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Gynae (Owen) > Menstrual problems > Flashcards

Menstrual problems Flashcards

1
Q

Management of premenstrual syndrome

A

Mild
- lifestyle- exercise, small meals 2-3 hours apart, stop smoking alcohol
Moderate
- COCP
Severe
- SSRI for luteal phase or continuous

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2
Q

Presentation of premenstrual syndrome

A

Physical
- bloating
- breast pain
Emotional
- anxiety
- mood changes
- fatigue

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3
Q

What causes mittelschmerz

A

In ovulation a small amount of fluid is released

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4
Q

What is a cervical ectropion

A

Increased oestrogen levels can cause the transformation zone to move down into the ectocervix

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5
Q

Symptoms of cervical ectropion

A

Post coital bleeding from trauma to cervix (columnar cells more fragile than squamous)
Dyspareunia
Increase in discharge

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6
Q

How does cervical ectropion appear

A

Reddening around the cervical OS
This is the shifting of transformation zone where columnar cells are visible which are red

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7
Q

Management of cervical ectropion

A

Ablation if very troublesome symptoms

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8
Q

Management of menorrhagia

A

Do they want contraception?
Yes
1st line- LNG-IUS
2nd line- COCP
3rd line- injection or implantable progestogen
NO
Do they have painful periods?
YES
Mefanemic acid
NO
Tranexamic acid

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9
Q

When suspect PCOS

A

Amenorrhoea, oligomenorrhoea, infertility
Signs of acne, hirsutism
Acanthosis nigricans
FHx

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10
Q

What is acanthosis nigricans

A

Dry rough skin with pigmented appearance

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11
Q

How is PCOS diagnosed in adults versus adolescents

A

Adults- rotterdam criteria
2 of
- amenorrhoea/infertility
- signs of hyperandrogenism (including just elevated testosterone)
- presence of cysts (over 12 measuring over 2mm or ovary size of over 10ml)

Adolescents
- hyperandrogenism and amenorrhoea required
If do not meet criteria then described as “at risk”

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12
Q

Most common cause of dysmenorrhoea

A

Primary dysmenorrhoea

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13
Q

Pathophysiology of PCOS

A

Production of LH greatly increased causing excess androstenedione which enters the blood and is converted to oestrone which inhibits LH surge. As such ovulation does not occur meaning that dominant follicle either degenerates or becomes a cyst

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14
Q

What is thought to cause anterior production of LH production in PCOS

A

Presence of hyperinsulinaemia causes proliferation of theca cells as they have insulin receptors. LH production increases

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15
Q

Consequences of high androstenedione

A

Hrisutism
Male pattern baldness
Acne

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16
Q

Where does acanthosis nigricans develop

A

Folds of neck, groin and underarms

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17
Q

What bloods tests do you do in PCOS

A

Sex hormone binding globulin
Free androgen index
Total testosterone
LH
FSH
Prolactin and thyroid

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18
Q

What can happen to prolactin in PCOS

A

Slightly raised

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19
Q

What is sex hormone binding globulin

A

Protein in the blood which binds to testosterone primarily

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20
Q

What is sex hormone binding globulin in PCOS

A

Low

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21
Q

What is the free androgen index

A

(100x testosterone)/ SHBG
This is a measure of total free testosterone essentially

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22
Q

What happens to free androgen index PCOS

A

Raised

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23
Q

Important things to screen for in PCOS

A

Wellbeing
Sleep apnoea
CVD risk

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24
Q

Who with PCOS should be offered OGTT

A

BMI over 25
Not overweight but other risk factors like fhx
Non white

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25
Q

Who gets an annual OGTT with PCOS

A

Impaired fasting glucose
Impaired glucose tolerance

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26
Q

What should PCOS people have annually

A

Weight monitoring
BP checks

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27
Q

How to manage amenorrhoea in PCOS

A

If prolonged amenorrhoea (1 in 3 months) then prescribe cyclical progestogen for 14 days to induce a withdrawal bleed and then refer for TVUSS
If over 10mm get sampling
If normal then offer either low dose COC, cyclical progestogen or LNG-IUS depending on whether wants withdrawal bleeds or has acne etc
If does not wish to have any of these then refer to specialist where will be offered USS every 6-12 months
Weight loss also useful

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28
Q

Management of acne in PCOS

A

First line is COCP- co-cyprindiol
If needed follow acne pathway
Healthy lifestyle

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29
Q

Management of hirsutism in PCOS

A

Healthy lifestyle
Discuss methods of hair reduction- waxing and removal

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30
Q

Management of infertility in PCOS

A

Healthy lifestyle- stop smoking and lose weight especially when overweight
Refer to specialist where can prescribe 1st line clomifene and then add metformin or use first line when overweight
Second line includes- gonadotrophins, Pulsatile GNRH and ovarian drilling

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31
Q

MOA of clomifene

A

Occupies oestrogen receptors in brain without activating them which stimulates GNRH release and ultimately FSH

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32
Q

Inheritance of androgen insensitivty syndrome

A

X-linked

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33
Q

Investigations for androgen insensitivty syndrome

A

Karyotyping- 46 XY
Testosterone levels very high

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34
Q

When suspect androgen insensitivty syndrome

A

Amenorrhoea
Breast development as can get conversion of testosterone to oestrogen
No pubic hair anywhere
Groin swellings which are undescended testicles

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35
Q

Management of androgen insensitivity syndrome

A

Counselling that should raise as a girl
Bilateral orchidectomy
Oestrogen therapy

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36
Q

Causes of secondary dysmenorrhoea

A

Endometriosis
Adenomyosis
PID
Fibroids
Cu IUD

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37
Q

Difference in pain for secondary dysmenorrhoea

A

Can start a few days before

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38
Q

Pain in dysmenorrhoea

A

Starts within a few hours of period and can radiate to back or down thighs

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39
Q

Management of pain in primary dysmenorrhoea

A

Mefanemic acid and paracetamol
2nd line COCP
3rd line can use POP or Mirena

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40
Q

Complications of PCOS

A

Endometrial cancer
Stroke
CVD
Infertility
OSA

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41
Q

How many periods aim in PCOS for per year

A

3 to reduce Ca risk

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42
Q

What happens to PCOS patients when do IVF

A

OHSS

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43
Q

What happens to the majority of secondary oocytes in ovaries

A

Undergo atresia not from ovulation

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44
Q

When is prime time to assess levels of hormones

A

Day 2-5 of menstrual cycle

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45
Q

Why do you want to lose weight in PCOS

A

Adipose tissue synthesises oestrogen which can adds to oestrogen levels in blood

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46
Q

How does PCOS appear on USS

A

Pearl sign
Sagging of ovaries

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47
Q

What are signs of extremely high testosterone in women

A

Deep voice
Virilisation
Cliterol hypertrophy
Rapidly progressing hirsutism

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48
Q

Problem of using accutane in PCOS treatment

A

It is teratogenic so must be on contraception

49
Q

Why give COCP in PCOS

A

Increases SHBG

50
Q

If presenting with menorrhagia what are first line investigations

A

Clotting screen
FBC

51
Q

What type of drugs are tranexamic

A

Antifibrinolytic

52
Q

How is primary amenorrhoea defined

A

Failure to menstruate by 15 with secondary sexual characteristics
Failure to menstruate by 13 without secondary sexual characteristics

53
Q

What are spiral arteries

A

What supply the endometrium
Proliferate in the luteal phase

54
Q

What is most common cause of primary amenorrhoea

A

Turners

55
Q

What is second most common cause of primary amenorrhoea

A

Mullerian agenesis

56
Q

What is included in mullerian duct system

A

Uterus, cervix and upper 2/3 of vagina

57
Q

What is virilisation

A

When females develop male sexual characteristics

58
Q

What does cause of primary amenorrhoea depend on

A

Development of secondary sexual characteristics such as breasts

59
Q

Causes of priary amenorrhoea where development of secondary sexual characteristics

A

Endocrine
- CAH
- high prolactin
- thyroid dysfunction
- cushings
Androgen insensitivty (testosterone produced which can be converted to oestrogen)
Genitourinary dysfunction
- imperforate hymen
- mullerian agenesis
- transverse septum

60
Q

What is imperforate hymen

A

The hymen is memebrane which is partially closed in the vagina
If imperforate then completely occludes the vagina

61
Q

How does imperforate hymen present

A

Amenorrhoea with regular painful periods- eventually get abdo distention and discomfort from where uterus and cervix fill with blood. Can also get urinary retention

62
Q

What is investigation for imperforate hymen

A

Abdo USS
- shows haematocolpos and haematometra

63
Q

What is management of imperforate hymen

A

Incision under anaesthesia
Then evacuation of uterus and cervix

64
Q

Causes of haematocolpos and haematometra

A

Imperforate hymen
Transverse septum

65
Q

What is a transverse septum

A

When have tissue sitting across whole of vaginal canal

66
Q

Amenorrhoea with impaired sense of smell

A

Kallman

67
Q

Causes of primary amenorrhoea without secondary sexual characterstics

A

Constituional
Turners
Hypothalamic-pituitary dysfunction
- stress (mental and physical)
- weight loss
- kallmans

68
Q

What causes functional hypothalamic amenorrhoea

A

Excess exercise

69
Q

What defines secondary amenorrhoea

A

Absence of menstruation for 3-6 months after regular menses
Absence of menstruation for 6-12 months after oligomenhorrhoea

70
Q

How does mullerian agenesis present

A

Dyspareunia
Agenesis

71
Q

What does amenorhhoea with very little pubic har suggest

A

Androgen insensitivity

72
Q

Signs on examination of haematocolpos

A

Parting of labia may reveal blue bulging membrane
Abdominal mass

73
Q

If have examinaed the breasts when can next measure prolactin

A

48 hours

74
Q

Examinations for amenorrhoea

A

BMI
Inspection of whole body
- hirsutism
- acne
- striae
- buffalo hump
- galactorrhoea
- lack of pubic hair
- abdominal mass
Test visual fields

75
Q

Investigations for primary amenorrhoea

A

TSH
FSH/LH
Prolactin
Testosterone
TVUSS

76
Q

What looking for in TVUSS for primary amenorrhoea

A

Streak ovaries
Lack of uterus/ovaries

77
Q

What do if prolactin 500-1000
Primary amenorrhoea investigation

A

Repeat

78
Q

What can cause mild hyperprolactinaemia

A

Drugs
- anti-psychotics
- SSRI
- anti-emetics metoclopramide
Stress
PCOS
Renal impairment (can go as high as 2000)
Thyroid dysfunction

79
Q

How to interpret testosterone levels in primary amenorrhoea investigation

A

Normal- less than 2.5
2.5-5- PCOS
Over 5- CAH, Cushings, testosterone tumour, AIS

80
Q

What level of prolactin warrants an MRI

A

Over 1000

81
Q

Most common cause of hyperprolactinaemia in primary care

A

Stress or drugs

82
Q

When does normal referral for primary amenorrhoea get changed

A

If present younger than 13 or 15 but
- growth retardation
- 5 years post thelarche and no menses
- thyroid cause suggested
- androgen excess
- galactorrhoea

83
Q

Who to refer to for amenorrhoea

A

Gynaecologist most of time
Endocrinologist if hyperandrogenism, hyperprolactinaemia or thyroid causes suggested

84
Q

How to manage amenorrhoea caused by excess exercise, weight loss or stress

A

Refer all to endocrinologist to rule out pituitary tumour
If ruled out
Excess exercise- reduce exercise and refer to sports physician if possible
Stress- manage stress
Weight loss- dietician or relevant services if ED

85
Q

When do you consider osteoporosis prophylaxis for amenorrhoea

A

Over 12 months

86
Q

When refer to gynae for secondary amenorrhoea

A

POI in under 40
Recent uterine or cervical surgery suggesting asherman or endometritis
Infertility

87
Q

What is asherman syndrome

A

Amenorrhoea caused by recent uterine procedure or severe uterine infection which may have lead to adhesions meaning no functional endometrium

88
Q

Causes of endometritis

A

Recent rupture of membranes
IUD insertion
Hysteroscopy and biopsy
Cervical curettage
PID
C-section

89
Q

When manage osteoporosis risk in amenorrhoea

A

POI under 40
Hypothalamic hypogonadism
High prolactin

90
Q

How manage osteoporosis risk in amenorrhoea

A

Lifestyle- stop smoking and lose weight
Vit d levels
HRT considered if amenorrhoea over 12 months
- if functional hypothalamic give for 12 months and then stop for 6 months to see if menses return

91
Q

How manage osteoporosis risk in secondary amenorrhoea if caused by functional hypothalamic amenorrhoea

A

Give for 12 months and then stop for 6 months to see if menses return

92
Q

How to daignose asherman syndrome

A

Hysteroscopy

93
Q

What is seen on vaginal examination of imperforate hymen

A

Bulging membrane

94
Q

What are gonadotorphin levels in prolactinaemia

A

Low FSH and LH

95
Q

If present with galactorrhoea and amenorrhoea what do

A

Exclude thyroid causes and renal dysfunction
Then MRI

96
Q

What is vulvodynia

A

Presence of pain in vaginal/vulvar region for 3 months with no identifiable cause

97
Q

Difference between unprovoked and provoked vulvodynia

A

Unprovoked- present most of time without identifiable trigger
Provoked- has identifiable trigger like speculum or sex

98
Q

What is most common cause of discharge in a prepubescent girl

A

Vulvovaginitis

99
Q

What causes vulvovaginitis in a prepubescent girl

A

Due to low oestrogen the vaginal mucosa is very thin meaning susceptible to infections

100
Q

Management of vulvovaginitis

A

Good hygiene
Wear cotton undergarments

101
Q

If have hyperprolactinaemia causing amenorrhoea what are first investigations

A

Rule out other causes
Hypothyroidism
CKD

102
Q

What is it called if somenoe has AIS

A

Male intersex

103
Q

Management plan if unprovoked vulvodynia

A

First line- amitryptylline
Second line- gabapentin or pregabalin

104
Q

What is premenstrual dysmorphic syndrome

A

A severe form of premenstrual syndrome whereby exhibit only the psychological symptoms of PMS without the physical

105
Q

Investigation for pre menstrual syndrome

A

Symptom diary for 2 cycles

106
Q

What is average size of dominant follicle

A

2cm

107
Q

What produces the oestrogen near ovulation

A

Dominant follicle

108
Q

What determines a cycle length

A

How long it takes to produce a dominant follicle
Luteal phase is fixed 14 days in everyone

109
Q

If a fundus at umbilicus is 20 weeks what is it coming out of pelvis

A

12 weeks

110
Q

What type of drug is mefanemic acid

A

Prostaglandin inhibitors

111
Q

How to treat asherman syndrome

A

Hysteroscopy with adhesiolysis
Postoperative systemic oestrogen

112
Q

What defines primary dysmenorrhoea

A

It occurs within 1 year of menache

113
Q

In PMS, how give the COCP

A

Omit pill free period

114
Q

What is best drug for dysmenorrhoea if dont want to take a pill every day

A

Mefanemic acid as can be given as a short course

115
Q

Cause of menopause with liver problems, joint pain and diabetes

A

Haemochromatosis

116
Q

What must do before TVUSS in PCOS amenorrhoea assessment

A

Give progesterone for 14 days to induce bleed

117
Q

What is given to reduce endometrial cancer risk in PCOS

A

Low dose COCP
Cyclical progesterone every 14 days in 3 months

118
Q

How does a post hysterectomy bladder injury present

A

Anuria
Pain
Blood in urine

Gynae (Owen) (11 decks)

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