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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Menstrual problems and the menopause > Flashcards

Menstrual problems and the menopause Flashcards

1
Q

What triggers menstruation?

A

A fall in progesterone

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2
Q

Mean blood loss during menstruation

A

30-40ml

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3
Q

What is menorrhagia?

A

Heavy periods - >80 mls per cycle

Interferes with quality of life

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4
Q

What is dysmenorrhoea?

A

Painful periods

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5
Q

What an cause dysmenorhoea

A
  • Primary - no known cause
    • Without organ dysmorphy
    • Increased prostaglandins can cause excessive uterine contractions
  • Secondary - known cause
    • Associated with pathology
    • Endometriosis/adenomyosis
    • PID
    • Fibroids
    • Copper coil
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6
Q

What is intermenstrual bleeding?

A

Bleeding between periods not caused by coitus

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7
Q

What can cause intermesntrual bleeding?

A

Cervical polyps

Carcinoma

Vaginitis

Hormonal contraception

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8
Q

What is post coital bleeding?

A

Vaginal bleeding after sex

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9
Q

What can cause post coital bleeding?

A

Cervical trauma

Endometrial and vaginal carcioma

Chlamydia

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10
Q

What is oligomenorrhoea?

A

Infrequent periods

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11
Q

What commonly causes oligomenorrhoea?

A

PCOS

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12
Q

What is amenorrhoea?

A

No periods (can be primary or secondary)

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13
Q

What would you want to ask about in a menstrual history?

A

MR FLOPPI DICS

  • Menopause
  • Regularity
  • Flow - light/heavy, flooding, clots
  • Last menstrual period
  • Odd bleeding - Post coital, post menopausal, intermenstrual
  • Dysmenorrhoa
  • Initiation - menarche
  • Cycle - days on, days off, Contraception
  • Smear history
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14
Q

What is regarded as normal menstrual cycle length?

A

4-5 days on/21-35 days off

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15
Q

What is the mean blood loss from menstruation?

A

30-40 mls

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16
Q

What are features of normal menstruation?

A
  • Duration between two and seven days
  • Flow less than 80 mL
  • Occurring in cycles of 24 to 35 days
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17
Q

What are symptoms of normal menstruation?

A
  • Abdominal pain and cramps
  • Vaginal bleeding
  • Nausea
  • Diarrhoea
  • Sweating
  • Fatigue
  • Irritability
  • Dysphoria (unhappiness)
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18
Q

What is primary amenorrhoea?

A

Menstruation has not occured yet - pre-menarche

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19
Q

When does primary amenorrhoea need investigation?

A

16 year old or 14 year old with no breast development

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20
Q

What is secondary amenorrhoea?

A

When periods stop for >6 months other than due to pregnancy

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21
Q

What is primary dysmenorrhoea?

A

Pain without organ pathology - often starting with anovulatory cycles after menarche. It is crampy with ache in the back or groin, worse during the first day or two

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22
Q

What are options for managing primary dysmoenorrhoea?

A
  • NSAIDs - mefenamic acid - during menstruation
  • Paracetamol
  • COCP
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23
Q

What is secondary dysmenorrhoea?

A

Dysmenorrhoea with pathology - e.g. adenomyosis, endometriosis, PID, fibroids

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24
Q

What are causes of secondary dysmenorrhoea?

A
  • Adenomyosis
  • Endometriosis
  • PID
  • Fibroids
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25
Q

What should you always screen for in a woman with post-coital bleeding?

A

Chlamydia

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26
Q

What are causes of post-menopausal bleeding?

A

!!Endometrail cancer until proven otherwise!!

  • Vaginitis (often atrophic)
  • Foreign bodies - pessaries, tampons
  • Carcinoma of cervix/vulva
  • Endometrial/cervical polyps
  • Oestrogen withdrawal
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27
Q

What should you always test for in secondary amenorrhoea?

A

PREGNANCY!! - most common cause of amenorrhoea in woman of childbearing age

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28
Q

What is the most likely cause of primary amenorrhoea if secondary sexual characteristics are absent?

A

Most likely delayed puberty. Should also consider genetic causes - turner’s syndrome, androgen insensitivity

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29
Q

What is the most likely cause of primary amenorrhoea if secondary sexual characteristics are present?

A

Can just be normal variant

Anatomical causes:

  • Congenital absence of uterus
  • Imperforate hymen
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30
Q

Can exercise cause priamry amenorrhoea?

A

Yes - if excessive

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31
Q

Can low body weight cause primary amenorrhoea?

A

Yes

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32
Q

What can cause primary amenorrhoea?

A
  • Chromosomal problem - turner’s etc.
  • Hypothlalamic - Physiological delay, weight loss/anorexia, heavy exercise, GnRH deficiency
  • Pituitary - partial/total hypopituitarism, hyperprolactinaemia, adenoma, trauma
  • Ovarian - True agenesis, prem. ovarian failure, PCOS
  • Primary hypothyroid
  • Adrenal hyperplasia
  • Imperforate hymen

Coeliac

Normally not a big deal - tends to be that puberty is late and reassurance is all that is needed. May need to exclude something like turners.

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33
Q

What are causes of secondary amenorrhoea?

A
  • Physiological - pregnancy, lactation, menopause
  • Hypothalamic - weight loss, heavy exercise, stress
  • Pituitary - hyperprolactinaemia, hypopituitarism
  • Ovarian - PCOS, prem. ovarian failure, surgery/radio/chemo, virilising ovarian tumours
  • Primary hypothyoridism
  • Adrenal hyperplasia/tumour
  • Hysterectomy
  • Endometrial ablation
  • Minera IUS

Sheehans - pituitary failure

Asherman’s - adhesions in endometrium

HPO axis most common

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34
Q

What is premature ovarian failure?

A

Cessation of ovarian function before the age of 40 - usually due to depletion of primordial follicles

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35
Q

How would you investigate someone presenting with amenorrhoea?

A
  • Bedside -
    • ​Urinary pregnancy test,
    • Dipstick
  • Bloods
    • bHCG
    • FSH/LH,
    • Serum free androgen,
    • Prolcatin,
    • TFTs,
    • Testosterone, oestrogen
  • Imaging -
    • ​TVUSS/TAUSS,
    • MRI

Karotype

Blood 17 hydroxyprogesterone - congenital adrenal hyperplasia

36
Q

Why might you look at serum ostrogen in someone with primary amenorrhoea?

A

Low in primary ovarian failure

37
Q

Why might you do serum prolactin levels in amenorrhoeic individuals?

A

Look for hyperprolactinaemia

38
Q

Why might you do TFTs in someone with amenorrheoa?

A

Look for primary hypothyroidism

39
Q

When might you do an MRI head in someone with amenorrhoea?

A

If serum prolactin levels are high - look for pituitary tumour causing hyperprolactinaemia

40
Q

How can ammenhorea be managed?

A

Clomifene

GnRH to restart axis

41
Q

What are causes of menorrhagia?

A
  • Dyfunctional uterine bleeding
  • IUCD
  • Fibroids
  • Endometriosis
  • Adenomyosis
  • Pelvic infection
  • Polyps - endometrial, cervical
  • Hypothyroidism
  • Coagulation disorders
  • Endometrial carcinoma - post menopausal
42
Q

What investigations would you consider doing in someone with menorrhagia?

A
  • Bedside - pregnancy test
  • Bloods - FBC, TFTs, Testosterone, coagulation screen, bhcg

Generall if <45 no further testing
If >45 fibroids, polyps, endometrial thickness

  • Imaging - Pelvic USS
  • Other - biopsy (ig age>45, persistant IMB), hysteroscopy (fibroids)

Check smear history

43
Q

Why might you do an FBC in someone with menorrhagia?

A

Look for signs of anaemia

44
Q

Why might you do TFTs in someone with menorrhagia?

A

Look for Hypothyroidism

45
Q

What should be considered as first line treatment for menorrhagia?

A

Mirena IUS

46
Q

How does the mirena IUS help with menorrhagia?

A

Releases levonogestral into the endometrial cavity, leading to atrophy

47
Q

What medications can be used to manage menorrhagia?

A
  • Mirena IUS - FIRST LINE
    • Releases levonogestrel into endometrial cavity causing atrophy
  • Taken during bleeding
    • Antifibrinolytics - Tranexamic acid
    • NSAIDs
  • COCP - SECOND LINE
  • Progestogen injection - THIRD LINE
    • Eg northisterone
48
Q

Why are NSAIDS/tranexamic acid used during bleeding in menorrhagic patients?

A

Reduce blood loss

49
Q

How does transexamic acid work?

A

Prevents plasminogen to plasmin

50
Q

What surgical options are available for managing menorrhagia?

A

Consider benefits and risk of each - reserved for non-responders to medication (family should be complete)

  • Endometrial ablation - thermal balloon, microwave, electrical impedence
    • ​One off removal of endometrium to below basal layer
    • Treatment done through cervic
    • Will still require contraception
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
    • ​Types include: subtotal, total, total with bilateral salpingo-oophorectomy, radical (wertheim’s)

50% of hysterectomies are for DUB

51
Q

Risks of hysterectomy

A
  • Infection
  • DVT
  • Bweol/BV injury
  • Altereted bladder function/adhesions
52
Q

What is premenstrual syndrome?

A

A condition which manifests with distressing physical, behavioural, and psychological symptoms in the absence of organic or psychiatric disease, regularly occurring during the luteal phase of the menstrual cycle and with significant improvement by the end of menstruation

53
Q

What are symptoms of PMS?

A
  • Mood swings
  • Irritability
  • Depression
  • Bloating
  • Breast tenderness
  • Headache
  • Reduced visuospatial ability
  • Increase in accidents
54
Q

What is the menopause?

A

Time of waning fertility leading up to the last period. It is a retrospective diagnosis, having said to occurered 12 months after the last period

55
Q

What is the average age of menopause in the UK?

A

52

56
Q

What causes menopause?

A

Ovarian failure leading to reduction in oestrogen production and increase in FSH production.

57
Q

What is peri-menopause?

A

Transition from cyclic menstrual bleeding to a total cessation of menses happens over about 4 years. It is marked irregularity and periods of amenorrhoea ue to declining progesterone and oestradial levels

58
Q

What are features of the menopause?

A

Usually lasts 2-5 years (up to 7)

  • Cycle
    • Menstrual irregularity
  • Vasomotor disturbance
    • Sweats,
    • Palpitations,
    • Flushes,
    • Palpitations
  • Atrophy of oestrogen dependent tissues - breast, genitalia, skin
  • Vaginal dryness -> UTIs, dyspareunia, trarumatic bleeding
  • Stress incontinence
  • Osteoporosis
  • Mood changes - depression, anxiety, loss of libido, tiredness
59
Q

What happens to levels of LH/FSH in the menopause?

A

Increase due to reduced oestrogen negative feedback

FSH >30IU/L suggestive

60
Q

What are features of hot flushes experienced in menopause?

A

Last about 3 minutes

  • Feeling of warmth
  • Nausea
  • Palpitations
  • Sweating
61
Q

Why are menopausal women at increased risk of UTI?

A

Due to vaginal glycogen depletion, leading to increased vaginal pH

62
Q

When do atrophic changes tend to appear in menopausal women?

A

Years after menopause

63
Q

How would you manage someone going through the menopause?

A

Split into three categories:

Lifestyle modifications

  • Diet and exercise
  • Sleep
  • Relaxation

HRT​

Non HRT

  • Oestrogen cream - vginal dryness
  • Osteoporosis prevention - weight bearing exercise, Vit D and calcium, bisphosphonates

Other

  • Mirena coil - if menorrhagic
  • Contraception - until 1 year amenorrhoeic
  • May need SSRIs - venlafaxine
64
Q

What should those without a uterus going through the menopause be given in terms of hormonal replacement therapy?

A

Oestrogen only HRT

65
Q

What are examples of vaginal HRT preparations?

A
  • Oestradiol tablets
  • Ring pessaries
  • Vaginal cream
66
Q

What HRT preparations should be used in women with a uterus?

A

Oestrogen and progesterone (combined) HRT

67
Q

What regimen of HRT should be used in women who are still having (irregular) periods or are within 12 months of their last period?

A

Oestrogen and cylical progestogen - usually results in regular withdrawal bleeding

68
Q

When is continuous combined HRT used?

A

In women who are post-menopausal for more than 2 years

69
Q

How long after their last menstrual period is a woman considered fertile?

A

About 2 years

70
Q

What are contraindications to HRT?

A
  • Oestrogen dependent cancer
  • Undiagnosed PV bleeding
  • Untreated endometrial hyperplasia
  • Past PE
  • Deranged LFTs
  • Pregnancy
  • Breastfeeding
  • Phlebitis
71
Q

What are side effects to HRT?

A
  • Fluid retention
  • Bloating breast tenderness
  • Nausea
  • Headaches
  • Leg cramps
  • Dyspepsia
  • Mood swings
  • Depression
  • Acne
  • Backache
72
Q

What should be done at annual check up in someone going through menopause?

A
  • Breasts
  • BP
  • Weight
  • Abnormal bleeding
73
Q

How would you manage/prevent osteoporosis in someone going through the menopause?

A
  • Calcium supplementation
  • Vit D supplementation
  • Bisphosphonates
  • Strontium
  • SERMS
74
Q

What should not be used as first line treatment for osteoporosis in menopausal women?

A

HRT - unless treating menopausal symtpoms

75
Q

What are risks fo HRT?

A
  • Increased breast cancer risk
  • Increased endometrial cancer risk
  • Increased ovarian cancer risk
  • Double risk of VTE
  • Increased risk of stroke
76
Q

How long is HRT normally continued for?

A

Ususally 2-3 years - decision to extend beyond this dependent on circumstances. Will be

77
Q

How long should you use contraception after last period?

A

12 months after last period in women > 50

24 months after last period in women <50

78
Q

What should you consider as differential diangosis for someone presenting with features of menopause?

A
  • Pregnancy
  • Hyperthyroidism
  • Hypothyroidism
  • Anorexia
  • Medications
79
Q

What are causes of post-coital bleeding?

A
  • Trauma
  • Ectropian
  • Cervicitis
  • Cervical/endometrial polyp
  • Cervical cancer
  • Vaginitis
  • Vaginal cancer
  • Vulval dermatitis
  • Vulval cancer
  • STI’s - gonorrhoea, chlamydia
80
Q

What are causes of intermenstrual bleeding?

A
  • Physiological
  • Trauma
  • Ovarian tumour
  • Uterus - endometritis/PID, polyp, hyperplasia, fibroids, cancer
  • Cervix - cervicitis, polyp, cancer
  • Vagina - vaginitis, cancer
  • Vulva - dermatitis, dystrophy, cancer
  • Pregnancy - miscarriage, ectopic, molar pregnancy
  • Systemic - bleeding disorder, metastatic cancer
  • Iatrogenic - IUCD, HRT, POP, depoprovera
  • STI’s - gonorrhoea, chlamydia
  • Bleeding from somewhere else - urethra, bladder, anus, rectum
81
Q

Causes of menstrual problems

A

PERIODS

  • PID
  • Endometriosis
  • Really bad hypothyroidism
  • IUD
  • Ovarian cancer
  • DUB
  • Submucosal fibroids

FIGO classificaiton

  • Polyp
  • Adenomyosis
  • Eliomyoma
  • Malignancy
  • Coagulation eg von willebrands
  • Ovarian - PCO
  • Endocrine - thyroid
  • Iatrogenic eg warfarin
  • Not yet classified
82
Q

What is dysfunctional uterine bleeding?

A

Abnormal uterine bleeding without any obvious structural or systemic pathology

Note that 50% of hysterectomies for menorrhagia are for DUB

83
Q

Risk factors for osteoporosis

A

“SHATTERED”

Steroid use

Hyperthyroidism/hyperparathyroidism

Alcohol/smoking

Thin (BMI <22)

Testosterone reduction

Early menopause

Renal/liver fialure

Erosive/inflammatory disease eg RA

Dietary/malabsorption (calcium and vit D)

84
Q

Most common sites of osteoporotic fractures

A

Distal radius (wrist or colles’)

Neck of femur

Neck of radius

Vertebrae

85
Q

Medical management of osteoporosis

A

Weight bearing exercise

Adequate calcium and vit D

Bisphosphonates

HRT

86
Q

What’s andropause?

A

Menopause in men lol

Testosterone falls by 1% a year after a 30

DHEAS falls - fertility remains.

Leads to depression, loss of sex drive, erectile dysfunction and muscle mass

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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