Menstruation Flashcards
What is menopause
permanent end of menstruation resulting from loss of ovarian follicular activity
* 12 consecutive months of amenorrhea
What is the normal age range for menopause
usually occurs between 45-55
average is 51
What is considered early menopause
before the age of 40
What causes premature menopause
premature ovarian insufficiency
Give 5 perimenopausual symptoms
- vasomotor Sx: hot flushes/ night sweats
- amenorrhoea
- irritability and mood swings
- vaginal dryness
- disturbed sleep
What causes menopause
a lack of ovarian follicular function resulting in:
* low oestrogen and progesterone
* high LH and FSH
What is the perimenopause time period
starts with the first features of approaching menopause and ends 12m after the last period
A lack of oestrogen increases the risk of certain conditions. State 4
- cardiovascular disease
- osteoporosis
- pelvic organ prolapse
- urinary incontinence
When prescribing hormone replacement therapy, what is an important question to ask
if she has a uterus/ has had a hysterectomy
How is postmenopause managed in a woman with a uterus
HRT
* continuous combined regimen: oestrogen + progestogen
* oral / transdermal (estradiol)
When is transdermal HRT offered to woman in menopause
- BMI >30
- risk of gallstones
- high triglycerides
What can be given to woman in menopause with symptoms of vaginal atrophy
- vaginal oestrogen
+/- vaginal moisturiser
How is menopause managed in a woman without a uterus
transdermal/ oral oestrogen (ONLY) therapy
Why are progestogens added to oestrogens when managing menopause
reduce the increased risk of endometrial hyperplasia and carcinoma
How is perimenopause managed in women with a uterus
sequential regimen
* oestrogen and progestogen
* progestogen added for last 10-14d of cycle (monthly bleeds)
* progestogen added for 14d every 13w (3 monthly bleeds)
How are menopausal symptoms managed in women unable to take HRT
- SSRi - paroxetine
- gabapentin
- transdermal clonidine
What are the two phases of the menstrual cycle?
follicular phase and the luteal phase.
What is the follicular phase?
The phase from the start of menstruation to the moment of ovulation (approximately the first 14 days in a 28-day cycle)
What is the luteal phase?
From the moment of ovulation to the start of menstruation (the final 14 days of the cycle)
What marks the start of the menstrual cycle
- first day of menstruation
- endometrium is shed
Describe the follicular phase of the menstrual cycle
- pulses of GnRH from the hypothalamus stimulate LH and FSH release which induce follicular growth
- follicles secrete oestradiol and inhibin which suppress FSH secretion in a ‘negative feedback’
- only one follicle and oocyte mature (dominant follicle)
- dominant follicle continues to secrete oestradiol
- rising oestradiol levels become a +ve feedback signal on hypothalamus and pituitary cause LH levels to rise sharply: ovulation follows 36hrs later
Describe the luteal phase of the menstrual cycle
- after ovulation, the follicle that released the ovum becomes the corpus luteum
- corpus luteum secretes high levels of progesterone and a small amount of oestrogen
- towards the end of the phase, the corpus luteum degenerates and stops producing oestrogen and progesterone
- This fall in oestrogen and progesterone causes the endometrium to break down and menstruation to occur.
Describe the changes to the endometrium during the menstrual cycle
- shedding of the endometrium (menstruation)
- proliferative phase - high oestrogen levels stimulate thickening of the endometrium. cervical mucus more permeable
- secretory phase - cervical mucus thickens. stromal cells release prostaglandins which encourage the endometrium to break down and the uterus to contract
What is abnormal uterine bleeding
any variation from the normal menstrual cycle
* changes in regularity and frequency
* changes in duration of flow
* changes in amount of blood loss
Give 4 structural causes of abnormal uterine bleeding
PALM
* Polyps
* Adenomyosis
* Leiomyomas (fibroids)
* Malignancy and hyperplasia
Give 5 non-structural causes of abnormal uterine bleeding
COEIN
* Coagulopathy
* Ovulatory dysfunction
* Endometrial
* Iatrogenic
* Not yet specified
What is menorrhagia
heavy menstrual bleeding which interferes with the woman’s physical, emotional, social and material quality of life
* blood loss >80mL per cycle
Give 5 causes of menorrhagia
- dysfunctional uterine bleeding (absence of underlying pathology)
- uterine fibroids and polyps
- bleeding disorders ((e.g. Von Willebrand disease)
- PID
- Endometrial/ cervical malignancy
What clinical features of a menorrhagia history would indicate excess blood loss
- flooding
- passage of large clots
How is menorrhagia investigated
- FBC - may show anaemia
- pelvic exam - assess for masses
- transvaginal ultrasound - exclude structural causes
- coagulation/ thyroid testing if Hx indicates it
How is menorrhagia pharmacologically managed when the woman is trying to conceive
- Tranexamic acid
- mefenamic acid (if there’s associated pain)
How is menorrhagia pharmacologically managed when the woman is NOT trying to conceive
- intrauterine system - Mirena first line
- combined oral contraceptive pill
- long-acting progestogens
How is menorrhagia managed if medical management has failed
- referral to secondary care
- endometrial ablation - removal/ destruction of endometrium
- balloon thermal ablation
- hysterectomy - last resort
What is amenorrhoea
absence of menstruation
What is primary amenorrhea
- By 13 years when there is no other evidence of pubertal development
- by 15 years of age in girls with normal secondary sexual characteristics (such as breast development)
Give 5 causes of primary amenorrhoea
- gonadal dysgenesis (e.g. turners syndrome)
- Androgen insensitivity syndrome
- imperforate hymen/ FGM
- congenital adrenal hyperplasia
- constitutional delay
What is secondary amenorrhea
- cessation of menstruation for 3-6 months in women with previously normal and regular menses
or - 6-12 months in women with previous oligomenorrhoea
Give 5 causes of secondary amenorrhea
- Pregnancy
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure and menopause
thyrotoxicosis - Sheehan’s syndrome - severe PPH causing pituitary necrosis)
- Asherman’s syndrome (intrauterine adhesions)
How is amenorrhea investigated
- UPT or serum bHCG - exclude pregnancy
- LH and FSH levels
- prolactin
- FBC, U+Es, TFTs,
- gonadotrophins - secondary: low = hypothalamic cause, high = ovarian problem
How is primary amenorrhea managed
- treat underlying cause
- stress - CBT, healthy weight gain
- Ovarian causes - COCP
- hypopituitarism - pulsatile GnRH or COCP
How is secondary amenorrhea managed
- exclude pregnancy and menopause
- treat underlying cause
What is dysmenorrhea
excessively painful menstruation
What is primary dysmenorrhea
when there is no underlying pelvic pathology
What is thought to be partially responsible for primary dysmenorrhea?
Excessive endometrial prostaglandin production
What are the typical features of primary dysmenorrhea
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
How is primary dysmenorrhea managed
- 1st line: NSAIDs such as mefenamic acid and ibuprofen - They work by inhibiting prostaglandin production
- 2nd line: COCP
What is secondary dysmenorrhea
typically develops many years after the menarche and is the result of an underlying pathology
When does the pain usually start in women with dysmenorrhea
pain usually starts 3-4 days before the onset of the period
Give 4 causes of secondary dysmenorrhea
- fibroids
- adenomyosis
- endometriosis
- pelvic inflammatory disease
What should be done for all patients with secondary dysmenorrhea?
referral to gynaecology for investigation.
What is premenstrual syndrome (PMS)
describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle
Give 4 emotional symptoms of premenstrual syndrome
- anxiety
- stress
- fatigue
- mood swings
Give 3 physical symptoms of premenstrual syndrome
- bloating
- breast pain
- headaches
How is premenstrual syndrome managed
- general lifestyle changes, stress, exercise, alcohol restriction, smoking cessation, sleep etc
- regular, frequent (2-3 hourly), small, balanced meals rich in complex carbs
- COCP ( drospirenone)
- SSRi - continuously or just during the luteal phase
What is premature ovarian insufficiency
defined as menopause before the age of 40 years
characterised by hypergonadotropic hypogonadism
Give 5 causes of premature ovarian sufficiency
- idiopathic - mc
- iatrogenic - radio/ chemotherapy
- autoimmune - T1DM, thyroid etc
- infections - e.g. mumps
- bilateral oophorectomy
How does premature ovarian sufficiency present
- secondary amenorrhea
- hot flushes
- night sweats
- infertility
- vaginal dryness
How is premature ovarian sufficiency diagnosed
- younger than 40 years with typical menopausal symptoms and an elevated FSH (>25 IU/L)
- elevated FSH levels should be demonstrated on 2 consecutive blood samples taken 4-6 weeks apart
- low oestradiol
What conditions are women with premature ovarian failure at higher risk for due to the lack of oestrogen?
- Cardiovascular disease
- Stroke
- Osteoporosis
- Cognitive impairment
- Dementia
- Parkinsonism
How is premature ovarian sufficiency managed
- Traditional HRT or COCP until 51
- should be noted that HRT does not provide contraception
