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Obs & Gynae > Menstrual Cycle + PV bleeds > Flashcards

Menstrual Cycle + PV bleeds Flashcards

1
Q

Menarche

A

Starting of menstruation cycle

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2
Q

Menopause

A

Cessation of menses

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3
Q

Overview of follicular phase of menstrual cycle

A

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.

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4
Q

Overview of luteal phase of menstrual cycle

A

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.

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5
Q

Normal length and blood loss in cycle

A

21-35 days and blood loss of 60-80ml.

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6
Q

Differences between Menorrhagia, inter-menstrual blending and abnormal uterine bleeding

A

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.

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7
Q

Definition of amenorrhoea

A

Absence or cessation of menses.

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8
Q

Primary amenorrhoea

A

Primary = failure to being menses by 16yrs in females with normal secondary sexual characteristics or by 14yrs in females with no secondary sexual characteristics.

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9
Q

Secondary amenorrhoea

A

Absence of menses for greater than 6months in females with previous regular menses or for over 12months in females with oligomenorrhoea.

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10
Q

Physiological causes amenorrhoea

A 
Pregnancy and menopause (secondary).
Constitutional delay (primary) e.g. familial pattern.
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11
Q

Secondary sexual characteristics

A

breast development, body hair growth,

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12
Q

Causes of primary amenorrhoea with normal secondary sexual characteristics

A 
Anatomical = imperforate hymen, transverse vaginal septum.
Endocrine = Androgen insensitivity syndrome, hypothyroidism, hyperthyroidism, Cushing's, hyperprolactinaemia.
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13
Q

Causes of primary amenorrhoea with absent secondary sexual characteristics

A

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.

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14
Q

Causes of secondary amenorrhoea without excessive androgens

A 
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.
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15
Q

Causes of secondary amenorrhoea with excess androgen

A

Androgen secreting tumour in ovary or adrenal gland.

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16
Q

Complications of amenorrhoea

A

Osteoporosis, CV disease, infertility, psychological distress.

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17
Q

Investigations and diagnosis of primary amenorrhoea

A

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.

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18
Q

Turner’s Syndrome

A

Loss of X chromosome. 45X

Short stature, widely spaced nipples, scoliosis, web neck, no ovarian function.

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19
Q

Management of amenorrhoea

A

Treat cause.
Assess osteoporosis risk (Vit D supplements?)
Lifestyle advice - loose weight, decrease exercise etc.

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20
Q

Definition of menorrhagia

A

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.

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21
Q

Uterine or Ovarian causes of menorrhagia and differentiating features

A

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

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22
Q

Other causes of menorrhagia

A 
Coagulaopathy e.g. von Willebrand.
Hypothyroidism
DM
Anticoagulation therapy.
Chemotherapy.
IUS or IUD.
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23
Q

Clinical features or complications of menorrhagia

A

Anaemia (tired, SOB, pale)
Increased of endometrial hyperplasia.
Poor quality of life.

24
Q

Investigations and history of menorrhagia

A

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.

25
Q

Management of menorrhagia

A

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.

26
Q

What can you give to temporarily prevent menses e.g. on a holiday

A

Oral norethisterone

27
Q

Anatomical causes of primary amenorrhoea with normal secondary sexual characteristics

A

Transverse vaginal septum

Imperforate hymen

28
Q

Hormones from anterior pituitary gland

A

Growth hormone, TSH, ACTH, Prolactin, LH and FSH

29
Q

Hormones from posterior pituitary gland

A

ADH/Vasopression, Oxytocin.

30
Q

Causes of intermenstrual bleeding

A

Mid-cycle fall in oestrogen.

cervical polyps, cervical carcinoma, IUD, IUS, POCP, chlamydia, ectropian.

31
Q

Causes of post-coital bleeding

A

Cervical trauma
Cervical polyp
Cervical, endometrial or vaginal carcinoma.
Chlamydia.

32
Q

Causes of post-menopausal bleeding

A 
ENDOMETRIAL CARCINOMA.
Vaginitis.
Retained foreign body e.g. pessary.
Cervical or endometrial polyp.
Oestrogen withdrawal e.g HRT
33
Q

Primary and secondary dysmenorrheoa

A

Primary = no organ pathology. Secondary = associated with a pathology.

34
Q

Symptoms and pathophys of dysmenorrheoa

A

Crampy ache mostly worse on first 2 days of cycle. Excess prostaglandins cause uterine contractions leading to painful ischaemia.

35
Q

Red flag symptoms for dysmenorrheoa

A

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.

36
Q

Management of primary dysmenorrheoa

A

NSIAD e.g. mefenamic acid during menses.

Suppress ovulation via COCP.

37
Q

Pathologies in secondary dysmenorrheoa

A

PID, fibroids, endometriosis, adenometriosis, endometrial polyps, IUD insertion.
Associated with other symptoms e.g. dyspareunia.

38
Q

Definition of menopause

A

Biological state when menstruation permanently ceases due to loss of ovarian follicular activity. 12 months of amenorrhoea. Mean age in UK = 51.

39
Q

Premature menopause definition

A

Before 40yrs

40
Q

Perimenopause

A

Period before menopause marked by endocrine, biological and clinical features of approaching menopause e.g. irregular cycles.

41
Q

Physiology of menopause

A

Finite number of oocytes in female ovaries.
Ovarian function declines.
Oestrogen levels decrease, LH and FSH rise due to negative feedback.

42
Q

Causes of premature menopause

A

Genetic
Premature ovarian failure.
Autoimmune predisposition
Iatrogenic e.g. chemotherapy.

43
Q

Clinical features in perimenopause

A

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.

44
Q

Chronic disease risk with menopause (no HRT)

A

Premature menopause = Increase risk from CVD, dementia, osteoporosis, parkinsonism.
Postmenopause = CVD, stroke, osteoporosis.

45
Q

Diagnosing the menopause

A

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.

46
Q

Risks of HRT

A

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.

47
Q

Benefits of HRT

A

Decrease risk of osteoporosis and fragility fractures.

Relief of perimenopause symptoms.

48
Q

Contraception advice for menopause

A

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.

49
Q

Types of HRT

A

Combined = oestrogen and progesterone, if uterus present.

Oestrogen only - lack uterus (unopposed oestrogen increase endometrial cancer risk!).

50
Q

Contraindications for HRT

A 
Oestrogen dependent cancer.
Breast cancer
Breastfeeding
High LFTs
Hx of pulmonary embolism
Undiagnosed PV bleeding
Phlebitis
Uncontrolled HTN.
51
Q

Side effects of HRT

A 
Fluid retention
Breast tenderness
Headaches
Leg cramps
Dyspepsia
52
Q

Use of transdermal HRT patch

A 
Gastric disturbance e.g Crohn's
Hx of migraine or epilepsy
VTE risk females.
Patient choice
HTN females
Older females
53
Q

Premature ovarian failure

A

Cause of premature menopause and amenorrhoae.

FSH greater than 25IU/L in 2 samples 4 weeks apart

54
Q

Mittelschmerz pain.

A

Pain associated with ovulation

55
Q

Latency periods after starting contraception to it being effective

A 
COCP = 7 days
Depot injection =7days
Implant = 7days
IUS =7days
IUD = instant
POCP = 2days
56
Q

Hypogonadatrophic hypogonadism

A 
Low GnRH (hypogonad)
High FSH and LH
but 
Low oestrogen
Low testosterone
Impaired negative feedback mechanism.
57
Q

Causes of hypogonadatrophic hypogonadism

A 
Prader-Willi
Kallman's syndrome
Anabolic steroids
Cushing's syndrome
Hyperprolactinaemia
Pituitary tumour
Opiates
Excessive exercise

Obs & Gynae (17 decks)

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