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3a obs and gynae > Menstrual problems and fertility > Flashcards

Menstrual problems and fertility Flashcards

menstrual problems, menopause, fertility, PCOS

1
Q

Define primary amenorrhoea

A

when menstruation has failed to start by the age of 16 y/o

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2
Q

Define secondary amenorrhoea

A

when previous normal menses ceases for >6 months

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3
Q

List some of the causes of primary amenorrhoea

A

constitutional delay

psychological - anorexia, athleticism

hypothalamic failure - Kallmanns syndrome (deficiency of GnRH), tumours

gonadal failure - PCOS, Turners syndrome (webbed neck, short stature, missing digits), gonadal dysgenesis

endocrine - congenital adrenal hyperplasia, hypo/hyperthyroidism

other - imperforate hymen, transverse vaginal septum (get cyclical abdominal pain)

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4
Q

List some of the causes of secondary amenorrhoea

A

non pathological - menopause, pregnancy, post COCP, drugs, lactation

psychological - anorexia, athleticism

endocrine - adrenal tumours, Cushings

pituitary- pituitary tumours, sheehans syndrome (PPH causing pituitary necrosis)

ovarian- premature ovarian failure, ashermans syndrome (intrauterine adhesions), PCOS

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5
Q

What necessary investigations would you do for amenorrhoea?

A
  1. pregnancy test
  2. FHS and LH
  3. Testosterone
  4. prolactin
  5. TFT
  6. karyotype
  7. transvaginal ultrasound
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6
Q

Define dysmenorrhoea

A

painful cramping in the lower abdomen usually before or at the start of menstruation

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7
Q

What is the difference between primary and secondary dysmenorrhoea

A

primary dysmenorrhoea = the pain has no obvious organic cause or underlying pathology

secondary dysmenorrhoea = the pain occurs due to underlying pathology

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8
Q

What is the cause for primary dysmenorrhoea?

A

decrease in progesterone allowing prostaglandin release which causes myometrium to contract resulting in pain and ischaemia

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9
Q

What are the possible causes for secondary dysmenorrhoea?

A

endometriosis **
adenomyosis **
fibroids**
pelvic adhesions**

PID
malignancy
ashermans syndrome

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10
Q

How is dysmenorrhoea managed?

A

analgesia and symptomatic control

1st line = mefenamic acid (NSAID) - inhibit prostaglandin production
COCP
paracetamol

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11
Q

Define menorrhagia

A

excessive menstrual blood loss that interferes with the womens quality of life (>80ml +/- >7 days bleeding)

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12
Q

What are the possible causes of menorrhagia?

A

no underlying cause = dysfunctional uterine bleeding
uterine fibroids *
polyps *
endometriosis*
coagulation factors e.g. von willebrands disease, anticoagulants
hypothyroidism

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13
Q

How is menorrhagia managed?

A
  1. antifibrinolytics e.g. transexamic acid - reduce blood loss by 50%
  2. NSAIDs e.g. mefenamic acid
  3. COCP
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14
Q

Define dysfunctional uterine bleeding

A

diagnosis of exclusion, defined at abnormal uterine bleeding in the absence of pregnancy, genital tract pathology or systemic disease

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15
Q

What is a polycystic ovary?

A

a characteristic transvaginal ultrasound appearance of multiple (>12) small (2-8mm) follicles in an enlarged (>10ml) ovary

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16
Q

What is the criteria for polycystic ovary syndrome?

A

2/3 of the following criteria:

  1. polycystic ovary on ultrasound
  2. hirsutism: clinical +/- biochemical
  3. irregular periods/ infrequent ovulation
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17
Q

What are the causes of PCOS?

A

genetic
insulin resistance
obesity - especially central obesity
hyperandrogegism

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18
Q

What is the pathology behind PCOS?

A
  1. insulin resistance and raised insulin levels
  2. leads to overproduction of ovarian androgens
  3. reduces steroid hormone binding globulin production in liver which increases free androgen levels
  4. increased androgens disrupt folliculogenesis
  5. leads to small multiple ovarian follicles and irregular ovulation as hirsutism
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19
Q

How does PCOS present?

A 
hirsutism 
acne
obesity 
amenorrhoea/ oligomenorrhoea
sub fertility 
deepening voice
balding
reduced breast size
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20
Q

Which investigations are necessary for PCOS?

A

transvaginal ultrasound - detect PCO
raised insulin levels
raised LH levels

+testosterone, low SHBG, prolactin

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21
Q

How is PCOS managed?

A
  1. lifestyle - weight loss
  2. to treat hirsutism - COCP and spironolactone
  3. to treat insulin resistance - metformin
  4. for infertility - clomifine, IVF
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22
Q

What are the complications of PCOS?

A 
Type 1 diabetes
gestational diabetes 
endometrial cancer 
infertility 
CVD
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23
Q

what is the menopause?

A

cessation of menstruation - diagnosed after 12 months of amenorrhoea or after onset of symptoms
average age of 51 years

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24
Q

What is classed as premature menopause?

A

menopause under 40 y/o

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25
Q

What is perimenopause?

A

the time leading up to menopause

characterised by irregular periods and symptoms

26
Q

What are premenopausal symptoms?

A

central effects of decreased oestrogen levels:

  • vasomotor symptoms e.g. hot flushes, sweats
  • MSK symptoms e.g. joint pain
  • Low mood and sexual difficulties e.g. irritable, lack of concentration, lack of libido, fatigue

local effects of decreased oestrogen:
- urogenital symptoms e.g. vaginal dryness, dyspareunia, recurrent UTIs, urinary frequency, post menopausal bleeding

27
Q

What are the impacts of menopause?

A
  1. osteoporosis - DXA scan if RF for osteoporosis
  2. cardiovascular disease
  3. dementia
28
Q

How is menopause managed?

A
  1. holistic approach
  2. lifestyle advice - stop smoking, reduce alcohol, exercise, diet changes
  3. inform about medical options e.g. hormonal (HRT, vaginal oestrogen), non hormonal (clonidine), CBT
29
Q

What are the 2 types of oral HRT?

A
  1. sequential HRT : oestrogen given for every day of the month, but progesterone only given in the last 14 days of the month - at risk of endometrial cancer
  2. continuous combined HRT: oestrogen and progesterone given every day of the month - reduces risk of endometrial Ca
30
Q

Who should be prescribed transdermal HRT?

A 
gastric upset e.g. crohns
increase risk of VTE 
older women 
hypertensions
patients choice
31
Q

What are the benefits of HRT?

A

relief of menopause symptoms
bone mineral density protection
colorectal cancer prevention

32
Q

What are the risks of HRT?

A

breast cancer - if taking progesterone and oestrogen
venous thrombo embolism
cardiovascular disease
stroke
endometrial cancer - if only oestrogen HRT
ovarian cancer

33
Q

What are some of the causes for male infertility?

A

idiopathic oligospermia and asthenozoospermia
alcohol
smoking
drugs e.g. anabolic steroids, sulfrasalazine
obesity
syndromes: Klinefelters syndrome, kallmans syndrome
hypogonadism
varicocele, mumps orchitis, epididymitis

34
Q

How is semen analysed?

A

sample produced by masturbation and must be analysed within 1-2 hours

sample is studied for:

  1. count
  2. motility
  3. morphology

if abnormal sample, need to repeat after 12 weeks

35
Q

What is a normal semen analysis?

A

volume: >1.5 million
count: >15 million/ml
motility: >32%

36
Q

Define azoospermia

A

no sperm present

37
Q

Define oligospermia

A

<15 million/ml

38
Q

Define asthenospermia

A

absent or low motility

39
Q

If the sperm count is abnormal, what investigations are necessary?

A

testosterone, FHS, LH, prolactin
clinical examination - testicular size
karyotype - test for klinefelters, CF screen
repeat in 12 weeks

40
Q

What conservative advice is given for men with an abnormal semen analysis?

A 
weight loss
smoking cessation
diet (folic acid, zinc, vit E)
reduce alcohol intake 
wear loose clothing
41
Q

Define subfertile

A

if conception has not occurred after a year of regular unprotected intercourse

42
Q

What are the possible causes for female infertility?

A

unexplained

ovulatory factors - PCOS, premature ovarian failure, hypogonadism, adrenal tumours, hyperprolactinaemia, gonadal dysgenesis

tubal factors - infection (e.g. chlamydia, gonorrhoea, PID), surgery (adhesions), endometriosis

uterine/ peritoneal

other risk factors- alcohol, obesity, smoking, increasing age

43
Q

What initial advice is given to women struggling to conceive?

A

80% couples conceive within first year
preconception advice
refer to fertility doctor in a year (early referral if <35 y/o and known problem)

44
Q

What is included in preconception advice?

A 
stop smoking
weight loss: BMI 19-30
stop drinking alcohol
start taking folic acid 0.4mg
intercourse 2-3 times a week
45
Q

How is ovulation function assessed?

A

day 21 mid luteal progesterone levels**

day 2-5 progesterone

46
Q

How is tubular dysfunction assessed in fertility?

A

1st line = hysterosalpingogram (screen for tubal occlusion)

2nd = hysterosalpingo-contrast ultrasound sonography (safer as no radioactive contrast)

3rd = laparoscopy and methylene blue dye (visualise Fallopian tubes)

47
Q

How is someone helped with fertility if they have PCOS?

A
  1. normalise weight
  2. clomifene (antioestrogen)
  3. metformin
  4. laparoscopic ovarian diathermy
48
Q

What is clomifene?

A

= anti oestrogen
blocks oestrogen receptors in hypothalamus and pituitary which causes release of LH and FHS which helps follicular maturation

49
Q

How is the ovarian reserve tested?

A
  1. FSH levels (>8.9 = low)
  2. antral follicle count (<4= low)
  3. anti mullerian hormone (<5.4= low)
50
Q

What is the management plan for someone with tubular problems and sub fertile?

A

tubal surgery via laparoscopy
tubal catheterisation
IVF

51
Q

List the options involved in assisted conception

A

ovulation induction
intrauterine insemination
IVF
donor insemination/ egg/ embryo

52
Q

What are the risks of iVF?

A 
multiple pregnancy
ectopic pregnancy
miscarriage 
fetal abnormality
ovarian hyperstimulation syndrome
53
Q

Describe the IVF treatment cycle?

A

3 CYCLES OF IVF ON NHS IF <40 Y/O

  1. ovarian stimulation and monitory - 2 weeks
  2. egg collection
  3. insemination
  4. fertilisation check - day 1
  5. embryo culture - 2-5 days
  6. embryo transfer
  7. luteal support
  8. pregnancy test
54
Q

What should women be screened for if presenting with sub fertility?

A
  1. chlamydia screening
  2. cervical cancer testing
  3. TFTs (TSH)
  4. prolactin
  5. rubella status
  6. viral status (HepB, HepC, HIV)
55
Q

when should menopause be investigated?

A

<40 y/o or >45 y/o with atypical symptoms

56
Q

What investigations are done for the menopause or premature ovarian failure?

A
  1. FSH increase
    gives estimate of ovarian reserve
    increase FSH = decrease oocytes
    measure between day 2-5
  2. anti mullerian hormone decreasing
    produced in granulosa cells of natural/ pre natural follicles
    gives direct measurement of ovarian reserve
    stable throughout cycle
  3. oestrogen decreases
57
Q

should you still use contraception if someone is going through the menopause?

A

if 12 months after the last period in women > 50 years

OR 24 months after the last period in women < 50 years

58
Q

what are contraindications to HRT?

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

59
Q

which non HRT options are offered for management of menopause?

A

Vasomotor symptoms
fluoxetine, citalopram or venlafaxine

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not

60
Q

How is premature ovarian failure diagnosed?

A

FSH >25 IU/L (2 samples with 4 weeks apart) + >4 months of amenorrhoea

61
Q

define premature ovarian failure

A

menopause before the age of 40

3a obs and gynae (5 decks)

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