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Obstetrics + Gynaecology > Menstrual Disorders > Flashcards

Menstrual Disorders Flashcards

1
Q

What is the definition of menorrhagia?

A

Prolonged and increased (>80ml per period) menstrual flow (heavy bleeding)

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2
Q

What is metrorrhagia?

A

Regular intermenstrual bleeding

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3
Q

What is polymenorrhoea?

A

Menses occurring at < 21 days intervals

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4
Q

What is amenorrhoea?

A

Absence of menstruation for > 6 months

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5
Q

What is oligomenorrhoea?

A

Menses at intervals of > 35 days OR 5 or less menstrual cycles per year

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6
Q

What are the local causes of menorrhagia?

A 
Fibroids
Adenomyosis
Endocervical or endometrial polyp
Endometrial hyperplasia
IUD
PID
Endometriosis
Malignancy
Hormone producing ovarian tumours
Arteriovenous malformation
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7
Q

What are the systemic causes of menorrhagia?

A 
Endocrine:
- thyroid, DM, adrenal disease, prolactin
Haematological:
- vWD, ITP, clotting factor deficiency
Liver cirrhosis
Renal disease
Anticoagulants
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8
Q

What is dysfunctional uterine bleeding (DUB)?

A

Menorrhagia in the absence of pathology –> diagnosis of exclusion

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9
Q

What are the 2 types of DUB and their features?

A

Anovulatory (80%):
- irregular cycle at extremes of reproductive age
Ovulatory:
- regular heavy periods
- due to inadequate progesterone production by corpus luteum

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10
Q

What are the options for medical management of DUB?

A
  1. IUS (mirena coil) - first line
  2. COCP
  3. Tranexamic acid (antifibrinolytic)
  4. NSAIDs e.g. mefenamic acid
  5. Oral progestogens e.g. norethisterone + medroxyprogesterone acetate
  6. GnRH analogues/agonists
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11
Q

When are tranexamic acid and NSAIDs taken for menorrhagia?

A

Taken during menstruation only

Good for women who want to conceive

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12
Q

Give an example of GnRH analogues/agonists?

A

Goserelin

Buserelin

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13
Q

What are the side effects of GnRH analogues/agonists?

A

Long term use causes osteoporosis unless combined with HRT

–> only use short term (< 6 months)

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14
Q

When might surgical management be offered to women with menorrhagia?

A

Failure of medical management

not recommended if wanting to preserve fertility

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15
Q

What are the options for surgical management of menorrhagia?

A

Endometrial resection/ablation

Hysterectomy

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16
Q

What are the risks associated with endometrial ablation?

A

If becomes pregnant, risk of prematurity or morbidly adherent placenta –> must take COCP/HRT

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17
Q

What are the causes of intermenstrual bleeding?

A 
Cervical ectropion
PID and STIs
Endometrial or cervical polyps
Cervical cancer
Endometrial cancer
Undiagnosed pregnancy/pregnancy complications 
Hydatiform molar disease
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18
Q

What are the features of premenstrual syndrome?

A 
Bloating, cyclical weight gain
Mastalgia
Abdominal cramps
Fatigue
Headache
Depression
Changes in appetite + cravings
Irritability
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19
Q

How can premenstrual syndrome be treated if impacting quality of life?

A

SSRIs/SNRIs + CBT
Lifestyle changes for mild symptoms
COCP, transdermal oestrogen, short term GnRH analogues
Hysterectomy + bilateral salpingo-oophorectomy (last resort)

20
Q

What are the causes of post-coital bleeding?

A 
Cervical ectropion
Cervical cancer
Trauma
Atrophic vaginitis
Cervicitis secondary to STI
Polyps
Idiopathic
21
Q

What is cervical ectropion usually caused by?

A

Hormonal changes:

  • high oestrogenic states in pregnancy
  • use of COCP
22
Q

What are the causes of post-menopausal bleeding?

A 
Atrophic vaginitis (most common)
Endometrial polyps
Endometrial hyperplasia
Endometrial cancer
Cervical cancer
Ovarian cancer (oestrogen-secreting theca cell tumours)
Vaginal cancer - rare
23
Q

How is post-menopausal bleeding investigated?

A

Transvaginal USS first line to assess endometrial thickness

  • if < 3mm - reassure
  • if > 4mm –> biopsy
  • (if taking HRT, cut off is 5mm or less)

Women on Tamoxifen –> hysteroscopy + biopsy if first line (USS not helpful as endometrium will always be thick)

24
Q

How is atrophic vaginitis managed?

A

Topical oestrogen + vaginal lubricants

Consider HRT

25
Q

How is endometrial hyperplasia managed?

A

Dilatation and curettage
Progesterone treatment:
- IUS first line
- oral progestogens e.g. norethisterone

26
Q

What is the most common cause of menstrual irregularity?

A

PCOS

27
Q

Which criteria is used to diagnose PCOS and what are the criteria?

A

Rotterdam criteria - 2 of the following:

  • clinical or biochemical evidence of hyperandrogenism
  • polycystic ovaries on USS
  • oligo/amenorrhoea
28
Q

What are the signs of hyperandrogenism?

A 
Hirsutism
Acne
High free testosterone
Low sex hormone binding globulin
High free androgen index
29
Q

What are the clinical features of PCOS?

A

Obesity
Hypertension
Acanthosis nigricans (thickening + pigmentation of the neck, axillae + intertriginous areas)
Acne + hirsutism
Alopecia
Insulin resistance, DM, lipids –> increased CV risk
Irregular periods - infertility
Increased risk of endometrial hyperplasia + cancer

30
Q

What is the management for infertility in PCOS?

A 
Weight loss of 5-10% if BMI >30
First line: Clomifene
Can add metaformin
Ovarian drilling if clomifene unsuccessful 
Gonadotrophin injections
IVF last resort
31
Q

How is acne managed in PCOS?

A

Dianette

COCP

32
Q

How amenorrhoea managed in PCOS?

A

COCP
Cyclical medroxyprogesterone or IUS

–> to manage risk of endometrial hyperplasia/cancer

33
Q

What is dysmenorrhoea and how is it classified?

A

Excessive pain during the menstrual period

  • primary –> onset within 2 years of menarche, no underlying pathology
  • secondary –> develops years after menarche, result of underlying pathology
34
Q

What are the main causes of secondary dysmenorrhea?

A 
Endometriosis
Adenomyosis
PID
IUD (copper coil)
Fibroids
35
Q

How is dysmenorrhoea managed?

A

Stop smoking
NSAIDs first line e.g. mefenamic acid and ibuprofen (inhibit prostaglandin production)
COCP second line
Levonogestrel IUS - if also menorrhagia
GnRH analogues - best of symptomatic relief, esp when due to fibroids, when awaiting hysterectomy

36
Q

How is amenorrhoea categorised?

A

Primary (absence of menarche):
- age 16+ in the presence of secondary sexual characteristics
- age 14+ in absence of secondary sexual characteristics
Secondary:
- cessation of periods for > 6 months, after menarche

37
Q

How can causes of amenorrhoea be categorised?

A 
Hypothalamic
Pituitary
Ovarian
Adrenal gland
Genital tract
38
Q

What are the hypothalamic causes of amenorrhoea?

A

Functional disorders e.g. eating disorders, exercise
Severe chronic conditions e.g. thyroid, sarcoidosis
Kallmann syndrome

39
Q

What is Kallmann syndrome?

A

X linked recessive condition

–> failure of migration of GnRH cells

40
Q

What are the pituitary causes of amenorrhoea?

A

Prolactinomas
Other pituitary tumours e.g. acromegaly or Cushing’s (mass effect)
Sheehan’s syndrome
Destruction of pituitary gland e.g. radiation, AI disease
Post contraception amenorrhoea e.g. Depo-Provera

41
Q

What is Sheehan’s syndrome?

A

Post-partum pituitary necrosis secondary to massive obstetric haemorrhage

42
Q

What are the ovarian causes of amenorrhoea?

A

PCOS
Turner’s syndrome (45 XO)
Premature ovarian failure

43
Q

What is Turner’s syndrome?

A

Genetic condition –> amenorrhoea, lack of secondary sexual characteristics + infertility

  • short stature
  • webbed neck
  • aortic coarctation
44
Q

What is premature ovarian failure defined?

A

Primary ovarian insufficiency before age of 40 associated with menopausal symptoms
- low oestrogen + high FSH

45
Q

What are the adrenal causes of amenorrhoea?

A

Late onset/mild congenital adrenal hyperplasia

- high levels of 17-hydroxyprogesterone in the blood

46
Q

What are the genital tract causes of amenorrhoea?

A

Ashermann’s syndrome
Imperforated hymen/transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser syndrome (congenital absence of uterus)

47
Q

What is Ashermann’s syndrome?

A

Secondary to instrumentation of the uterus following surgical management of a miscarriage –> intrauterine adhesions

Obstetrics + Gynaecology (22 decks)

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