Menstrual disorders

Question 1

Briefly describe the hormonal control of the menstrual cycle?

Answer 1

• Increase in GnRH causes FSH and a little LH to be released by anterior pituitary gland.
• This causes the growth of follicles in the ovary; these then secrete oestrogen.
• Initially this inhibits LH but at a certain level in causes a surge in LH production. Oestrogen also causes growth of the endometrium
• This causes ovulation which causes the graafian follicle to be released.
• remaining part of the follicle (corpus luteum) then secreted progesterone.

Question 2

What is a normal volume of blood to lose in a single menstruation?

Answer 2

Less than 80ml

Question 3

How long does there have to be an absence on menstruation to be considered Amenorrhoea?

Answer 3

6 months

Question 4

What term describes: prolonged and increased menstrual flow

Answer 4

Menorrhagia

Question 5

What term describes: regular intermenstrual bleeding

Answer 5

Metrorrhagia

Question 6

What term describes: Menses ocuring more frequently than every 21 days

Answer 6

Polymenorrhoea

Question 7

What term describes: prolonged menses and intermenstrual bleeding

Answer 7

Menometrorrhagia

Question 8

What term describes: increased bleeding and frequent cycle

Answer 8

Polymenorrhagia

Question 9

How infrequently do periods have to come to be termes oligomenorrhoea?

Answer 9

Less frequently than every 35 days

Question 10

What is andenomyosis?

Answer 10

The presence of endometrial tissue within the myometrium.

Question 11

A women presents to your clinic complaining she has acute pain with her periods. She describes this as if her uterus is contracting and bearing down on her bladder. Se also says her periods are very heavy with clots and flooding.

Answer 11

Adenomyosis. (Ectopic endometrial tissue within the myometrium)

Question 12

A women presents to your clinic complaining of painful heavy periods and pain during sex. She also says she feels tired and pale.

Answer 12

Endometriosis.

Question 13

What is the gold standard investigation for endometriosis?

Answer 13

Laproscopy

Question 14

What NSAID is most useful in endometriosis?

Answer 14

Mefenamic acid

Question 15

What is the first line treatment for endometriosis in a women who does not wish to conceive yet?

Answer 15

1. Pain relief (NSAID)

2. Hormonal contraception (COCP)

Question 16

What non contracpetive hormonal treatment is used in the treatment of endometriosis?

Answer 16

Oral medroxyprogesterone

Question 17

A 30 year old lady has severe pain and dysmennorhea due to her endometriosis. She has tried the COCP and NSAIDS already and they haven’t given her much relief. What are the next options?

Answer 17

1. GnRH analogues - induing a reversible menopausal state and a regression of endometriosis deposits.
2. Surgical ablation/excision of endometriosis deposits. Laproscopic surgery should ideally be done at the time of diagnosis via diathermy, laser ablation or excision. Radical surgery would involve a total abdominal hysterectomy and salpingo - oophorectomy and is only done when all other treatment have failed and the family is complete

Question 18

What is the first line treatment for a women suffering from pain and menorrhagia who is wanting to fall preganant?

Answer 18

Tranexamic acid

Question 19

What is the first line treatment for menorrhagia in a women who does not wish to fall pregnant right now?

Answer 19

Mirena IUS

Question 20

What is the treatment for menorrhagia in a women who does not wish to fall pregnant but does not wish to use the mirena coil?

Answer 20

COCP

Tranexamic acid NSAID

Question 21

What is the treatment for menorrhagia if the COCP and NSAIDs are both thought to be unsuitable?

Answer 21

Oral progesterone northisterone (taken during the follicular and luteal phases

Question 22

Is oral northisterone appropriate for women wanting to conceive?

Answer 22

No. It is likely to inhibit ovulation (isn’t a reliable contraceptive though)

Question 23

A 17 year old girl presents with cyclical pelvic pain which is getting worse. On examination a pelvis mass is palpated

Answer 23

Imperforate hymen

Question 24

What is the treatment of an imperforate hymen?

Answer 24

Incision and drainage

Question 25

What are the FSH and LH levels like in PCOS?

Answer 25

High LH

Low FSH

Question 26

What will you see on US scan on a patient with PCOS?

Answer 26

Multiple follicular cysts up to 6 - 8mm in diameter (described as a pear necklace appearance)

Question 27

In a women with amenorrhoea what does the serum prolactin level have to be above to diagnose a hyperprolactinaemia

Answer 27

800 mU/L

Question 28

How does hyperprolactinaemia cause amenorrhoea?

Answer 28

Raised prolactin causes disturbance of the normal hypothalamic GnRH release which supresses LH pulsatility causing anovulation and amenorrhoea.

Question 29

What 2 drugs are used to treat hyperprolactinaemia?

Answer 29

Bromocriptine
Cabergoline
(Dopamine agonists)

Question 30

What does it mean if a women who is amennorhoeic responds to a progesterone challenge test?

Answer 30

• Uterus is present

- Some circulating oestrogen

Question 31

What is meant by dysfunctional uterine bleeding?

Answer 31

Excessive bleeding where no organic lesion can be found

Question 32

What is the mode of action of tranexamic acid?

Answer 32

Inhibits clot breakdown during menstruation

Question 33

What is the mode of action of mefenamic acid?

Answer 33

Alters the imbalance of vasodilator prostoglandin PGE2 and the vasoconstrictor PGF2a.

Question 34

What is removed in a subtotal hysterectomy?

Answer 34

Only the body of the uterus (the cervix is left)