Menstruation Flashcards
What hormones are responsible for:
- endometrial proliferation of the stromal cells and elongation of the glands ~day 13
- endometrial secretory changes (enlarged cells, swollen glands and increased vascularity) ~day 21
- what happens to cause shedding of endometrium and myometrial contraction?
- oestrogen causes the proliferation
- relatively more progesterone (from CL) causes the secretory changes
- the failure of CL -> withdrawal of hormonal support leading to shedding
PALM COEIN is an acronym to remember the 9 main categories of AUB (abnormal uterine bleeding)
PALM = structural causes
COEIN = non-structural causes
-name as many structural as poos:
P: Polyps
A: Adenomyosis
L: Leiomyomas (fibroids)
M: Malignancy/Hyperplasia
PALM COEIN is an acronym to remember the 9 main categories of AUB (abnormal uterine bleeding)
PALM = structural causes
COEIN = non-structural causes
-name as many non-structural as poos:
C: Coagulopathy O: Ovulatory Dysfunction E: Endometrial (primary disorder of local endometrial haemostasis regulation) I: Iatrogenic N: not yet specified
Irregular menstrual bleeding is defined as cycle-cycle variation of > how many days?
> 20 days
Amenorrhoea is defined as no bleeding in a how many month interval?
> 6 months
What is the normal frequency of menstrual bleeding? (either side of which would be termed infrequent/frequent MB)
clue: range covers 14days
-normal is every 24-38days
What is the normal duration for a period to last either side of which is referred to as either prolonged or shortened?
-normal 3-8days
Bleeding >1yr after the acknowledged menopause is “post-menopausal bleeding”.
On the other hand, at what age is bleeding termed “precocious menstruation”?
-bleeding before the age of 9yrs
Suggest 2 common causes of heavy menstrual bleeding:
- uterine fibroids
- polyps
- abnormalities of endometrial haemostasis
- thyroid disease
- coagulopathy
A family/personal hx of excessive post-insult bleeding/easy bruising in a women presenting with heavy menstrual bleeding may be suggestive of what?
-a coagulopathy such as von Willebrand’s disease
In the investigation of heavy menstrual bleeding,
- irregular enlargement of the uterus suggests ______
- adenomyosis is suggested by what? (with or without enlargement)
- enlarged -> fibroids
- adenomyosis -> tenderness
What addition to TVUS can be given to improve dx of intrauterine pathology e.g. polyps, submucosal fibroids..
-addition of 5-15ml of saline through cervix into uterus “saline ultrasound”
State 3 risk factors for endometrial cancer in younger women:
clue: history of which conditions predisposes this risk?
- obesity
- diabetes
- nulliparity
- history of PCOS
- family hx of HNPCC (non-polyposis CRC)
The pathway for management of heavy menstruation varies if women is trying to conceive or not, what are the 2 options initially in these cases?
-what will have been investigated and excluded first?
- tranexamic acid / NSAIDs
- progestogen IUS
- will have excluded: anaemia, local causes, malignancy and systemic causes
If the following fails to control heavy menstruation what approach is adopted?
- tranexamic acid / NSAIDs
- progestogen IUS
- SURGERY
- hysteroscopic or if not conceiving, hysterectomy
What class of medications does transexamic acid belong to? -NB: they are taken during menstruation only and reduce blood loss by ~50%
-anti-fibrinolytics
What is the mechanism by which NSAIDs work and are able to reduce blood loss by ~30% in women with HMB?
e.g. mefenamic acid
-inhibit prostaglandin synthesis
Myomectomy (removal of fibroids from myometrium) is done to remove fibroids when fertility is still desired.
Name 1 medication that can be given pre-operatively to reduce the size of the fibroids?
- GnRH Agonists
- or Ulipristal Acetate
Suggest 3 reasons to do an endometrial biopsy (usually with Pipelle):
- age >40yrs
- HMB with intermenstrual bleeding
- RFs for endometrial cancer
- HMB unresponsive to medical therapy
- if US suggests polyp or focal endometrial thickening
- prior to endometrial ablation (tissue wont be available for pathology)
- if AUB has resulted in acute admission
Give 3 causes of irregular/intermenstrual bleeding
- fibroids
- uterine/cervical polyps
- adenomyosis
- ovarian cysts
- chronic pelvic infection
- malignancy
Suggest 3 investigations for irregular menstrual bleeding:
- speculum exam (may reveal cervical polyp)
- check Hb
- exclude malignancy (TVUS)
- may do cervical smear
- endometrial biopsy
Give 2 pathological causes of secondary a/oligo-menorrhoea:
NB: physiolog inc: pregnancy, lactation, menopause, drug-related
- PCOS
- premature menopause
- hyperprolactinaemia
- hypo/hyper-thyroidism
- adrenal tumours
- cervical stenosis
Hypothalamic hypogonadism is a common cause of infrequent menstrual periods, what factors may lead to this?
-low weight/anorexia
-excessive exercise
(rarely tumours)
What is hyperprolactinaemia treated with (usually caused by pituitary hyperplasia or adenomas)
- DA agonists: e.g. Bromocriptine, -Cabergoline
- surgery
Post-coital bleeding (other than 1st time) is always abnormal.
What must you exclude?
What are common causes? name2
- exclude cervical carcinoma
- causes: cervical ectropions, benign polpys, cervicitis, vaginitis
How is polyps and how are ectropions causing post-coital bleeding managed?
- polyps are avulsed and sent for histology
- ectropions can be frozen w cryotherapy
why must precocious puberty be treated by arresting sexual development? What medication is used to achieve this?
- to allow normal growth (growth spurt will occur early with early fusion of epiphysis so shorter height reached)
- give GnRH agonists to inhibit sex hormone secretion
State 2 fts of McCune-Albright syndrome
-treated with c_____ a_____
- bone cysts, ovarian cysts, cafe au lait spots, precocious puberty
- cyproterone acetate
What is the pattern of inheritance of congenital adrenal hyperplasia (CAH)?
-Autosomal Recessive
