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Gynaecology > Menstrual Disorders > Flashcards

Menstrual Disorders Flashcards

1
Q

What is dysmenorrhoea?

A 
Primary = menstrual pain occurring with no underlying pelvic pathology 
Secondary = menstrual pain occurring with associated pelvic pathology
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2
Q

What causes period pains and what causes primary dysmenorrhoea?

A

As steroidal hormones drop at the end of a cycle the endometrial cells respond by releasing prostaglandins. These prostaglandins cause spiral artery vasospasm leading to shedding and bleeding and increased myometrial contractions. Primary dysmenorrhoea is due to excessive prostaglandins.

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3
Q

What are the risk factors for dysmenorrhoea?

A 
Early menarche 
Long menstrual phase 
Heavy periods 
Smoking 
Nulliparity
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4
Q

What sort of symptoms do patients suffering with dysmenorrhoea get?

A

Crampy pelvic pain lasting 2-3days around the time of the period.
Malaise
Nausea
Vomiting
Diarrhoea
Dizziness
Abdominal and pelvic examination are usually unremarkable bar uterine tenderness

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5
Q

What causes of secondary dysmenorrhoea should be ruled out before a diagnosis of primary dysmenorrhoea?

A 
Endometriosis 
Adenomyosis 
PID 
Adhesions 
Fibroids
IUD only

Check for abdominal masses, dyspareunia, history of STDs and surgery

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6
Q

How should dysmenorrhoea be investigated?

A

Speculum
Bi manual examination
Swabs both high vaginal and endocervical
If pelvic mass, then TVUSS

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7
Q

How should dysmenorrhoea be managed?

A

Treat cause
Stop Smoking
NSAIDs – mefenamic acid or ibuprofen
COCP or other hormone contraceptives

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8
Q

What is the premestrual syndrome?

A

Definition – psychological, physical or behaviour symptom in the luteal phase of the menstrual cycle that regress at onset of menses.

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9
Q

How is a diagnosis of premestrual syndrome made?

A

Diagnosis – most women self-diagnose but for a official diagnosis a diary will need to be filled out. Moderate/severe PMS includes interruption to daily life

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10
Q

What are the diagnostic criteria for pre menstrual syndrome?

A 
5 symptoms present for most of the late luteal phase with remission a few days after onset of menses and absence of symptoms post menses. At least one symptoms must be from the following list:
•	Depression, hopelessness
•	Anxiety
•	Affective lability – suddenly sad or tearful
•	Persistent anger/irritability
•	Decreased interest in usual activities
•	Change in appetite
•	Difficulty concentrating
•	Lethargy
•	Hypersomnia or insomnia 
•	Feeling of being overwhelmed
•	Breast tenderness, swelling, headaches, joint or muscle pain, bloating and weight gain
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11
Q

How can you help manage pre menstrual syndrome?

A
  • Hormonal Ovulation suppression – COCP but may worsen side effects so monitor. GnRH analogues also a possibility
  • Non-hormonal – SSRI, tricyclics
  • Surgery – removal of ovaries and uterus but must first test that symptoms resolve with a GnRH test.
  • Self Help – Healthy diet, Vitamins, exercise, stress reduction and CBT
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12
Q

What is menorrhagia

A

Definition – heavy menstrual bleeding – heavy being defined by the woman

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13
Q

What are the risk factors for menorrhagia?

A

Age – approaching menopause
Obesity
C-section and adenomyosis

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14
Q

What causes menorrhagia?

A

Dysfunctional uterine bleeding (formerly known as dysfunctional uterine bleeding) – Diagnosis of exclusion but the most common reason.

Fibroids – (benign neoplasm that increases SA and painful due to muscle contractions
Adenomyosis 
Endometriosis 
Hypothyroidism 
Endometrial Cancer 
Endometrial Polys – adenomas of the endometrium 
Chronic infection 
Coagulation disorders – VWM
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15
Q

What are the signs and symptoms of menorrhagia?

A

Fatigue
Shortness of breath
Anaemia
Bleeding that effects daily living

Tender uterus or cervical excitation point to adenomyosis or endometriosis

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16
Q

What questions should be asked in a full menstrual history?

A 
Age at menarche
Frequency
Duration 
Volume 
Clots?
Date of last menstrual period
17
Q

How should you investigate a woman presenting with menorrhagia?

A

FBC and TFT
Enquire about smear history and contraception
Abdominal palpation, speculum and bimanual examination – looking for masses
Important to rule out ectopic pregnancy
Endocervical and High vaginal swab
Coagulation screen
BMI

If <45 then only need thyroid function and FBC
If over 45 then:
USS followed by hysteroscopy and biopsy if endometrial thickness > 4mm

18
Q

How/when is menorrhagia managed medically?

A

Medical – no explanation or fibroids < 3cm. Consider whether they require contraception
• IUS Mirena Coil – side effects: irregular bleeding 4-6m and insertional issues.
• NSAIDS – Mefanamic acid – Gi upset and ulceration. Caution asthmatics, renal disease, and peptic ulcer. If cause is fibroids, then skip this step.
• Antifibrinolytic - Tranexamic acid – side effects: N and V
• COCP or Progestogen only pill (later likely to supress menstruation which may or may not be beneficial to the patient)

If necessary, GnRH analogues

19
Q

How/when is menorrhagia managed surgically?

A

Surgical – fibroids > 3cm
• Endometrial embolisation - least invasive via interventional radiology and 90% of women have significant or complete resolution.
• Endometrial Ablation (microwave, balloon or electrical) – suitable if family complete (although will still need contraception). Can cause, pain, bleeding or infection, damage to nearby organs including uterine puncture. 80% success rate at reducing painful periods.
• Hysterectomy either with or without the cervix. Ovaries are kept unless abnormal

20
Q

What is the definition of amenorrhoea?

A

Definition – the absence of menstrual periods
Primary – failure to commence menses. Either: girls aged 16+ in the presence of secondary sexual characteristics such as pubic hair/breast development or girls aged 14+ in the absence of secondary sexual characteristics.
Secondary – cessation of period for more than six months after the menarche

21
Q

Which hormonal organs can the problem be located to in amenorrhoea?

A

Hypothalamus
Pituitary
Ovaries
Adrenal glands

Genintal

22
Q

What hypothalamic causes of amenorrhoea are there?

A
  • Functional disorders – low eating/high exercise causes suppression of GnRH via Ghrelin and leptin
  • Severe chronic disorders – psychiatric disorders or both thyroid diseases (TRH stimulates prolactin and sex hormone binding hormone in hyper- binds oestrogen) and sarcoidosis
  • Kallmann syndrome – X-linked recessive disorder characterised by migration of GnRH cells and lack of sense of small.
23
Q

What pituitary causes are there for amenorrhoea?

A
  • Prolactinomas – prolactin supresses GnRH will also cause galactorrhoea
  • Other pituitary tumours e.g. Acromegaly or Cushing’s
  • Sheehan’s syndrome – post partum pituitary necrosis secondary to massive obstetric haemorrhage
  • Destruction of pituitary gland
  • Post contraception amenorrhoea – most commonly seen with depo
24
Q

What ovarian causes are there for amenorrhoea?

A
  • PCOS – more commonly causes oligomenorrhea
  • Turner’s syndrome – also short, webbed neck and aortic coarctation
  • Premature ovarian failure (POF) – primary ovarian insufficiency before the age of 40 resulting in early menopause – low oestrogen and high FSH
25
Q

What adrenal causes are there for amenorrhoea?

A

• Congenital adrenal hyperplasia (CAH) – at this age usually late onset or mild

26
Q

What genital causes are there for amenorrhoea?

A

Genital abnormalities – concealed bleeding and also pain
• Ashermann’s syndrome – intrauterine adhesions following instrumentation of the uterus, usually following surgical management of miscarriage
• Imperforate hymen/Transverse vaginal septum/cervical stenosis – obstruction
• Agenesis of the Mullerian-duct and so absence of the uterus and upper vagina

27
Q

What should be explored in the history of a patient with secondary amenorrhoea?

A 
Focus on sexual history and pregnancy risk 
Galactorrhoea or androgenic symptoms 
Menopausal symptoms 
Previous gynae surgery 
Drug use (dopamine) and eating/exercise
28
Q

How should amenorrhoea be investigated?

A

Detailed menstrual history
Pregnancy test
Bloods: Thyroid, Prolactin, FSH, LH, Progesterone, Oestrogen, Testosterone and SHBG
17 hydroxyprogesterone – CAH
USS to visualise ovaries
Karyotyping
Progesterone challenge to elicit a withdrawal bleed
• If they bleed there is adequate oestrogen and so likely anovulation and PCOS
• No bleed indicates low oestrogen or outflow obstruction

29
Q

How should amenorrhoea be managed?

A

Attempt to treat cause

Regulate periods using a hormonal contraceptive

Premature ovarian failure – HRT, Calcium and Vitamin D replacement

Symptoms control – hair growth (COCP) and acne (antibiotics)

Lifestyle advice – for causes related to weight encourage weight gain.

For PCOS encourage weight loss and maybe statins
Clomiphene and metformin – stimulate ovulation and regulate blood sugar in PCOS

Surgical intervention for pituitary tumours and genital tract abnormalities

30
Q

What is oligomenorrhoea?

A

Definition – irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods a year. Usually this is due to anovulation.

31
Q

What are the common causes of oligomenorrhoea?

A
  • PCOS
  • Contraceptive/Hormonal treatments
  • Perimenopause
  • Thyroid disease/Diabetes
  • Eating Disorders – both high and low BMI and excessive exercise
  • Ovarian resistance, incipient POF – rare.
  • Medications such as antipsychotics/epileptics – dopamine and prolactin
32
Q

What investigations should be considered in a women presenting with oligomenorrhoea?

A

Detailed menstrual history
Pregnancy test
Bloods: Thyroid, Prolactin, FSH, LH, Progesterone, Oestrogen, Testosterone and SHBG
17 hydroxyprogesterone – CAH
USS to visualise ovaries
Karyotyping
Progesterone challenge to elicit a withdrawal bleed
• If they bleed there is adequate oestrogen and so likely anovulation and PCOS
• No bleed indicates low oestrogen or outflow obstruction

33
Q

How should oligomenorrhoea be managed?

A

What are patients aims – regular periods or fertility
Treat underlying causes if any are found
Attain normal BMI
For regular cycles:
COCP or cyclical progestogens
For PCOS a minimum of 3 periods a year to reduce risk of endometrial hyperplasia
Full fertility screen if ovulation induction is required

34
Q

What is the most common cause of pelvic pain presentations in women?

A

In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz).

35
Q

What is an endometrial polyp?

A

Endometrial Polyp – benign growth of endometrial tissue – Adenoma malignant 1%. More common in women over age of 40.

36
Q

What is the most common cause of abnormal uterine bleeding?

A

Endometrial polyp is the most common cause of abnormal uterine bleeding

Gynaecology (19 decks)

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