Menstrual Cycle and its Disorders Flashcards
what is menarche and what does it mean
beginning on menstruation, beginning of the end of puberty
what is the average age and normal range for menarche in the western world?
9-16, average age 13/14
what hormonal changes occur around 8 years old that lead to the menarche
GnRH release increases in frequency leading to steadily increasing oestrogen level from the ovary leading to thelarche, adrenarche and menarche with an accompanying release in GH
what are the stages of the 28 day menstrual cycle
days 1-4 menstruation
days 5-13 proliferative phase
days 14-28 luteal/secretory phase
what occurs in days 1-4 of the menstrual cycle
endometrium is shed and myometrium contracts
what occurs in days 5-13 of the menstrual cycle
GnRH release is increased causing follicular release and development
the most developed follicle releases oestradiol which suppresses FSH
oestradiol release leads to an LH surge which peaks at day 14, also encourages endometrium development
what occurs in days 14-28 of the menstrual cycle
day 14 = peak of LH surge = ovulation
corpus luteum releases progesterone
progesterone leads to glandular development of the endometrium
if egg is not fertilised and placenta development is not initiated corpus luteum begins to fail and progesterone /oestradiol production falls causing menstruation
what is the lower normal age limit for menopause
40
what is the normal length of time for menses/bleeding
1-7 days
what is the normal amount of blood loss in menstruation
<80ml
what is the normal range in menstrual cycle lengths
23-35 days
what is the definition of menorrhagia
> 80ml of blood loss in a 23-35 day cycle lasting <8 days in an appropriately aged woman with an impact in function
what is the aetiology of menorrhagia
majority have normal histology and ovulation is not affected, and it is thought to be due to subtle differences in the endometrial fibrinolytic/prostaglandin sensitivity systems
pathologically, fibroids (30%) and polyps (10%)
rarely it is VW disease, hypothyroidism, anticoagulation therapy
what are the clinical features of menorrhagia
passing of clots
‘flooding’
symptoms of anaemia
how should you investigate menorrhagia
history + exam FBC TFT/clotting if indicated transvaginal USS biopsy if endometrial thickness >10mm on USS, polyps suspected, >40, non resolving hysteroscopy is also an option
how do you treat menorrhagia
1st line if not trying to conceive - IUS
if trying to conceive: tranexamic acid (only during bleeding)
2nd line: tranexamic acid IUS fails
NSAIDS (mefanamic acid) - consider gastroprotection
COCP
3rd line
progestogens
GnRH agonists
surgical management
if polyp is found - excise
fibroids = myo/hysterectomy
uterine artery embolisation (for fibroids in women who dont want a hysterectomy)
outside of fibroids hysterectomy may be last resort anyway
what are common causes for irregular cycles/intermenstrual bleeding
anovulatory cycles - common in early and late reproductive years
pelvic pathology: fibroids, polyps, adenomyosis, chronic pelvic infection, ovarian cysts
malignancy in older women
what are possible investigations for irregular cycles/intermenstrual bleeding
check Hb for anaemia
cervical smear for malignancy
USS (>35, <35 if medical treatment has failed, fibroids and ovarian masses)
biopsy if endometrial thickness >10mm on USS, >40, polyps are suspected or medical management has failed
what is the medical treatment for irregular cycles/intermenstrual bleeding and when is medical treatment considered
when there is no anatomical cause considered and patients functioning is impaired
1st line - IUS/COCP
2nd line - Transexamic acid, NSAIDS, progestogens, GnRH agonists
whats the surgical treatment for irregular cycles/intermenstrual bleeding
same as menorrhagia
if polyp is found - excise
fibroids = myo/hysterectomy
uterine artery embolisation (for fibroids in women who dont want a hysterectomy)
outside of fibroids hysterectomy may be last resort anyway
whats the definition of oligomenorrhea
> 35 day cycle for more than 6 months
what are the most common causes of secondary amenorrhea
PCOS
premature menopause
hyperprolactinaemia
what is hypothalamic hypogonadism
physiological stress (anorexia/excessive exercise) leading to low GnRH release causing amenorrhea
may be a tumour but thats rare
how do you treat hypothalamic hypogonadism
supportive, hormone replacement via COCP/HRT
