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4th Year GOSH > Menstrual Cycle/Menstrual Problems > Flashcards

Menstrual Cycle/Menstrual Problems Flashcards

1
Q

Endometrial effects in proliferative phase?

A

Endometrium thickens ↑ stromal cells, ↑ glands, blood vessels.
By ovulation endometrium 2-3mm thick.

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2
Q

Endometrial effects in secretory phase?

A

↑secretion, ↑lipids and glycogen, ↑blood supply
Endometrium 4-6mm thick
Optimal condiitons for implantation of fetilised egg

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3
Q

What happens to endometrium if no fertilisation?

A

Vasodilation (vasospasm) –> necrotic layers of endometrium separate from uterus –> uterine contractions –> menstruation

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4
Q

Cervical effects of menstrual cycle?

A
  • Mucus production from columnar glands
  • Stringy and runny midcycle (spinnbarkeit) –> facilitates sperm access at ovulation
  • Tenacious and inelastic in luteal phase (moderated by progesterone)
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5
Q

Definition of abnormal menstrual bleeding (AUB)?

A

Any menstrual bleeding that is either:
o Abnormal in volume (excessive duration or heavy)
o Abnormal in regularity, timing (delayed or frequent)
o Non-menstrual (IMB, PCB, PMB)

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6
Q

Structural causes of AUB?

A

PALM

Polyps (endometrial/cervical)
Adenomyosis
Leimyoma
Malignancy/pre-malignancy

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7
Q

Non-structural causes of AUB?

A

COEIN

Coagulopathy
Ovulatory dysfunction (PCOS, hypoT)
Endometrial disorders (inflammatory - endometritis)
Iatrogenic (COCP, IUS, warfarin)
Not yet classified
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8
Q

Questions to ask to determine whether coagulation problems are present?

A

Heavy from menarche?
FH?
PPH?

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9
Q

Definition of heavy menstrual bleeding?

A

Excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material QoL.

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10
Q

History in menorrhagia?

A 
•	How heavy is the bleeding?
o	Clots (including size), flooding.
o	Frequency of pad change, type of pad
o	Waking at night to change protection
o	How is it affecting her daily life?
  • Associated symptoms? – pain/pressure
  • Anaemia symptoms?
  • Smear history
  • Gynae history  contraception use
  • Past obstetric history
  • Medical (bleeding disorders), drug (warfarin), social, family histories.
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11
Q

Examination in menorrhagia?

A

• Anaemia common.

• Pelvic signs often absent
o Irregular enlargement of uterus suggests fibroids
o Tenderness with or without enlargement suggests adenomyosis
o Ovarian mass may be felt

• Tenderness and immoblile pelvic organs are common with infection/ endometriosis (not a cause but may co-exist)

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12
Q

Main investigation in menorrhagia? Bloods if history suggests?

A

FBC (Hb)

Coagulation (VW disease screen) and TFTs

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13
Q

Further investigations in menorrhagia if indicated?

A

TV USS Pelvis - indicated if enlarged uterus, mass, treatment failure - assess endometrial thickness, exclude fibroid/ovarian mass/polyps

Hysteroscopy - Allows inspection of uterine cavity – detection of polyps and submucous fibroids that could be resected.

Endomtrial biopsy - done at hysteroscopy with a Pipelle – to exclude endometrial malignancy or premalignancy.

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14
Q

Indications for endometrial biopsy in menorrhagia

A

o If endometrial thickness >10mm or polyp suspected
o If woman >40 years old with recent onset menorrhagia
o IMB
o Not responding to treatment

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15
Q

1st line medical treatment for menorrhagia?

A

Mirena coil – reduces menstrual flow by >90% with considerably fewer side effects.

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16
Q

2nd line medical treatments for menorrhagia?

A
  • Antifibrinolytics (tranexamic acid) - Taken during menstruation only. Reduce blood loss by 50% - few side effects.
  • NSAIDs (Mefanamic acid) - Inhibit prostaglandin synthesis –> reduce blood loss by 30%. Also useful for dysmenorrhoea. Similar side effects to aspirin.
  • Combined Pill - Induces lighter menstruation – less effective if pelvic pathology present. Use limited - complications more common in older patients.
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17
Q

3rd line medical treatments for menorrhagia?

A

• Progestogens - Taken in high doses orally/IM –> amenorrhoea. Bleeding follows withdrawal. NOT CONTRACEPTIVE.

GnRH agonists - Produce amenorrhoea. Unless add-back HRT used, duration limited to 6 months. Bleeding follows withdrawal.

18
Q

Surgical options for menorrhagia?

A

Endometrial ablation - destruction of endometrium –> amenorrhoea or lighter periods (not contraceptive)

Uterine artery embolisation - collateral circulation keeps uterus alive.

Hysterectomy - last resort - uterus normal in 50%

19
Q

When is irregular menstruation/IMB more common?

A

At extremes of reproductive age

20
Q

Two main causes of irregular bleeding/IMB?

A

Anovulatory cycles

Pelvic pathology

21
Q

What are anovulatory cycles and why do they cause IMB?

A

No ovulation –> no progesterone - oestrogen cannot support growing endometrium –> bleeding = oestrogen breakthrough bleed

22
Q

What pelvic pathology can cause irregular bleeding/IMB?

A

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

MALIGNANCY

23
Q

Investigations in IMB/irregular bleeding?

A

FBC - assess effect of blood loss
Exclude malignancy
- smear if needed
- USS - >35 or not responding to treatment
- Biopsy - if thickened, polyp suspected, >40

24
Q

1st line management of IMB/irregular bleeding?

A

IUS or COCP

25
Q

2nd line managment of IMB/irregular bleeding?

A

Progestogens - give on a cyclical basis to mimic normal cyle
HRT - can regulate bleeding in perimenopause

Other treatments for menorrhagia can be used.

26
Q

Causes of primary amenorrhoea?

A 
Anorexia nervosa
Physiological athleticism
Hyperprolactinaemia
Hypo/hyperthyroidism
Adrenal tumours/hyperplasia
PCOS
Premature ovarian failure
Imperforate hymen
Transverse vagainal septum
Turner's syndrome
27
Q

Non-pathological causes of secondary amenorrhoea?

A

Pregnancy
Lactation
Menopause
Drugs

28
Q

Pathological causes of secondary amenorrhoea?

A 
Anorexia nervosa
Physiological athleticism
Hyperprolactinaemia
Hypo/hyperthyroidism
Adrenal tumours
PCOS
Premature ovarian failure
Asherman's syndrome
Cervical stenosis
29
Q

What is post-coital bleeding?

A

ALWAYS ABNORMAL must exclude carcinoma

30
Q

Causes of post-coital bleeding?

A 
Situations where cervix not covered in healthy squamous epithelium --> more likely to bleed after mild trauma
•	Cervical carcinoma
•	Cervical ectropion
•	Cervical polyps
•	Cervicitis, vaginitis
31
Q

Management of post-coital bleeding?

A
  • Cervical examination – smear taken.
  • If polyp evident –> avulsed and sent for histology
  • If smear -ve –> ctropion can be frozen with cryotherapy
  • Otherwise –> colposcopy to exclude malignant cause
32
Q

What causes pre-menstrual syndrome?

A

Progesterone - occurs in luteal phase

33
Q

Features of pre-menstrual syndrome?

A

Behavioural changes – ‘tension’, irritability, aggression, depression, loss of control.

Physical symptoms – bloatedness, minor GI upset, breast pain.

34
Q

Medical management of premenstrual syndrome?

A

• SSRIs – continuous or intermittently in second half of cycle.

• Ablation of cycle
o Continuous oral contraception; oestrogen HRT patches.
o Trial of GnRH agonist and add-back oestrogen therapy –> perimenopause.
o Bilateral oophorectomy

35
Q

Supplements to help premenstrual syndrome?

A
  • Oil of evening primrose oil – good for breast tenderness
  • Pyridoxine (vitamin B6) – good in mild doses, can cause neuropathy in excess.
  • Vitex agnus-castus extract
36
Q

Diagnostic criteria for PCOS?

A

(2/3 needed)
o PCO on USS
o Irregular periods (>35 days apart)
o Hirsutism (Clinical – acne or excess body hair, Biochemical – raised serum testosterone)

37
Q

Aetiology of PCOS

A

Disordered LH production and peripheral insulin resistance –> increased insulin –> raised ovarian androgen production

Environmental factors (weight) can modify phenotype

38
Q

Clinical features of PCOS?

A 
•	Obesity
•	Acne
•	Hirsutism
•	Oligomenorrhoea/ amenorrhoea
•	Subfertility/miscarriage
Changes in weight over time will alter insulin levels and severity of syndrome.
39
Q

Bloods in PCOS?

A

Anovulation - FSH (↑ in ovarian failure, ↓in hypothalamic disease, normal in PCOS)
Prolactin (to exclude prolactinoma)
TSH

Hirsutism - Serum testosterone levels (androgen-secreting tumour or congenital adrenal hyperplasia if very raised)

LH - Often raised in PCOS but not diagnostic

40
Q

Complications of PCOS?

A

• Diabetes - 50% develop TIIDM; 30% develop gestational diabetes  risk reduced by weight reduction
• Endometrial cancer -
More common after many years of amenorrhoea due to unopposed oestrogen action.
• Normal oestrogen levels so not at risk of osteoporosis.

41
Q

Treatment for PCOS?

A

Weight Reduction - Will reduce insulin levels  improvement in PCOS symptoms

COP - If fertility not required –> regulates menstruation and treats hirsutism. 3-4 bleeds per year necessary to protect endometrium

Antiandrogens -
Cyproterone acetate/spironolactone – effective for hirsutism, but conception must be avoided.

Metformin - Insulin sensitizer –> reduces insulin levels –> reduces androgens and hirsutism and promotes ovulation.

Eflonithine - Topical antiandrogen for facial hirsutism.

4th Year GOSH (23 decks)

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