Menstruation

Question 1

Describe pubertal development in girls?

Answer 1

Breast buds
Growth of pubic hair
Axillary hair
Menarche - menses begin

Starts at 8 years

Menarche from 10 year onwards

Question 2

What are risk factors for early menarche?

Answer 2

Low birth weight
African
Short and overweight in childhood
Urban environment

Question 3

When should delayed puberty be investigated?

Answer 3

No periods by 16

No signs of puberty by 14

Question 4

How is the menstrual cycle controlled?

Answer 4

Hypothalamus-pituitary-ovarian axis

Pulstaile release of GnRH from the hypothalamus
Stimulate anterior pituitary to produce gonadotrophs: FSH and LH
FSH/LH stimulate ovary to produce oestrogen and progesterone
Ovarian hormones modulate the production of FSH/LH by feeding back on hypothalamus/pituitary

Question 5

Describe the hormonal changes in the menstrual cycle.

Answer 5

1-4: FSH levels high

• Stimulates development of primary ovarian follicle
• Follicle produces oestrogen

5-10:

• Oestrogen stimulate development of glandular proliferative endometrium and cervical mucus receptive to sperm - stringy and clear
• Oestrogen contrails FSH/LH by negative and positive feedback

14:

• Oestrogen levels high enough to stimulate LH surge
• LH surge stimulates ovulation
• Primary follicle releases ovum and forms corpus lute
• Corpus luteum produces progesterone

14-28

• Progesterone prepares endometrial lining for implantation
• Glands become convoluted (Secretory phase)
• Cervical mucus becomes viscid and hostile to sperm and is no longer stringy and clear

Menses:

• If ovum is not ferilised, corpus luteum breaks down so hormonal levels fall
• This allows FSH to rise, restarting the cycle
• Hormone leve fall causes spiral arteries in uterine endothelial lining to constrict and lining sloughs - menstruation

Question 6

What is menstruation?

Answer 6

Loss of blood and uterine epithelial slough
Lasts 2-7 days
Usually heaviest at beginning

Normal loss is 20-80ml

Question 7

What happens in menopause?

Answer 7

Ovaries fail to develop follicles
Without hormonal feedback from the ovaries, gonadotrophin levels rise
Periods cease

Question 8

How can menstruation be postponed?

Answer 8

Norethisterone from 3 days before period is due until bleeding is acceptable
Or take 2 packets of COCP without break

Question 9

What is primary amenorrhoea?

Answer 9

Failure to start menstruating

Needs investigation in 16yo or in 14yo who has no breast development

Question 10

What is secondary amenorrhoea?

Answer 10

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

Question 11

What are causes of primary amenorrhoea?

Answer 11

Turner's syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Malformation of genital tract
Imperforate hymen

Question 12

What are causes of secondary amenorrhoea?

Answer 12

Hypothalamic amenorrhoea (stress, excessive exercise)
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis/hypothyroidism
Sheehan’s syndrome (postpartum pituitary gland necrosis due to hypovolaemia and blood loss at pregnancy)
Asherman’s syndrome (intrauterine adhesions)

Question 13

Who develops ovarian insufficiency/failure?

Answer 13

Secondary to chemotherapy, radiotherapy, surgery

Genetic disorders - Turner’s syndorme

Question 14

What investigations in amenorrhoea?

Answer 14

Exclude pregnancy with urinary or serum hCG
Gonadotrophin: low levels indicate hypothalamic cause, raised levels suggest ovarian problem
Prolactin
Androgen levels - raised in PCOS
Oestradiol
TFT

Question 15

What is oligomenorrhoea?

Answer 15

Infrequent periods
Common at extremes of reproductive life when regular ovulation does not occur
Menstrual cycles in adolescents are typically < 45 days even in 1st year

Question 16

What is dysmenorrhoea?

Answer 16

Painful periods ± N/V

Question 17

What is primary dysmenorrhoea? Pain? Cause?

Answer 17

Pain without underlying organ pathology
Often sorting with anovulatory cycles after the menarche

Crampy with ache in back or suprapubic groin, worse during first day or two

Excess prostaglandins cause painful uterine contraction, producing ischaemic pain

Question 18

What is management for primary dysmenorrhoea?

Answer 18

NSAIDs: inhibit prostaglandin production
e.g. mefenamic acid during menstruation to reduce contractions and pain
Paracetamol
COCP second line

Question 19

What is secondary dysmenorrhoea?

Answer 19

Associated pathology

More constant through period
Associated with depression dyspareunia
Develops many years after menarche

Pain starts 3-4 days before onset of period

Question 20

What are causes of secondary dysmenorrhoea?

Answer 20

Endometriosis
Adenomyosis
Fibroids
Pelvic inflammatory disease

IUCD increase dysmenorrhoea (not Mirena)

Question 21

What is intermenstrual bleeding

Answer 21

May follow a mid cycle fall in oestrogen production

Question 22

What are causes of intermenstrual bleeding?

Answer 22

Cervical polyps
Cervical ectropion
Carcinoma
Cervicitis/vaginitis
Hormonal contraception
IUCD
Chlamydia
Preganncy related

Question 23

What are causes of post-coital bleeding?

Answer 23

Cervicial ectropion - more common in women on COCP
Cervicitis e.g. secondary to chlamydia
Cervical trauma
Polyps
Cervical carcinoma

Screen for chlamydia and treat
Refer all with persistent bleeding

Question 24

What is post-menopausal bleeding? Causes?

Answer 24

Occuring > 1 year after the last period
Endometrial cancer until proven other wise

Other causes: 
Atrophic Vaginitis
Foreign bodes
HRT - periods or spotting in some women taking HRT
Endometrial hyperplasia due to long-term oestrogen therapy
Carcinoma of cervix or vulva
Endometrial or cervical polyps
Oestrogen withdrawal

Question 25

What investigation for PMB?

Answer 25

Two week wait TVUSS for endometrial cancer - endometrial depth <5mm is acceptable >4mm - endometrial biopsy during hysteroscopy
CT Pelvis and abdomen