal ovarian failure or suppression)
- pregnancy/lactation
- menopause 
Hypothalamic  (decrease in GnRH release)
- weight loss/anorexia 
- heavy exercise
- stress 
Ovarian 
- polycystic ovaries (decrease oestrogen and progesterone release)
Uterine/vaginal 
- surgery (hysterectomy)
- endometrial ablation 
- IUS
21
Q

Investigations of primary amenorrhoea

A 
History
- family history, weight, exercise, sexual activity and stress 
Examination 
- secondary sexual characteristics (Tanner staging) 
Bloods 
- plasma FSH and LH
- oestrodiol
- prolactin 
Karyotype
X-ray for bone age 
Cranial imaging 
Ultrasound
22
Q

What is looked for on an ultrasound when investigating primary amenorrhoea

A

Uterus not present - karyotype
Uterus present
- normal anatomy = hormone profile
- outflow tract obstruction e.g. imperforate hymen or transverse vaginal septum

23
Q

What is the most common cause of anovulatory ovarian subfertility

A

Polycystic ovarian syndrome

- 20% of women

24
Q

What is Asherman syndrome, and how is it managed

A

Excessive curettage of endometrial cavity
Management
- hysteroscopy; allows breakdown of adhesions
- IUCD to ensure adhesions don’t reform

25
Q

Define dysmenorrhoea

A

Cramping lower abdominal pain

- may radiate during menses

26
Q

Define primary and secondary dysmenorrhoea

A

Primary
- idiopathic (onset within one year of menarche)
- usually associated with commencement of ovulatory cycles and higher prostaglandin level, causing contractions
Secondary
- due to pelvic pathology; onset years after menarche
- associated with endometriosis/adenomyosis

27
Q

Investigations for ?dysmenorrhoea

A

Pelvic ultrasound
- transabdominal may be useful for reassurance if normal in primary
- transvaginal if pelvic mass suspected e.g. endometrioma
Laparoscopy
- if endometriosis or PID suspected
- if initial management fails

28
Q

What is the management in dysmenorrhoea

A

Dependant on cause of pain, fertility wishes, patient choice and co-morbidities
Involves
- conservative/lifestyle
- medical non-hormonal (NSAIDs/analgesia)
- medical hormonal (same as heavy menopausal bleeding - suppression of endometrial activity)
- surgical

29
Q

What is the surgical management for dysmenorrhoea

A

Diathermy or laser
Removal or endometrioma
Release of adhesions
Hysterectomy +/- oophorectomy

30
Q

Define intermenstrual bleeding (IMB)

A

Bleeding (including brown discharge) between periods

31
Q

Define post-coital bleeding (PCB)

A

Bleeding after intercourse

32
Q

Define postmenopausal bleeding (PMB)

A

Bleeding occurring over 12 months after last menstrual bleeding

33
Q

What are the causes of IMB, PCB or PMB

A

Originates from the cervix, vulva, uterus and vagina

  • infection
  • trauma
  • polyp
  • cervical ectropion
  • neoplasm/cancer
  • contraception
  • pregnancy
34
Q

Assessment and investigation of IMB, PCB and PMB

A 
Cervical smear history
- negative smear within last 3 years
- don't take unless it is due, as the smear is only a screening test 
Speculum and bimanual examination 
- urgent colposcopy referral if suspicious of cancer
STD screen and treat
- refer to GUM if positive
Urine pregnancy test
35
Q

What are the referral pathways for IMB, PCB and PMB

A

Urgent gynaecology referral for women >35 years with persistent PCB or IMB (over 4 weeks)
Routine gynaecology referral for women <35 years with PCB or IMB for over 12 weeks
- a single heavy episode of PCB or IMB at any age
Reassurance
- women <35 with normal findings and results
- most resolve within 6 months
- if on hormonal contraception/mirena you should consider changing or stopping

Obstetrics & Gynecology (14 decks)

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