Menstrual cycle and disorders Flashcards
what are the stages of female sexual development in order?
Thelarche = occurs at 9-11 years Adrenarche = occurs at 11-12 years Menarche = 13 years and is the final stage
define adrenarche
Adrenarche = growth of pubic hair, occurs at 11-12 years
define menarche
Menarche = 13 years and is the final stage
Define Therlache
Thelarche = breast development, occurs at 9-11 years
what day is the start of the menstraul cycle?
first day of your period/mentraution
what are the phases of the menstraul cycle and when?
Days 1–4: menstruation
-shedding endometrium
Days 5–13: proliferative phase
- proliferative endometrium
Days 14–28: luteal/secretory phase
- basal endometrium - secretory endometrium
what are the landmarks of normal menstraution? eg normal start time, normal stop, length etc?
Menarche <16 years Menopause >45 years Menstruation 3–8 days in length Blood loss <80 mL Cycle length 24–38 days No intermenstrual bleeding (IMB)
define AUB - abnromal uterine bleeding?
any variation from the normal menstrual cycle,
this includes changes in regularity and frequency of menses,
in duration of flow, or in amount of blood loss
why is fsh much lower than lh around the day 14 mark?
there had been a negative feeedback on fsh prodcution from ostradiol and inhibin produced by the follicles.
spike in oestradiol levels causes positive feedback on LH hence LH surge
which hormones cause follicular growth and lead to the maturation and therefore survival of 1 follicle over the remaining antral follicles?
LH and FSH (mainly)
what are the causes of abnormal uterine bleeding?
PALM-COEIN (‘palm-coin’)
PALM - structural:
Polyps
Adenomyosis
Leiomyomas (fibroids) –Submucosal –Other
Malignancy and hyperplasia
COEIN - medical:
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet specified
what 6 charactersitics are used to assess abnormal utreine bleeding - FIGO?
Volume
Regularity (cycle-to cycle variation)
Frequency (normal every 24–38 days)
Duration (normal3–8 days)
Irregular, non-menstrual bleeding
eg Premenstrual and postmenstrual spotting
Bleeding outside reproductive age:
eg Postmenopausal bleeding,Precocious menstruation
what are the limits for Prolonged menstrual bleeding
and Shortened menstrual bleeding?
Bleeding >8 days duration
Bleeding <3 days duration
what are the limits for frequent and Infrequent menstrual bleeding?
Bleeding at intervals >38 days apart (5 wks+) - so menstraul cycle occurs between 38 days - 6 months.
Bleeding at intervals <24 days apart (>3 wks)
what is the new term for oligomennorhea?
most common cause?
Infrequent menstrual bleeding
most common: PCOS
how are the following defined:
Irregular menstrual bleeding
Absent menstrual bleeding (amenorrhoea)
irreg: Cycle-to-cycle variation >20 days
absent: No bleeding in a 6-month interval
define heavy menstraul bleeding clinically and objectively?
what was the previous term for this?
clinical:
Excessive menstrual blood loss which interferes with
the woman’s physical, emotional, social and material
quality of life, and which can occur alone or in
combination with other symptoms
objective:
This is blood loss of >80 mL in
an otherwise normal menstrual cycle. This value corresponds to the maximum amount that a woman on
a normal diet can lose per cycle without becoming
iron deficient. In practice, actual blood loss is rarely
measured.
The cycle is REGULAR!
previously - mennorhagia
define Postmenopausal bleeding
Bleeding occurring more than 1 year after the acknowledged menopause
define Precocious menstruation
Bleeding before the age of 9 years
define primary amennorhea?
Absence of menstruation despite signs of puberty
before age 16 usually
define secondary amennorhea?
most common cause? other causes?
Absence of menstruation for 3-6 months in a woman who has previously menstruated.
Most common = pregnancy. Other causes include high/low BMI, stress, exercise, prolactinoma
define Dysfunctional Uterine Bleeding?
Irregular bleeding due to anovulation or an anovulatory cycle (may be anatomical e.g. uterine fibroids)
what are the 2 forms of heavy menstraul bleeding?
mennorhagia - regualr cycle
metrorraghia - irregular cycle
what are the cause and characteristics of Anovulation/Anovulatory Menses?
Menstrual cycle without ovulation (often very light due to absence of progesterone)
define Dysmenorrhoea?
name some causes
Menstrual pain
associated with high prostaglandin levels in the endometrium
is due to contraction and uterine ischaemia.
what is the most common form of Abnormal uterine bleeding?
HMB - heavy menstraul bleeding / mennorghia
what is the aetiology and most common causes of HMB/menorragia?
Uterine fibroids - 30%
polyps - 10%
uterine prostaglandin levels pevic infection gynae malignancy thyroid disease anticoagulant therapy coagulopahties eg vWD
women has HMB, she has personal and fhx of excessive bleeding after surgery/trauma or easy bruising.
what is possible aetiology?
coagulopathy may be suggested
by a family or personal history of excessive bleeding after surgery/trauma or easy bruising
what are the hallmarks of excessive blood loss?
History:
- flooding - sheets become soaked with blood while sitting or lying down
- passage of clots
examination:
- anaemia
- Irregular enlargement of uterus = fibroids
- Tenderness with/without enlargement = adenomyosis
name some risk factors for endometrial carcinoma in young woman?
obesity,
diabetes, nulliparity,
history of polycystic ovary syndrome(PCOS)
family history of hereditary nonpolyposis colorectal cancer (HNPCC).
how can HMB be investigated?
Hb
Coagulation and TFTs
TVUS: local organic causes o Endometrial thickness o Exclude fibroid \+ saline ultrasound o endometrial biopsy (hysteroscopy or pipelle)
Hysteroscopy: allows inspections of uterine cavity and detection of polyps and submucous fibroids
how would you ivx the following that need biopsy:
endometrial hyperplasia, cancer
endometrial focal thickening or a polyp
endometrial hyperplasia, cancer -> biopsy by pipelle or hysteroscopy
endometrial focal thickening or a polyp -> biopsy by hysteroscopy-guided evaluation.
what is the management of HMB?
First line - Intrauterine system (IUS) - mirena coil
- progestogen-impregnated IUD/mirena
- dont give if wishes to conceive
2nd line - if wishes to conceive.
Antifibrinolytics (tranexamic acid) - take during menses
NSAIDs - Mefenamic acid - if + period pain
COCP - if not trying for kids
3rd line
Progestogens (high-dose oral or intramuscular)
GnRH analogues
4th line - surgery - If all above fails
- hysteroscopy
-polyp, fibroid removals, endometrial ablation etc - Radical
myomectomy
hysterectomy (if above fails or not indicated)
uterine artery embolisation
what are the complicatoins of management of HMB?
COCP
- Less effective if pelvic pathology is present
- complications in older patients
GnRH - Risk of osteoporosis and HRT - Bleeding follows withdrawal - Unless add-back hormone replacement therapy (HRT) is used, duration is limited to 6 months.
indications of biopsy in HMB?
Age >40 years
HMB with intermenstrual bleeding (IMB)
Risk factors for endometrial cancer
HMB unresponsive to medical therapy
If ultrasound suggests a polyp or focal endometrial
thickening (perform hysteroscopy)
Prior to endometrial ablation/diathermy as tissue will
not be available for pathology (unlike TCRE)
If abnormal uterine bleeding has resulted in acute
admission
in the resection of fibriods, when can you use:
Transcervical resection of fibroid (TCRF)
Myomectomy
what are the benefits?
what other technique can be used?
Transcervical resection of fibroid (TCRF):
submucosal fibroid
uo to 3cm diameter
improves fertility
Myomectomy: up to 4 myometrial fibroid up to 8cm preserve fertility. gnrh shrink fibroid first
other:
uterine artery emboliisation
if endometrial ablation surgery or the IUS - intrauterine system are to be used, what ivx MUST be done first?
Endometrial biopsy
how is Irregular Menstruation and Intermenstrual Bleeding investigated?
1.Hb
- Exclude malignancy
- CervicalSmear
- US of cavity for women >35 years with irregular/IMB, also for younger women where medical tx has failed
3.Endometrial biopsy, preferably at hysteroscopy
how is Irregular Menstruation and Intermenstrual Bleeding managed?
- Drugs
o IUS or COCP - first line
- if anovulatory, no structural causes
o High dose progestogens can be used - mimic normal menstruation if given cyclically - Surgery
o pull off Cervical polyp – histology
o Same surgery options as menorrhagia
define haematometra
causes?
involving collection or retention of blood in the UTERUS.
It is most commonly caused by an imperforate hymen or a transverse vaginal septum.
define haematocolpos
causes?
A haematocolpos is the accumulation of blood in the VAGINA.
It usually presents as increasing abdominal distention and monthly discomfort without bleeding.
It is usually due to an imperforate hymen.
What is the most congeital and acquired causes of amenorrhea / oligomennorhea?
congenital : Turner’s (ovary)
acquired: PCOS (ovary)
epidemiology of premature menopause?
1 in 100
name some physiological causes of amenorrhea / oligomennorhea?
pregnancy
lactation
postmenopausal
constitutional delay
name some pathological causes of amenorrhea / oligomennorhea?
organ troubles: hypothalamus, pituitary, thyroid, ovary etc
drugs: progestogens, GnRH analogues
and, sometimes, antipsychotics
pathological primary:
- congenital
- acquired: pre puberty
pathological secondary:
- acquired: post puberty .. pcos, pof, high prolactin
what are the most common causes of secondary amennorhea?
what would ivx show and management?
- PCOS
ivx: E2 normal
Mx : later - Premature menopause/ ovarian failure
ivx: High FSH/LH, Low E2
Mx: HRT - Hyperprolactinaemia
Pituitary hyperplasia or Benign adenoma
Ivx: Prolactin levels
- Mx : Bromocriptine or Cabergoline
prolactin is high in which cause of a/oligomennorhea?
Hyperprolactinaemia
Hypothyroidism - beecause TRH increases to increase TSH but then prolacitn increases too.
a/oligomennorheea, 46 XY, increased testosteerone.
which condition?
androgeen insensitivity
a/oligomennorhea 45 XO
which condition
What would ivx show?
Mx?
tuners
do karyotype
low E2
mx - HRT, GHormone
a/oligomennorhea + Normal
secondary sexual characteristics
which condition?
Imperforate hymen /
Transverse vaginal septum
causing haematocolpos/metra
most common causes of abnormal postcoital bleeding?
Cervical ectropions,
benign polyps
invasive cervical cancer
account for most cases
Cervicitis, Atrophic vaginitis
Mx of postcoital bleeding?
Smear
Avulsion of polyp + histology (doesn’t require anaesthesia)
Ectropian can be frozen with cryotherapy
Colposcopy to check for malignancy
what are the types of dysmenorrhea?
causes and mx?
primary - 50% women. NSAIDs / cocp resolves it.
secondary - due to pelvic pathology
Pain often precedes and is relieved by the
onset of menstruation.
causes: fibroids, adenomyosis, endometriosis, PID and ovarian tumours
medical treatment eg NSAIDs may not work
uterine nerve ablation (LUNA) not beneficial
what are the characteristics and causes of precocious puberty?
The growth spurt occurs early, but final height is reduced due to early fusion of the epiphyses.
causes:
- 80% unknown
- Increased gnrh release eg meningitis, hypothyroid
- Ovary/adrenal
- Increased E2 release
- ovarian/adrenal tumour -> hormones -> develop early
- McCune - albright
what is McCune - albright syndrome?
Mx?
bone and ovarian E2 producing cysts -> precocious puberty
café au lait spots
fibrous dysplasia of bones
GNAS mutation
Treatment is with cyproterone acetate (an antiandrogenic progestogen)
what are the 2 forms of Ambiguous development
and intersex conditions?
give brief aetiology and presentation?
CAH (females) and AIS (males)
Congenital adrenal hyperplasia:
- increased androgen function
- Ambiguous genitalia at birth
- at puberty -> cliteromegaly and amenorrhoea
- 21-hydroxylase deficiency
Androgen insensitivity sundrome
- Receptor insensitivity to androgens
- Appears female
- Uterus is absent and rudimentary testes present
what is the aetiology and presentation of CAH?
MX?
Congenital adrenal hyperplasia:
- Ambiguous genitalia at birth
- at puberty -> cliteromegaly and amenorrhoea
- Autosomal recessive
- 21-hydroxylase deficiency
- Increased ACTH -> increased androgens
- Glucocorticoid deficiency -> Addisonian crisis
MX: cortisol and mineralocorticoid replacement
what is the aetiology and presentation of AIS?
Mx?
Genetics: Androgen receptor mutatoins or otherwise.
Receptor insensitivity to androgens -> peripheral conversion to oestrogens
Appears female
Diagnosis when she presents with amenorrhoea
Uterus is absent and rudimentary testes present
Removed to due risk of possible malignant change
Mx: Oestrogen? replacement therapy should be commenced - How are you tellin them what gender to be
what is the period for PMS?
epidemiology?
2 WEEKS BEFORE PERIOD /
Luteal phase of mentraul cycle.
95% of women experience PMS, 5% it is debilitating
ivx for PMS?
Psychological evaluation – depression and neurosis can present as PMS
Women should complete menstrual diaries – record mood and sx for 2 cycles
how is PMS managed?
First line:
SSRIs – continuously or intermittently in second half of cycle
Continuous oral contracaeption
100ug oestrogen HRT patches may be useful
Second line:
GnRH agoinsts and add back oestrogen therarpy may be tried
Final result = Bilateral oophorectomy (+HRT / COCP)
Others:
Supplements: evening primrose oil for breast tenderness, pyridoxine (vit b6) 50mg BD can help
Vitex agnus-castus extract - Chasteberry can help PMS
CBT may be appropriate
thw following ivx findings point to which causes of a/oligomennorhea:
Low GnRH, Low FSH/LH, Low Oestradiol
how would you manage this?
hypothalamic causes
eg due to excess excercise, anorexia nervosa, psychological
Mx:
HRT/COCP
Anorexia -psych input
supportive
what is add back therapy?
This is when women being treated with GnRH are given
small amounts of additional progesterone +- oestrogen to preserve:
bone density and to relieve:
vasomotor symptoms eg hot flushes, insomnia
what is cervical ectropion?
eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu.
what type of drug is Tranexamic acid?
plasminogen activator inhibitor that acts as an anti-fibrinolytic to prevent heavy menstrual bleeding.
woman; has HMB, no pain, wants to try for kids. what treatment?
tranexamic acid
woman; has HMB, + menstrual pain, wants to try for kids. what treatment?
woman; has HMB, not wanting to try for kids. what treatment?
kids - Mefenamic acid - nsaid
no kids - IUS: mirena
whuch drug can be used as a short-term option to rapidly stop heavy menstrual bleeding?
Norethisterone 5 mg tds PO - a progestogen
woman is going on holiday but her period is coing up to interfere, she wants to stop bleeding, what will you prescribe?
how should she take it?
Norethisterone 5 mg tds PO - a progestogen
start taking 3 days before period
what is the best way to assess ovulation?
passmed
Day 21 Progesterone test is the most reliable test to confirm ovulation (with 28 day cycle)
if 35 day cycle then. . 21+7 = day 28 progesterone best
what day is the mid luteal progesterone measured in a woman with a :
28 day menstraul cycle
35 day menstraul cycle
28 day menstraul cycle: day 21
35 day menstraul cycle: day 28
list red flags in hx and ivx of woman with HMB requiring further ivx?
A Age >40
B Intermenstrual bleeding
C Endometrial thickness (ET) >10 mm in a premenopausal woman
D ET >4 mm in a postmenopausal woman
E Fibroids or polyps
what is the most common cause ofmennorhagia
DUB
