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OBGYN > Menstrual Disorders > Flashcards

Menstrual Disorders Flashcards

1
Q

What is puberty?

A

The onset of sexual maturity marked by the development of 2ndary sexual characteristics

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2
Q

How does puberty get triggered?

A

Hypothalamic-pituitary axis - “wakes” then “wakes up” the ovaries

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3
Q

What is happening in the body from 8 years of age?

A

GnRH pulses increase => FSH/LH increase => oestrogen increases => responsible for the dev of 2nddary sexual characteristics

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4
Q

What is precocious puberty?

A

Secondary sexual characteristics before age 8 and menstruation before age 9

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5
Q

What is delayed puberty?

A

No sexual secondary characteristics by age 14 and no mensuration by age 16

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6
Q

What are the stages of puberty?

A
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7
Q

What hormonal feedback plays a role in puberty?

A

Low estrogen levels have a + feedback on thalamus = encourage secretion of FSH & LH
Intermediate estrogen levels have a - feedback on GnRH = less LH & FSH
Higher estrogen levels have a + feedback on LH & FSH
LH surger happens about …hours before ovulation
Corpus luutheum = produces estrogen and progesterone but relaivtively high levels of progesterone

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8
Q

What are the 5 stages of puberty?

A
  • growth spurt (~11yrs)
  • thelarche = breast dev
  • adrenarche = pubic hair dev
  • menarche = average 13yrs is reducing
  • axillary hair growth

Usually this order but variations can occur

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9
Q

When does the growth spurt last till in puberty?

A

Up until 15-16 years

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10
Q

How is menstruation at the start of puberty?

A

Irregular at first - anovulatory cycles: prior to maturation of feedback loop between ovaries and pituitary/hypothalamus, then becomes regular

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11
Q

What do hormonal changes in the menstural cycle lead to?

A
  • ovulation
  • endometrial changes (preparing for implantation)
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12
Q

What are the stages of the menstrual cycle?

A
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13
Q

What part of the menstural cycle is consistently the same length regardless of overall cycle length?

A

Secretory/luteal phase is a constant 14 days

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14
Q

What are the different parts of the menstrual cycle?

A

Days 1-4: menstruation: endometrium shed, myometrium contracts

Day 5-13: proliferative/follicular phase:

Days 14-28: secretory/luteal phase:

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15
Q

What are the normals for the menstrual cycle?

A

<16 Yrs: Menarche
>45 Yrs: Menopause
3-8 Days: Menstruation
<80 Ml: Blood loss
24-38 Days: Cycle length

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16
Q

When is said to be early menopause?

A

40-45

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17
Q

When is said to be premature menopause?

A

<40

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18
Q

What is menorrhagia?

A

Heavy menstural bleeding

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19
Q

What are the two definitions of menorrhagia?

A
  • blood loss of >80ml per month in an otherwise normal menstrual cycle
  • excess menstrual blood loss that interferes with a woman’s quality of life and can occur alone or in combination with other symptoms (QOL = physical, emotional, social and material)
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20
Q

Why is the limit of menorrhagia 80ml?

A

Blood loss of 80ml is the most a woman on a normal diet can loose without becoming iron deficient

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21
Q

How common is menorrhagia?

A

5% of women aged 30-49 yrs consult their GP due to heavy periods or menstrual problems

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22
Q

What is the etiology of menorrhagia?

A
  • uterine
    fibroids 30%
    polyps 10%
    endometrial hyperplasia
    endometrial ca
    endometriosis/ adenomyosis
  • cervical
    carcinoma
    polyp
  • pelvic
    ovarian cancer
    chronic pelvic infection
  • thyroid disease (hypo)
  • coagulation disorder
    vW, anticoagulants, thrombocytopenia
  • IUD - esp the copper coil
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23
Q

What is a fibroid?

A

Benign tumour of the myometrium

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24
Q

What will the majority of women with menorrhagia have?

A

No histological abnormality and regular cycles

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25
Q

What may menorrhagia result from in cases where there is no histological abnormalities?

A
  • endometrial haemostasis
  • uterine prostaglandin levels
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26
Q

What do the prostaglandins cause?

A
  • PG12 and PGE2 = vasodilation
  • PGF2 = constriction
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27
Q

How does FIGO group the etiologies of menorrhagia?

A

PALM (structural)
P; Polyp
A; Adenomyosis
L; Leiomyoma (Fibroid)
M;Malignancy / Hyperplasia

COEIN (non-structural causes)
C; Coagulation disorder
O; Ovulatory dysfunction
E; Endometrial (primary disorder of mechanisms regulating haemostasis)
I; Infection / Iatrogenic (medications)
N; Not yet known

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28
Q

What are the clinical features you must ask about in the history of women with menorrhagia?

A
  • nature and duration of bleeding (flooding, clots, pads)
  • length and regularity of cycle
  • associations : IMB, PCB, discharge, pain, urinary symptoms
  • effect on QOL, consider symptomatic anaemia, ADLS, sexual function
  • investigations: FBC?
  • treatments: tried to date (may include contraceptives)
  • risk/causation: thyroid, family Hx of coagulation problems
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29
Q

What are the guidelines on examination of a woman presenting with menorrhagia?

A

. NICE guidelines: offer a physical exam if HMB with other related symptoms and in all going for IUS.

RCPI guidelines suggest examination should include abdominal and pelvic examination where feasible (later less so in young women newly sexually active)

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30
Q

What signs may be seen on clinical examination of a patient with menorrhagia?

A

-General –> anaemia (facial, conjunctival, nail bed pallor)

-Abdominal examination: palpable mass (e.g. fibroid or ovarian mass) or tenderness (adenomyosis, endometriosis, PID)

-pelvic-> signs of different issues

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31
Q

What clinical features and signs may be seen on pelvic examination in a woman with menorrhagia?

A
  • cervical abnormality
  • uterine: tenderness: adenomyosis
  • uterine: irregular enlargement: fibroids
  • uterine: mobility/retroverted (?PID, endometriosis)
  • ovarian mass/adnexal tenderness
  • pouch of Douglas assessment - often nil
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32
Q

What investigations are done for menorrhagia?

A
  • Labs FBC +/-ferritin/ironstudies +/-tfts & coag no need for hormonal studies in HMB unless other cause for doing them
  • TVUS: endometrial thickness, large polyps, fibroids, ovarian mass.
  • Endometrial biopsy: indications: RCPI guidelines
  • Hysteroscopy:
    -if irregular bleeding: IMB/PCB
    -u/s suggestion of endometrial polyp or cancer
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33
Q

What are the RCPI guidelines for who to endometrial biopsy with menorrhagia?

A
  • > 45 yrs
  • <45 yrs with obesity or PCOS
  • IMB
  • failure to respond to treatment

*others:
- endometrial thickness variable (>4 post menopause)
- endometrial polyp on TVUS
- prior to endometrial ablation

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34
Q

How dos endometrial thickness appear on TVUS?

A
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35
Q

What biopsy can be used to take a biopsy of the endometrium outside of hysteroscopy?

A

Pipelle biopsy = suction currette

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36
Q

What are the issues with pipelle biopsy?

A

blind biopsy so if negative not great as could easily have missed
D&C is a diagnostic test not a treatment but some willl bleed less a bit after D&C

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37
Q

How is menorrhagia managed?

A
  • treat underlying pathology
  • medical
  • surgical
  • needs to take account of symptoms but also desire for fertility
  • Ursula tried for minimum of 3 months
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38
Q

What are the first line medical treatments for menorrhagia?

A
  • IUS – progesterone-impregnated coil
  • Reduces menstrual flow by> 90%
  • Less s/e than systemic tx
  • Contraceptive
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39
Q

What are the second line medical treatments of menorrhagia?

A
  • antifibrinolytics = tranexamic acid
  • NSAIDS = mefanamic acid (ponstan)
  • COCP
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40
Q

How does tranexamic acid help menorrhagia?

A
  • taken during menstruation
  • reduce blood loss by about 50%
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41
Q

How does NSAID mefanamic acid treat menorrhagia?

A
  • inhibit prostaglandin synthesis
  • reduce blood loss by ~30%
  • similar s/e profile to regular NSAIDs
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42
Q

When is mefanamic acid used in preference to tranexamic acid for the treatment of menorrhagia?

A

If a lot of dysmenorrhea

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43
Q

How does the COCP help treat menorrhagia?

A

Lighter periods: reduce blood loss by up to 43%

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44
Q

Who has problems with COCP for the treatment of menorrhagia?

A

Older women

Pelvic pathology

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45
Q

How does ponstan (mefanamic acid) work in the treatment of menorrhagia?

A

Dual effect in inhibiting prostaglandin syntetase but also antagonising at prostaglandin receptor sites

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46
Q

What medical treatments are the third line in the treatment of menorrhagia?

A
  • progestagens (high dose): norethisterone 15mg daily from days 5-26 of cycle (or every day will induce amenorrhoea), injectables
  • GnRH analogues: induce amenorrhea
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47
Q

How do GnRH analgoues work?

A
  • cause pituatiry to down regular it’s receptors causing less of FSH, LH production

= induce a medial menopause

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48
Q

How are GnRH analgoues limited in the treatment of menorrhagia?

A
  • limited to 6 months
  • unless add back HRT then can use them for 2 years
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49
Q

When is surgical treatment for menorrhagia esp good?

A

In cases of proven pathology

Treat underlying pathology
(Eg endometrial polyp, fibroids)

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50
Q

What are the surgical treatments of menorrhagia?

A
  • endometrial ablation techniques
  • hysterectomy
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51
Q

What is endometrial ablation technique?

A

Removal or destruction of endometrium

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52
Q

What does endometrial ablation usually achieve for menorrhagia treatment?

A
  • lighter periods or amenorrhea
  • usually <10 weeks size
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53
Q

What are some issues with endometrial ablation that are important to remember?

A
  • reduce fertility but not sterilizing - still need contraceptives
  • less satisfied than with hysterectomy
  • 20% repeat or later hysterectomy
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54
Q

What are the 2 types of endometrial ablation?

A
  • 1st gen
  • TCRE - trans cervical resection of endometrium
  • TC rollerball ablation
  • 2nd gen
  • use of microwave probes, thermal balloons, cryotherapy or radiotherapy
55
Q

Why is 2nd generation endometrial ablation better?

A

safer, easier to perform, shorter hospital stay and can be under local, lower risk of perforation

56
Q

When is a hysterectomy done for menorrhagia?

A

Last resort

57
Q

What are the different approaches to a hysterectomy?

A

Transvaginal

Abdominal

Laparoscopic

58
Q

What is removed in a Total hysterectomy?

A

Uterus and cervix

59
Q

What is removed in a Subtotal hysterectomy?

A

Uterus

60
Q

What is removed in a Radical hysterectomy?

A

Uterus, cervix and upper third of vagina

61
Q

Why would a subtotal hysterectomy be done?

A

Quicker, less blood loss, if cervix has a lot of adhesions, may be better for sexual function BUT ongoing bleeding and cannot be done for cancerous reasons

62
Q

What are possible indicators of significant pathology in menorrhagia that warrant early investigation? (9)

A

New or worsening over 45 years
High BMI
PCOS
Tamoxifen use
Family history of endometrial or Lynch 2 Ca
Abdominal mass
IMB
PCB
Anaemia not responding to medical management

63
Q

A 45y/o presents with a 6/12 history of menorrhagia, pelvic pain and a pelvic mass. Which one of the following is the most appropriate initial diagnostic investigation
A) Endometrial pipelle
B) CT pelvis
C) MRI pelvis
D) Abdominal u/s
E) TVUS

A

E) most likely diagnose multiple fibroids or ovarian neoplasm

64
Q

Dysmenorrhoea may be treated with tranexamic acid

A

False

65
Q

Hysterectomies for DUB are on the increase

A

False

66
Q

The maximum duration of use for GnRH analogues is 3 months

A

False its 6 and 2 years if also giving HRT

67
Q

What is amenorrhea?

A

Absent menstruation

68
Q

What is primary amenorrhea?

A

Menstruation not started by 16yrs

69
Q

What can primary amenorrhea be accompanied by?

A
  • failure to develop 2ndary sexual characteristics (by 16)
  • or if they have 2ndary sexual characteristics then likely outflow tract is the problem
  • either way a congenial or acquired anomaly before normal time of puberty
70
Q

What is secondary amenorrhea?

A

Previously normal menstruation ceases for 3/12 or greater

71
Q

What most commonly causes secondary amenorrhea? (3)

A
  • premature menopause
  • PCOS
  • hyperprolactinaemia
72
Q

What is infrequent menstrual bleeding (oligomenorrhoea)?

A

1-2 periods in a 90 day time space

(Old definition = cycle lasting between 35days - 6 months)

73
Q

How is amenorrhea classified?

A
  • physiological = pregnancy, breastfeeding, menopause, familial/genetic delay of menstruation
  • pathological = endocrine, anatomical and medications
74
Q

What are the different pathological causes of amenorrhea?

A
  • endocrine = not all, but hypothalamus, pituatiry, thyroid, adrenals and ovaries
  • anatomical = uterus and outflow tract
  • medications = progesterone, post OCP, GnRH analogues, antipsychotics, H2 receptor antagonists, some antihypertensives (methyldopa, verapamil)
75
Q

What are some causes of amenorrhea due to hypothalamic hypogonadism? (5)

A
  • physiological (stress)
  • weight change (<45kg or increase)
  • excessive exercise
  • tumour
  • kallmanns syndrome
76
Q

What is kallmanns syndrome?

A

Problem with hypothalamic neurons = low GnRH and lack of sense of smell

77
Q

What hormonal changes are seen in hypothalamic hypogonadism causes of amenorrhea?

A

Low GnRH, FSH/LH, estradiol

78
Q

How is hypothalamic hypogonadism as a cause of amenorrhea managed?

A
  • supportive treatment - psych evaluation if anorexia
  • COCP, HRT
  • treat low BMD
79
Q

What are pituitary causes of amenorrhea? (3)

A
  • hyperprolactinaemia
  • Sheehans Syndrome
  • pituitary tumours
80
Q

What is happening in Sheehans syndrome?

A

Sheehans syndrome (ischaemic necrosis of the ant pituitary gland due to severe primary PPH, you get pituitary hyperplasia in preganncy so you need a greater blood supply, ant. Pituitary has a different blood supply than posterior as it is supplied via the hypothalamus in a portal system so lower pressure system that is more susceptiable to lower pressure ischaemia) (no FSH, LH after delivery wont begin periods again, no prolactin = wont lactate, low ACTH may lose pubic hair)

81
Q

A 21 y/o woman presents with an eight month history of secondary amenorrhoea. She has had a milky white discharge from her breasts in the last four months. General examination is unremarkable. Both breasts appear normal: milk can be expressed from the left breast. Pelvic examination is normal.
What is the likely diagnosis?
What specific physical finding would you look for on examination?
What key investigation would you perform?
What would be your first line treatment?
List one other way this condition might present?

A

Hyperprolactinaemia
Likely diagnosis - raised prolactin
Physical finding = bitemporal haemianopia (optic chaism cross above pituatiry gland)
Ix = prolactin level, then a CT or MRI
First line treatment= dopamine agonists can shrink prolactin producing tumours

Hypothyroid can cause raised prolactin
ACTH -> cholesterol and then - mineral corticosteroids, glucocorticoids and androgens
The oids are dependent on 21 hydroxyl and in CAH tat is deficient so more gets shoved down the pathway to androgens

82
Q

What is hyperprolactinaemia?

A

Raised prolactin reduced GnRH release

83
Q

What are some causes of hyperprolactinaemia? (5)

A
  • pituitary adenoma
  • pituitary hyperplasia
  • PCOS
  • hypothyroid
  • psychotropic meds (risperidone)
84
Q

What are the symptoms of hyperprolactinaemia? (4)

A
  • Oligo/amenorrhea
  • Galactorrhea
  • Headaches
  • bitemporal hemianopia

(HOG)

85
Q

What investigations would you do for hyperprolactinaemia?

A

Labs

+/- CT

86
Q

What treatments would you consider with hyperprolactinaemia?

A
  • medications: dopamine agonist (bromocriptine, cabergoline) (Dopamine inhibits PRL release)
  • surgery
87
Q

What issues with thyroid can cause amenorrhea?

A

Hypo/hyperthyroid

  • hypothyroid leads to raised prolactin levels = amenorrhea
88
Q

What issues with the adrenals can cause amenorrhea?

A
  • congenital adrenal hyperplasia (CAH)
  • virilising tumours
89
Q

What is congenital adrenal hyperplasia?

A
  • autosomal recessive
  • deficiency of 21-hydroxylase - raised ACTH/androgens
90
Q

What is seen at birth with congenital adrenal hyperplasia? (2)

A
  • ambiguous genitalia
  • addisonian crisis
91
Q

What is seen at puberty with congenital adrenal hyperplasia? (2)

A
  • enlarged clitoris
  • infrequent or absent menstruation
92
Q

What are the treatments for congenital adrenal hyperplasia?

A

Replace mineralocorticoid and glucocorticoid

93
Q

What acquired conditions of the ovary can cause amenorrhea? (3)

A
  • PCOS
  • premature menopause
  • virilising tumours
94
Q

What are congential ovarian causes of amenorrhea? (3)

A
  • turners syndrome (45X0)
  • gonadal dysgenesis
  • androgen insensitivity
95
Q

What are the issues with the ovaries that cause amenorrhea?

A

PCOS: primary, secondary, or infrequent menstruation
Turners: one X chromosome absent. Short stature, poor 2 sc, normal intelligence
Gonadal dysgenesis: poorly formed ovary due to abnormalities of X chromosomes
Androgen insensitivity: genetically male. Cell receptor not responsive to androgens. Converted to oestrogens. Phenotypically female – uterus absent, small testes- removed due to possible malignant change. https://ghr.nlm.nih.gov/condition/androgen-insensitivity-syndrome#genes
Gonadal dysgenesis is used to describe those situations in which primordial germ cells reach the ovary but are progressively destroyed so that few remain by the time of puberty.

Virilising tumuors = sex cord tumours eg theca cell tumour

Androgen insentivity is a problem with the cell surface receptor of androgens -> person is genetically male XY, but cell receptors don’t respond to androgens so they become phenotypically female (secondary sexual characteristics a/w/ female -> remove testes as risk of cancer and then allow them to decide)

96
Q

What are the acquired outflow tract issues that cause amenorrhea? (3)

A
  • cervical stenosis
  • asherman’s syndrome
  • endometrial resection or ablation

(Cervical stenosis: canal occluded by fibrosis after endometrial resection, cone biopsy or carcinoma
Asherman’s syndrome: adhesions within the uterus so the cavity becomes partly obliterated. Pregnancy, infection or trauma: excessive currettage at ERPC or following delivery
Endometrial resection or ablation - intentional)

97
Q

What are the congenital causes of outflow tract issues that cause amenorrhea? (3)

A
  • imperforate hymen
  • transverse vaginal septum
  • vaginal aplasia +/- uterus (Mayer-Rokitansky syndrome)

(Primary amenorrhea with normal secondary sexual characteristics)

98
Q

What is haematocolpos?

A

Blood in vagina

99
Q

What is haematometra?

A

Blood in uterus

100
Q

Causes of secondary amenorrhoea include (T/F)
Hypothyroidism
Turner syndrome
Bulimia
Asherman syndrome

A

All true except turners syndrome which causes primary amenorrhea

101
Q

What is ashermans syndrome?

A

intrauterine adhesions (cotton candy cloud appearance in hysterscopy)

102
Q

How may imperforate hymen and transverse vaginal septum present?

A

Amenorrhea but cramps every month

103
Q

A 16 y/o girl attends the clinic with her mother. They are both worried that she has not started to menstruate yet.

What investigations would you perform

A
  • hormonal screen, ultrasound, karyotype (turners)
  • hormonal screen = FSH, LH, prolactin, testosterone, TFTs, estradiol (note if someone was mensturating then do FSH, LH and estradiol at D2-D4 of the cycle
104
Q

Why is it hard to measure GnRH?

A

GnRH is pulsatile

105
Q

What is dysmenorrhea?

A

Painful menstruation

106
Q

What is a/w/ dysmenorrhoea?

A
  • high PGs (increased uterine activity)
  • ischaemia: hypercontraction - ‘uterine angina’
  • ? Role for vasopressin (increases synthesis of prostaglandins and myometrial activity)
  • ? Role of psychology (mother puts her expectations of pain onto her daughter
107
Q

What is primary dysmenorrhea?

A

No organic cause (pelvic pathology) is found

108
Q

What is secondary dysmenorrhea?

A

Pain is due to pelvic pathology

109
Q

When is primary dysmenorrhea common?

A

Menarche or 6 months - 1 yr after

Peak age 15-25

110
Q

How common is primary dysmenorrhea?

A

50% of women

10% severe

111
Q

What are some thoughts about primary dysmenorrhea?

A
  • a/w/ ovulation (can be 1-2yrs after menarche due to delay in ovulatory cycle)
  • higher than average PGs in menstrual fluid
112
Q

What are the clinical features of primary dysmenorrhea?

A
  • cramping pain: lower abdo, radiating to thighs/back
  • starts around time of period and lasts 24-72 hours
113
Q

What examination should be done for primary dysmenorrhea?

A
  • abdominal examination
  • no pelvic exam if not sexually active
114
Q

What are the treatment options for primary dysmenorrhea?

A
  • lifestyle: stop smoking
  • reduce PGs - NSAIDs
    And/or
  • reduce ovulation - COCP
  • other options: paracetamol, spasmonal, IUS, tocolytics, TENS, behavioural therapy
115
Q

When is pelvic pathology more likely in cases of primary dysmenorrhea?

A

If medical treatment fails - need to investigate (10%)

116
Q

Who does secondary dysmenorrhea affect?

A

Older women - uncommon before 25

117
Q

What are the features of secondary dysmenorrhea?

A

Pain proceeds onset of period for several days and may last throughout the period (or be relieved by it)

118
Q

What may be seen with secondary dysmenorrhea?

A

Associated symptoms like menorrhagia, deep dyspareunia, irregular bleeding

119
Q

What are the etiologies of secondary dysmenorrhea? (6)

A
  • fibroids (overgrowth of myometrium, diagnose with u/s)
  • adenomyosis (where endometrium grows into myometrium - diagnose with pathology, pelvic MRI)
  • endometriosis (laparoscopic surgery)
  • PID (high vaginal and endocervical swabs)
  • functional ovarian cysts/tumours
  • IUCD = intrauterine contraceptive device

Treatment based on cause

120
Q

What are some possible investigations you would do for secondary dysmenorrhea?

A
  • abdominal and pelvic exam
  • vaginal exam if sexually active
  • high vaginal swab/ endocervical swab
  • pelvic ultrasound - if uterine enlargement or adnexal mass present
  • transvaginal ultrasound
  • MRI scan
  • laparoscopy
  • laparotomy with biopsy
121
Q

What is postcoital bleeding (PCB)?

A

Vaginal bleeding following intercourse

122
Q

What is PCB a 🚩 for?

A

Cervical carcinoma

123
Q

What are the potential causes of PCB? (4)

A
  • cervical ectropion
  • cervical polyps
  • cervicitis/ vaginitis
  • cervical carcinoma
124
Q

When is cervical ectropion more likely?

A

If pregnant or on OCP as hormonal change, will reverse after it

125
Q

What does the management of PCB involve?

A
  • examine cervix - take smear
  • if polyp - removal and send for histology
  • if ectropion - cryotherapy
  • if abnormal smear - colposcopy
126
Q

What can irregular menstruation and IMB coexist with?

A

Menorrhagia

127
Q

When is irregular menstruation and IMB common?

A

At extremes of reproductive age

128
Q

What causes irregular menstruation and IMB?

A

Anovulatory cycles or pelvic pathology

129
Q

How is irregular menstruation and IMB handled in adolescents?

A

Often treat medically initially and if not settling investigate
(Eg COCP, progestogens, Mirena)

130
Q

What is the definition of irregular periods?

A

Periods with cycle to cycle variation of >20 days

131
Q

True/false

Premenstrual syndrome relates to behavioural, psychological and physical symptoms that occur in the follicular phase of a woman’s menstrual cycle

A

False - luteal phase

132
Q

SBA

Which one of the following characteristically presents with IMB?
A) Intramural fibroid
B) Uterine polyp
C) CIN
D) Moderate dyskaryosis
E) adenomyosis

A

B

133
Q

SBA

Which one of the following characteristically presents with PCB?
A) Submucosal fibroid
B) Cervical ectropion
C) CIN
D) Moderate dyskaryosis
E) adenomyosis

A

B

134
Q

What medications can cause amenorrhea? (6)

A
  • progesterone
  • post OCP
  • GnRH analogues
  • antipsychotics
  • H2 receptor antagonists
  • some antihypertensives (methyldopa, verapamil)

OBGYN (25 decks)

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