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Gynaecology > Menstrual cycle and its disorders > Flashcards

Menstrual cycle and its disorders Flashcards

1
Q

1st

A

1st

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2
Q

How do you ask about prolapse?

A

Does you ever get a dragging sesnation or feel a mass in or at the vagina?

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3
Q

Average age for menarche in the west?

A

13 years

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4
Q

What stimulates puberty?

A

Hypothalamic-pituitary axis
GnRH pulses increase in frequency and amplitude from age 8 - increases FSH and LH release from pituitary
These stimulate oestrogen release from ovary

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5
Q

What is thelarche and when does it happen?

A

Beginning of breast development

Occurs first at 9-11 years

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6
Q

What is adrenarche and when does it happen?

A

Growth of pubic hair - starts at age 11-12 years

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7
Q

3 phases of menstrual cycle

A

Day 1-4: menstruation
Day 5-13: proliferative phase
Day 14-28: luteal/secretory phase

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8
Q

Details of 2nd phase of menstrual cycle

A

Day 5-13: proliferative phase (follicle grows, releases oestradiol causing endometrium to reform - thickens, LH surge leads to ovulation)

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9
Q

Details of 3rd phase of menstrual cycle

A

Day 14-28: Luteal/secretory phase - egg released, corpus luteum remains, secretes oestradiol and progesterone - secretory changes in endometrium - no fertilisation, corpus luteum fails, hormones drop and endometrium breaks down

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10
Q

How do oestrogen and progesterone levels change during the menstrual cycle?

A

Progesterone levels raise slowly from phase 1 until reaches max in middle of luteal phase - then drops back to lowest in mid luteal
Oestrogen levels raise more quickly and reach max at ovulation - then drop steadily through luteal phase

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11
Q

How do LH and FSH levels change during menstrual cycle?

A

LH and FSH surge at ovulation

Also slight increase in FSH at end/beginning of cycle

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12
Q

What is menorrhagia?

A

Heavy menstrual bleeding

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13
Q

What is clinical definition of menorrhagia?

A

Excessive menstrual blood loss that interferes with womans physical, emotional, social and material quality of life

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14
Q

What is the objective definition of menorrhagia?

A

Blood loss of >80ml in otherwise normal menstrual cycle

But actual blood loss is rarely measured

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15
Q

What are the two most common pathological causes of menorrhagia?

A

Fibroids (30% of HMB)

Polyps (10% of HMB)

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16
Q

What pathological causes are most likely to cause irregular bleeding? x4

A

Chronic pelvic infection
Ovarian tumours
Endometrial and
Cervical malignancy

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17
Q

What are rare systemic causes of menorrhagia? x3

A

Thyroid disease
Haemostatic disorders such as von Willebrands disease
Anticoagulant therapy

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18
Q

What are two signs of excessive blood loss in menorrhagia?

A

Flooding

Passage of large clots

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19
Q

Investigations in menorrhagia? x4

A

FBC and Hb - anaemia
Coag and TFTs - systemic cause
Transvaginal US - local pathology

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20
Q

What are clinical indicators for endometrial biopsy with menorrhagia? x5

A 
Endometrial thickness >10mm
Polyp suspected 
Woman >40 years old with recent onset menorrhagia 
IMB 
Not responded to treatment
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21
Q

Further investigation which can be done in menorrhagia

A

Hysteroscopy

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22
Q

What is the first line treatment for menorrhagia?

A

IUS - not good if want to conceive

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23
Q

Second line treatments for menorrhagia? x3

A

Antifibrinolytics taken during menstruation - tranexamic acid (few side effects and available without prescription)
NSAIDs - also good for dysmennorhoea
COC - less effective if pelvic pathology

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24
Q

Third line treatments for menorrhagia x2

A

Progestogens - work but bleeding will follow withdrawal

GnRH agonists - duration limited to 6 months unless HRT taken - risks and concerns associated

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25
Q

What are the hysteroscopic surgical treatments for menorrhagia? x3

A

Polyp removal
Endometrial ablation (reduces fertility but not sterilising)
Transcervical resection of fibroid (up to 3cm in diameter)

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26
Q

More radical surgical options for menorrhagia? x3

A

Myomectomy (removal of fibroids from myometrium) open or laparoscopic surgery (GnRH agonists used to reduce fibroid size first)
Hysterectomy - last resort
Uterine artery embolisation - effects on fertility not clear

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27
Q

When are irregular bleeding and intermenstrual bleeding most common?

A

At extremes of reproductive age

28
Q

What are pathological non-malignant causes of irregular menstruation and intermenstrual bleeding? x5

A

Fibroids, uterine and cervical polyps, adenomyosis, ovarian cysts and chronic pelvic infection

29
Q

When are malignant causes more likely to be cause of irregular bleeding?

A

Older women, esp. if a recent change

30
Q

Which malignancies can cause irregular bleeding? x3

A

Endometrial
Ovarian
Cervical

31
Q

Investigations in irregular bleeding x4

A

Hb to check anaemia
Cervical smear
US exam if >35
Endometrial biopsy if endometrium thickened, polyp suspected, woman >40 or if surgery/IUS will be used

32
Q

First line treatment for irregular bleeding with no anatomical cause

A

IUS or COC

33
Q

Second line treatment for irregular bleeding

A

Progestogens but irregular bleeding will follow withdrawal

34
Q

What is amenorrhoea

A

Absence of menstruation

35
Q

What is difference between primary and secondary amenorrhoea?

A

Primary is when periods haven’t started by age 16, secondary is when previous menstruation ceases for 6 months or more

36
Q

What is definition of delayed puberty?

A

Secondary sex characteristics not present by age 14

37
Q

What is oligomenorrhoea

A

Menstruation which occurs every 35days to 6 months

38
Q

What drugs can cause amenorrhoea?

A

GnRH analogues
Progestogens
Sometimes antipsychotics (increase prolactin levels)

39
Q

What are the most common causes of secondary amenorrhoea or oligomenorrhoea? x3

A

Premature menopause
Polycystic ovary syndrome
Hyperprolactinaemia

40
Q

What can lead to hypothalamic hypogonadism and subsequent amenorrhoea?

A

Psychological factors, low weight/AN or excessive exercise

41
Q

What is the cause of pituitary related amenorrhoea?

A

Hyperprolactinaemia - cause by pituitary hyperplasia or benign adenomas (rarely pit tumours or Sheehans syndrome)

42
Q

What is Sheehans syndrome

A

Rare severe post-partum haemorrhage causing pituitary necrosis and varying degrees of hypopituitarism

43
Q

Treatment of hyperprolactinaemia causing amenorrheoa

A

Bromocriptine, cabergoline - occasionally surgery

44
Q

What thyroid problems can cause amenorrhoea

A

Over-activity or under-activity of the thyroid can cause it

Hypothyroid leads to raised prolactin levels and amenorrhoea

45
Q

What sort of amenorrhoea can PCOS cause?

A

Primary or secondary amenorrhoea

But oligomenorrhoea is more common

46
Q

What are congenital causes of amennorhoea? x4

A

Turners syndrome
Gonadal dysgenesis (ovary imperfectly formed due to mosaiic abnormalities of X chromosome)
Gonadal agenesis
Androgen insensitivity

47
Q

What can outflow tract problems leading to amenorrhoea cause?

A

Eg. imperforate hymen or transverse vaginal septum - obstruct menstrual flow - therefore accumulates over months in the vagina (haematocolpos) or uterus (haematometra) - may be palpable abdominally

48
Q

What is Ashermans syndrome?

A

Uncommon consequence of excessive curettage at evacuation of retained products of conception

49
Q

Causes of post-coital bleeding? x4

A

Cervical carcinoma
Cervical ectropion
Cervical polyps
Cervicitis, vaginitis

50
Q

Investigation of postcoital bleeding? x3

A

Smear from cervix
Avulsion of polyp if present
Colposcopy

51
Q

Management of post-coital bleeding if due to ectropion

A

Can freeze it with cryotherapy

52
Q

What is dysmenorrhoea associated with?

A

High prostaglandin levels in the endometrium

Due to contraction and uterine ischaemia

53
Q

What is primary dysmenorrhoea

A

When there is no organic cause for dysmenorrhoea - usually coincides with start of menstruation
NSAIDs and COC to treat

54
Q

What is secondary dysmenorrhoea

A

When pain is due to pelvic pathology

Pain often preceeds and is relieved by the onset of menstruation

55
Q

What else is common with secondary dysmenorrhoea x3

A

Deep dyspareunia
Menorrhagia
Irregular menstruation

56
Q

Causes of secondary dysmenorrhoea? x5

A 
Fibroids 
Adenomyosis
Endometriosis 
PID 
Ovarian tumours
57
Q

What is the definition of precocious puberty?

A

When menstruation occurs before age 10 or other secondary sexual characteristics before age 8

58
Q

What is the consequence for height in precocious puberty?

A

Early growth spurt but final height reduced due to early fusion of the epiphyses

59
Q

Treatment of precocious puberty

A

GnRH agonists - inhibit sex hormone secretion and cause regression of secondary sexual characteristics

60
Q

How often is no cause found for precocious puberty?

A

In 80% of cases

61
Q

Central causes of precocious puberty x5

A

Increased GnRH secretion - meningitis, encephalitis, CNS tumours, hydrocephaly and hypothyroidism - may all prevent normal pubertal inhibition of GnRH release from hypothalamus

62
Q

Ovarian/adrenal causes of precocious puberty?

A

Increased oestrogen secretion - Hormone producing tumours of the ovary or adrenal glands (McCune-Albright syndrome)

63
Q

What is McCune-albright syndrome?

A

Bone and ovarian cysts, cafe au lait spots and precocious puberty
- Treat with antiandrogenic progestogen

64
Q

Drug management of PMS x2

A

SSRIs in second half of cycle

Ablating the cycle with contraception

65
Q

What is good for the breast tenderness of PMS

A

Evening primrose oil

Gynaecology (8 decks)

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