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Y5 - Obstetrics & Gynaecology > Menstrual physiology and problems > Flashcards

Menstrual physiology and problems Flashcards

1
Q

Define menorrhagia

A

Excessive bleeding that interferes with a womans life. Objectively, >80ml loss.

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2
Q

Commonest cause of menorrhagia?

A

Idiopathic. Subtle abnormalities in endometrial haemostasis or uterine prostaglandin levels.

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3
Q

What are the major pathological causes of menorrhagia?

A

Fibroids (30%) and polyps (10%)

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4
Q

What are the rare causes of Menorrhagia?

A

Thyroid disease, Haemostatic disorder (von Willebrands), Anticoagulants, Coagulopathy.

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5
Q

Clinical presentation of Menorrhagia?

A

Flooding, clots.

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6
Q

What are the examination findings in fibroids?

A

Irregularly enlarged uterus.

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7
Q

What are the examination findings in adenomyosis?

A

Tenderness without enlargement.

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8
Q

What investigations would you perform in Menorrhagia?

A

Anaemia - Hb.

Systemic causes - TFTs, coagulation.

TVUSS.

Biopsy / hysteroscopy if USS indicated.

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9
Q

What are the indications for an endometrial biopsy?

A

Endometrial thickness >10mm premenopausal, >4mm postmenopausal.

Polyp.

>40y.

+ Intermenstrual bleeding.

Acute admission due to menorrhagia.

Ablative surgery to be performed.

IUS to be used to control bleeding.

Not responding to Tx.

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10
Q

What are the two methods of obtaining an endometrial biopsy?

A

Pipelle. Hysteroscopy.

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11
Q

What is the first line treatment for menorrhagia?

A

IUS. Reduces menstrual flow by >90% with few side effects. But can’t conceive!

Note - copper IUD may increase loss.

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12
Q

What is the second line treatment for menorrhagia?

A

Antifibrinolytics (tranexamic acid) to be taken during menstruation. 50% decrease in loss. No need for prescription. Good if trying to conceive.

NSAIDs (mefanamic acid) inhibit prostaglandin synthesis. 30% decrease in loss. Also good for dysmenorrhoea.

COCP. But less effective if pelvic pathology present.

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13
Q

What are the third line treatments for menorrhagia?

A

Progestogens wil cause amenorrhoea, but withdrawal restarts bleeding.

GnRH agonists cause amenorrhoea. Duration limited to 6m without HRT. S/E osteoporosis and CVD.

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14
Q

What are the surgical treatments for Menorrhagia?

A

Hysteroscopic removal of polyps.

Endometrial ablation lightens periods, retains fertility.

Transcervical resection of fibroids (mucosal fibroids of up to 3cm).

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15
Q

What are the radical treatments for Menorrhagia?

A

Myomectomy - removal of fibroids from myometrium. Used when fertility required.

Hysterectomy - last resort!

Uterine artery embolisation - retains uterus and avoids surgery. ?fertility effects.

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16
Q

What are the causes of irregular / intermenstrual bleeding?

A

Anovulatory cycles. Common just after menarche and before menopause.

Pelvic pathology: fibroids, polyps, adenomyosis, ovarian cysts, chronic infection.

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17
Q

What investigations would you perform in irregular / intermenstrual bleeding?

A

Anaemia - Hb.

Exclude malignancy.

USS if >35y or <35y and treatment failed.

Endometrial biopsy.

18
Q

What is the treatment for anatomically normal irregular bleeds?

A

IUS.

COCP.

Progestogens.

HRT in perimenopause.

Also - Antifibrinolytics and NSAIDs.

19
Q

What is the treatment for anatomically abnormal irregular bleeding?

A

Surgery! Note that ablative techniques are less useful as they rarely get rid of all endometrium, so some bleeding continues.

20
Q

What is the definition of Amenorrhoea? What is primary vs secondary?

A

Absence of menstruation.

Primary = no period by 16y.

Secondary = previously normal menstruation stops for >6m.

21
Q

What is oligomenorrhoea?

A

Infrequent menstruation occuring every 35d-6m.

22
Q

What are the physiological causes of amenorrhoea?

A

Secondary: Pregnancy, Menopause, Lactation.

Primary: Constitutional delay

23
Q

What are the common pathological causes of amenorrhoea?

A

Most common are secondary causes:

Premature menopause.

PCOS.

Hyperprolactinaemia.

24
Q

What are the hypothalamic causes of amenorrhoea?

A

Hypotholamic hypogonadism. This can be due to:

  • Low weight
  • Anorexia nervosa
  • Excessive exercise

This causes low GnRH, hence low FSH, LH and oestradiol.

Prolonged hypo-oestrogenism requires monitoring and treatment with oestrogen (bone protection) and progesterone (endometrium protection) using COCP.

25
Q

What are the pituitary causes of amenorrhoea?

A

Hyperprolactinaemia. Usually caused by pituitary adenomas or hyperplasia.

Sheehan’s syndrome. Rare. Severe PPH causes pituitary necrosis and hypopituitarism.

26
Q

What is the treatment for hyperprolactinaemia?

A

Bromocriptine, or

Cabergoline, or

Rarely surgery.

27
Q

What are the adrenal and thyroid causes of amenorrhoea?

A

Hyper / hypothyroidism. Hypo causes raised prolactin levels and anaemia.

Congenital adrenal hyperplasia / virilising tumours.

28
Q

What are the ovarian causes of amenorrhoea?

A

PCOS. Can cause primary or secondary.

Premature menopause.

Turner’s syndrome.

Gonadal dysgenesis.

29
Q

What are the anatomical causes of amenorrhoea?

A

Imperforate hymen.

Transverse vaginal septum.

Cervical stenosis.

Asherman’s syndrome.

30
Q

What are the common causes of post-coital bleeding?

A

Cervical carcinoma.

Cervical ectropion.

Cervical polyps.

Cervicitis / vaginitis.

31
Q

What is the management of postcoital bleeding?

A

Inspect cervix and take smear.

Polyp -> avulse and send for histology.

Normal smear - ectroption can be frozen.

Abnormal smear - colposcopy.

32
Q

What causes dysmenorrhoea?

A

High prostaglandin levels cause contraction and uterine ischaemia.

33
Q

What is primary dysmenorrhoea? How do you manage it?

A

Dysmenorrhoea with no organic cause. Coincides with start of menstruation. Common - 50% of women.

Management - NSAIDs or ovulation suppression (COCP).

34
Q

What is secondary dysmenorrhoea? What are the common causes?

A

Pain due to pelvic pathology. Pain precedes and is relieved by menstruation.

Caused by: fibroids, adenomyosis, endometriosis, PID, ovarian tumours.

35
Q

What is the definition of precocious puberty?

A

Menstruation occuring before age 10, or secondary sexual characteristics by age 8.

It causes shortened final height due to early epiphyseal fusion.

36
Q

What are the causes of precocious puberty?

A

Idiopathic in 80%.

Central causes - increased GnRH: meningitis, encephalitis, CNS tumours, hydrocephaly, hypothyroidism.

Ovarian / adrenal - increased oestrogen: hormone producing tumours

McCune-Albright syndrome: bone and ovarian cysts, cafe au lait spots and precocious puberty.

37
Q

What is the treatment for precocicous puberty?

A

Idiopathic: GnRH agonists.

Tumours: removal.

McCune-Albright: cyproterone acetate.

38
Q

What causes intersex conditions in genetic females?

A

Excess androgens.

Congenital adrenal hyperplasia. Recessive inheritance. Defective cortisol production causing increased ACTH and excess androgens. Presents at birth with ambiguous genitalia. May get addisonian crises. Treat with cortisol and mineralocorticoid replacement.

Rarely: androgen-secreting tumours or Cushing’s syndrome.

39
Q

What causes intersex conditions in genetic males?

A

Insufficient androgens.

Androgen insensitivity syndrome. Androgens don’t bind so are converted peripherally to oestrogens. Person appears to be female, so presents with amenorrhoea and an absent uterus. Treat by removing rudementary testes and replacing oestrogen.

40
Q

What days does the menstruation phase occur on? What happens?

A

Days 1-4.

Endometrium is shed as hormones withdraw.

Myometrial contraction occurs, which can be painful.

41
Q

What days does the proliferative phase occur on? What happens?

A

Days 5-13.

GnRH pulses cause LH and FSH secretion. LH and FSH cause antral follicles to mature.

The follicle produces Oestradiol and inhibin. These cause negative feedback on FSH, positive feedback on LH and endometrial reformation and proliferation.

The LH surge causes ovulation to occur.

42
Q

What days does the luteal / secretory phase occur on? What happens?

A

Days 14-28.

Follicle becomes the corpus luteum and secretes oestradiol and progesterone.

This causes the endometrium to swell and blood supply to increase.

If the egg isn’t fertilised, the corpus luteum starts to fail, so the cycle starts over again.

Y5 - Obstetrics & Gynaecology (28 decks)

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