Menstrual Cycle Disorders

Question 1

• What does continuous administration of exogenous progestogens result in in terms of the cycle?

Answer 1

Results in the maintenance of a secretory endometrium therefore delaying mensuration (surely its important to let it go at some point?)

Question 2

The acronym for the main categories of causes of AUB?

Answer 2

PALM-COEIN:

Question 3

What does the PALM side refer to?

Answer 3

Structural causes diagnosed on imaging/biopsy.

Question 4

What does the COEIN side refer to?

Answer 4

Underlying medical disturbances resulting in AUB. Essentially non-structural causes.

Question 5

PALM stands for?

Answer 5

Polyps; Adenomyosis; Leiomyomas (fibroids; submucosal or other); Malignancy and hyperplasia

Question 6

COEIN stands for?

Answer 6

Coagulopathy; Ovulatory dysfunction; Endometrial (i.e. disorder of mechanisms that stop local bleeding); Iatrogenic or, Net yet specified

Question 7

Most common cause of HMB that is usually found with a patient?

Answer 7

Most have no histological issue so may result from abnormalities of haemostasis, or prostaglandin levels. Usually ovulatory cycles (in comparison to irregular)

Question 8

HMB: When a pathology is found what is the most common types?

Answer 8

Fibroids (30%) and polyps (10%)

Question 9

What investigations would you want to do to assess heavy menstrual bleeding?

Answer 9

FBC Hb - for anaemia; Thyroid function & coagulation - for systemic causes (if suggestive); Transvaginal ultrasound (TVU) for local structures

Question 10

HMB: When should you consider an endometrial biopsy?

Answer 10

Age >40, HMB unresponsive to medical therapy, HMB w/ IMB, RFs for endometrial cancer, or if TVU suggests.

Question 11

What are some RFs in younger women for endometrial cancer?

Answer 11

Obesity, diabetes, nulliparity, PCOS. (basically unopposed oestrogen increases risk)

Question 12

What are most common causes of IMB/irregular

Answer 12

Either anovulatory cycles (esp after menarche and before menopause) and pelvic pathology (non-malignant: poplyps, fibroids, adenomyosis, cysts and chronic pelvic infection OR malignant: ovarian/cervical and esp endometrial)

Question 13

Ix for IMB & irregular menstruation?

Answer 13

FBC Hb; then exclude malignancy: smear, TVU for over 35s (& in younger if Tx failed)… then same reasons to take an endometrial biopsy if indicated.

Question 14

Mx 1st line for IMB/irregular

Answer 14

IUD or COCP. plus second line options like for HMB or including progestogens to simulate a normal cycle via on and off.

Question 15

What are some general categories that can be used to classify causes of amenorrhoea?

Answer 15

Either physiological (i.e. pregnancy etc) Pathological (HPA axis, thyroid, ovary, uterus) drugs (such as progestogens, GnRH analogues)

Question 16

3 most common pathological causes of 2ndry amenorrhoea/oligomenorrhoea?

Answer 16

1. Premature menopause 2. PCOS 3. Hyperprolactinaemia

Question 17

What are some causes of postcoital bleeding?

Answer 17

Cervical carcinoma/ectropion/polyps. Or cervicitis, vaginitis. (basic cause is cervix not being covered in healthy squamous epithelium)

Question 18

Definition of precocious puberty?

Answer 18

Menstruation occurs before 9. Usually no pathological cause. Use GnRH agonists.

Question 19

So in summary the causes of HMB vs irregular bleeding are usually?

Answer 19

HMB: usually ovulatory. No actual pathology. (maybe anatomical)

Irregular: often anovulatory; PCOS (sometimes anatomical)

Question 20

Summarise the investigations for menstrual disorders

Answer 20

FBC, TVU.

If IMB, >40, thickened endometrium or risk factors for endometrial cancer +- endometrial biopsy (w/ hysteroscopy)

Question 20

Summarise the investigations for menstrual disorders

Answer 20

FBC, TVU.

If IMB, >40, thickened endometrium or risk factors for endometrial cancer +- endometrial biopsy (w/ hysteroscopy)

Question 21

So the 3 phases are? And which is always the same length?

Answer 21

Menstrual, proliferative (oestrogen) and secretory (always 14 days for egg to travel and corpus luteum alive)

Question 22

First line for HMB (vs IMB)

Answer 22

Heavy will be the coil as very effective w/ fewer side effects (compared to either for IMB)

Question 23

What are we worried about in HMB and so what do we do if they are old enough?

Answer 23

Worried about endometreosis. So pipelle biopsy if > 40. Or if they have RFs for endometrial cancer or HMB + IMB

Question 24

What are we thinking with IMB so what do we do if they are old enough?

Answer 24

About structural so ultrasound if older than 35. Same rules apply for endometrial biopsy

Question 25

Nice doesn’t really mention

Answer 25

Any of these aribtriary ages

Question 26

Nice doesn’t really mention

Answer 26

Any of these aribtriary ages

Question 27

Most common cause of primary ammenorhoea?

Answer 27

Turners syndrome

Question 28

Common causes of secondary ammenorhoea?

Answer 28

Ovarian insufficency, hypothalamic/pituitary, PCOS, thyroid, hyperprolactinaemia