Menstrual Cycle + PV bleeds Flashcards
Menarche
Starting of menstruation cycle
Menopause
Cessation of menses
Overview of follicular phase of menstrual cycle
From 1st day of menses until ovulation. Low progesterone, low but gradually rising oestrogen. Higher levels of FSH and LH which rise to peak to give ovulation.
Overview of luteal phase of menstrual cycle
From ovulation until the beginning of a new cycle/menses. Ovulation triggered by peak in LH and rising FSH. After these peak their levels decrease and progesterone and oestrogen synthesis increases.
Normal length and blood loss in cycle
21-35 days and blood loss of 60-80ml.
Differences between Menorrhagia, inter-menstrual blending and abnormal uterine bleeding
Menorrhagia = heavy menstrual bleeding at predictable times in cycle.
Intermenstrual bleeding = PV bleeding occurring at clearly defined and predictable times in cycle.
Abnormal uterine bleeding = any PV bleeding that is in abnormal volume, regularity, time or non related to menses.
Definition of amenorrhoea
Absence or cessation of menses.
Primary amenorrhoea
Primary = failure to being menses by 16yrs in females with normal secondary sexual characteristics or by 14yrs in females with no secondary sexual characteristics.
Secondary amenorrhoea
Absence of menses for greater than 6months in females with previous regular menses or for over 12months in females with oligomenorrhoea.
Physiological causes amenorrhoea
Pregnancy and menopause (secondary). Constitutional delay (primary) e.g. familial pattern.
Secondary sexual characteristics
breast development, body hair growth,
Causes of primary amenorrhoea with normal secondary sexual characteristics
Anatomical = imperforate hymen, transverse vaginal septum. Endocrine = Androgen insensitivity syndrome, hypothyroidism, hyperthyroidism, Cushing's, hyperprolactinaemia.
Causes of primary amenorrhoea with absent secondary sexual characteristics
Turner’s syndrome (gonadal dysgenesis).
Prader-Willi syndrome (chromosome 15).
Kallman’s syndrome (failure of GnRH neurones) also have no sense of smell.
Anorexia nervosa.
Chemotherapy.
Poorly controlled DM, coeliac disease, TB.
Excessive exercise.
Causes of secondary amenorrhoea without excessive androgens
Polycystic ovary syndrome. Premature ovarian failure. Hyperprolactinaemia. Sheehan's syndrome postpartum Asherman's syndrome (adhesions) Progesterone contraception devices, radiotherapy, chemotherapy and surgery (hysterectomy). Hypogonadotropic hypogonadism = Weight loss, excessive exercise, stress, depression. Cervical stenosis and adhesions. Thyroid disease.
Causes of secondary amenorrhoea with excess androgen
Androgen secreting tumour in ovary or adrenal gland.
Complications of amenorrhoea
Osteoporosis, CV disease, infertility, psychological distress.
Investigations and diagnosis of primary amenorrhoea
History of family menarche and drug history.
Menopausal symptoms.
Visual fields for a pituitary tumour.
Examine features of Turner’s, PCOS or thyroid disease.
Pregnancy test.
Pelvic US
Serum prolactin, TSH, FSH and LH, testosterone.
Turner’s Syndrome
Loss of X chromosome. 45X
Short stature, widely spaced nipples, scoliosis, web neck, no ovarian function.
Management of amenorrhoea
Treat cause.
Assess osteoporosis risk (Vit D supplements?)
Lifestyle advice - loose weight, decrease exercise etc.
Definition of menorrhagia
Heavy and excessive menstrual blood loss occurring during the female’s cycle. The menses interferes with the woman’s physical, emotional, social and material quality of life. Greater than 80ml of blood is lost, requiring changing of sanitary items every 1-2hrs and passage of clots greater than 2.54cm.
Uterine or Ovarian causes of menorrhagia and differentiating features
Idiopathic/not identified.
Dysfunctional uterine bleeding (exclusion diagnosis)
Uterine fibroids (pelvic pain and dysmenorrhea).
Endometriosis and adenomyosis (dyspareunia, dysmenorrhea, sub fertility, pelvic pain).
PID
Pelvic infection e.g. chlamydia (vag discharge, postcoital bleed, fever).
Endometrial polyps.
Endometrial hyperplasia or carcinoma (postcoital bleed, intermenstrual bleed, pelvic pain).
PCOS
Other causes of menorrhagia
Coagulaopathy e.g. von Willebrand. Hypothyroidism DM Anticoagulation therapy. Chemotherapy. IUS or IUD.
Clinical features or complications of menorrhagia
Anaemia (tired, SOB, pale)
Increased of endometrial hyperplasia.
Poor quality of life.
Investigations and history of menorrhagia
Cervical screening history.
Sexual and menstrual history.
Drug history and contraception.
Abdo and bimanual pelvic exam, plus speculum exam.
FBC for anaemia.
TSH, coagulation screen, STI test - identify cause.
Management of menorrhagia
1st line/primary care = IUS/Mirena, Tranexamic acid (antifibrinolyic) or NSAID e.g. Mefenamic acid, COCP. Can use combinations.
2nd line/secondary care = GnRH agonist Subcut or IM
Surgical. = Hysterectomy, endometrial ablation, uterine artery embolisation.
What can you give to temporarily prevent menses e.g. on a holiday
Oral norethisterone
Anatomical causes of primary amenorrhoea with normal secondary sexual characteristics
Transverse vaginal septum
Imperforate hymen
Hormones from anterior pituitary gland
Growth hormone, TSH, ACTH, Prolactin, LH and FSH
Hormones from posterior pituitary gland
ADH/Vasopression, Oxytocin.
Causes of intermenstrual bleeding
Mid-cycle fall in oestrogen.
cervical polyps, cervical carcinoma, IUD, IUS, POCP, chlamydia, ectropian.
Causes of post-coital bleeding
Cervical trauma
Cervical polyp
Cervical, endometrial or vaginal carcinoma.
Chlamydia.
Causes of post-menopausal bleeding
ENDOMETRIAL CARCINOMA. Vaginitis. Retained foreign body e.g. pessary. Cervical or endometrial polyp. Oestrogen withdrawal e.g HRT
Primary and secondary dysmenorrheoa
Primary = no organ pathology. Secondary = associated with a pathology.
Symptoms and pathophys of dysmenorrheoa
Crampy ache mostly worse on first 2 days of cycle. Excess prostaglandins cause uterine contractions leading to painful ischaemia.
Red flag symptoms for dysmenorrheoa
Abnormal cervix on examination - cervical cancer?
Persistent intermenstrual or postcoital bleeding - cervical or endometrial cancer?
Palpable abdo or perlvic mass that is not indicative of a fibroid.
USS shows cancer signs.
Management of primary dysmenorrheoa
NSIAD e.g. mefenamic acid during menses.
Suppress ovulation via COCP.
Pathologies in secondary dysmenorrheoa
PID, fibroids, endometriosis, adenometriosis, endometrial polyps, IUD insertion.
Associated with other symptoms e.g. dyspareunia.
Definition of menopause
Biological state when menstruation permanently ceases due to loss of ovarian follicular activity. 12 months of amenorrhoea. Mean age in UK = 51.
Premature menopause definition
Before 40yrs
Perimenopause
Period before menopause marked by endocrine, biological and clinical features of approaching menopause e.g. irregular cycles.
Physiology of menopause
Finite number of oocytes in female ovaries.
Ovarian function declines.
Oestrogen levels decrease, LH and FSH rise due to negative feedback.
Causes of premature menopause
Genetic
Premature ovarian failure.
Autoimmune predisposition
Iatrogenic e.g. chemotherapy.
Clinical features in perimenopause
Vasomotor = hot flushes, night sweats, palpitations.
MSK = joint and muscle pain, osteoporosis.
Genital and Urinary = vaginal atrophy and dryness, dyspareunia, UTI, incontinence.
Psych = mood swings, sleep disturbance, low libido.
Chronic disease risk with menopause (no HRT)
Premature menopause = Increase risk from CVD, dementia, osteoporosis, parkinsonism.
Postmenopause = CVD, stroke, osteoporosis.
Diagnosing the menopause
Low oestrogen and high LH and FSH but NICE does not recommend routine blood testing if over 45yrs.
Diagnosing premature = 2 FSH blood samples raised.
Risks of HRT
VTE = increased risk with oral HRT only.
CVD and stroke = small increase in risk with oral HRT only.
Breast cancer = increase risk with combined HRT, the risk reduces if woman stop HRT.
Benefits of HRT
Decrease risk of osteoporosis and fragility fractures.
Relief of perimenopause symptoms.
Contraception advice for menopause
If woman is less than 50yrs, still fertile for 2yrs so need contraception.
If woman is over 50yrs, still fertile for 1yr so need 1yrs contraception.
Types of HRT
Combined = oestrogen and progesterone, if uterus present.
Oestrogen only - lack uterus (unopposed oestrogen increase endometrial cancer risk!).
Contraindications for HRT
Oestrogen dependent cancer. Breast cancer Breastfeeding High LFTs Hx of pulmonary embolism Undiagnosed PV bleeding Phlebitis Uncontrolled HTN.
Side effects of HRT
Fluid retention Breast tenderness Headaches Leg cramps Dyspepsia
Use of transdermal HRT patch
Gastric disturbance e.g Crohn's Hx of migraine or epilepsy VTE risk females. Patient choice HTN females Older females
Premature ovarian failure
Cause of premature menopause and amenorrhoae.
FSH greater than 25IU/L in 2 samples 4 weeks apart
Mittelschmerz pain.
Pain associated with ovulation
Latency periods after starting contraception to it being effective
COCP = 7 days Depot injection =7days Implant = 7days IUS =7days IUD = instant POCP = 2days
Hypogonadatrophic hypogonadism
Low GnRH (hypogonad) High FSH and LH but Low oestrogen Low testosterone Impaired negative feedback mechanism.
Causes of hypogonadatrophic hypogonadism
Prader-Willi Kallman's syndrome Anabolic steroids Cushing's syndrome Hyperprolactinaemia Pituitary tumour Opiates Excessive exercise
