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Obstetrics and Gynaecology > Menstruation > Flashcards

Menstruation Flashcards

1
Q

What is dysmenorrhoea?

A

Excessive pain during menstrual period

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2
Q

How does dysmenorrhoea commonly present?

A

Lower abdominal or pelvic pain

Radiate to pelvis and thighs

+ malaise, nausea, vomiting, dizziness, diarrhoea

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3
Q

What investigations would you request for dysmenorrhoea?

A

High vaginal and endocervical swabs - infection?
Transvaginal USS - if masses on examination
Speculum exam
Cervical smear - if nearly due
Pelvic USS

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4
Q

Compare the pain in primary vs secondary dysmenorrhoea

A

primary: Pain at onset of menses. Often within first 2 years of menarche
secondary: Pain precede start of menses by days. Occur years after menarche

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5
Q

What can cause secondary dysmenorrhoea?

How is it managed in primary care?

A 
Endometriosis
Adenomyosis
PID
Adhesions
Fibroids
Non-gynae such as IBD and IBS

Refer all to gynae for investigation

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6
Q

What is primary dysmenorrhoea?

A

Pain in absence of any underlying pelvic disorder -

Diagnosis of exclusion

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7
Q

What causes primary dysmenorrhoea?

A

Excess release of prostaglandins from endometrial cells:

  • Spiral artery vasospasm
  • Increase myocetrial contractions
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8
Q

What are the risk factors for primary dysmenorrhoea?

A

Early menarche
Heavy periods
Smoking
Nullparity

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9
Q

How is primary dysmenorrhoea managed?

A

Stop smoking, TENS, heat

  1. NSAIDs (inhibit prostaglandin production)
    - mefenamic acid and naproxen
  2. Hormones: Monophasic use of COCP, IUS
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10
Q

How is primary amenorrhoea defined?

A

Menses not occurred by:
14 - absence of any secondary sexual characteristics
16 - other secondary sexual characteristics developing normally

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11
Q

How is secondary amenorrhoea defined?

A

Menstruation occurred before but has stopped for 6 successive months

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12
Q

What is oligomenorrhoea?

A

Irregular periods with intervals between cycles of >35 days or <9 periods in a year

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13
Q

What is a good way of categorising differentials of amenorrhoea?

A 
Hypothalamic - low GnRH
Pituitary
Ovarian
Genital tract
Other
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14
Q

What are some causes for reduced GnRH i.e. hypothalamic amenorrhoea?

A

Secondary:

  • Eating disorders
  • Severe chronic conditions - thyroid

Primary:
- Kallmann syndrome (poor smell and hearing)

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15
Q

What pituitary issues can lead to amenorrhoea?

A

All secondary:

  • Prolactinomas - prolactin suppress GnRH
  • Other pituitary tumours - mass effect
  • Sheehan’s syndrome - blood loss in childbirth
  • Prolonged contraceptive use - down regulate pituitary
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16
Q

What ovarian issues can cause amenorrhoea?

A

Secondary:

  • PCOS
  • Premature ovarian failure

Primary:
- Turner’s syndrome

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17
Q

How is premature ovarian failure characterised?

A

Amenorrhoea + raised gonadotrophins (FSH and LH) before 40

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18
Q

What conditions affecting the genital tract can cause amenorrhoea?

A

Secondary: Ashermann’s syndrome - intrauterine adhesions following uterine surgery

Primary: Mechanical obstruction - imperforate hymen

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19
Q

What are the other causes of amenorrhoea?

A

Secondary:
- Pregnancy

Primary:

  • Congenital adrenal hyperplasia
  • Constitutional delay
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20
Q

What are the primary causes of amenorrhoea?

A 
Congenital adrenal hyperplasia
Constitutional delay
Mechanical obstruction
Turners syndrome
Kallmann syndrome
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21
Q

What questions do you need to ask in a history about amenorrhoea?

A 
Full menstrual history
Poss. of pregnancy
Galactorrhoea
Vasomotor symptoms 
Acne, hirsutism, balding
Exercise and eating habits
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22
Q

What investigations would you request for a women with amenorrhoea?

A 
FSH and LH
Total Testosterone
BMI
Pregnancy test
Prolactin
Thyroid function
Pelvic USS
Sex hormone binding globulin
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23
Q

What would a raised FSH and LH in the context of amenorrhoea indicate?

A

Ovarian failure

Turner’s

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24
Q

What would a normal to low FSH and LH in the context of amenorrhoea indicate?

A

Constitutional delay

Hypothalamic cause

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25
Q

What may a raised total testosterone in amenorrhoea indicate?

A

Congenital adrenal hyperplasia

PCOS

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26
Q

What would an a)low and b)raised sex hormone binding globulin in amenorrhoea indicate?

A

Low - contraceptive pill

Raised - obesity

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27
Q

How can amenorrhoea be managed?

A

COCP or POP - regulate periods

Hormone replacement with vitamin D and calcium if ovarian failure

Weight management

Metformin - PCOS

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28
Q

Define menorrhagia

A

Excessive menstrual loss that interferes with the women’s daily living

29
Q

What is the average blood loss in a menstrual cycle?

A

30-40ml

30
Q

What can cause menorrhagia?

A

Anovulatory cycles
Structural issues - fibroid, polyp, adenomyosis
Systemic conditions - hypothyroidism, clotting disorder
Copper coil
PID
Malignancy

31
Q

How would you assess a woman with menorrhagia?

A

FBC - anaemia
TV USS - palpable mass, dysmenorrhoea, intermenstrual bleeding, treatment failure

+/- Abdominal exam - masses
+/- Pelvic exam
+/- Speculum exam

32
Q

What is dysfunctional uterine bleeding?

A

Menorrhagia which can’t be attributed to specific cause

50% of cases

33
Q

How is menorrhagia managed?

A

Do not need contraception?
Mefenamic acid or TXA

Need contraception?

  1. Mirena IUS
  2. COCP
  3. long acting progesterone e.g. depo-provera
34
Q

What are the surgical management options for menorrhagia?

A

Endometrial ablation

Hysterectomy

35
Q

What is menopause?

A

Permanent cessation of menstruation

36
Q

What is the average age of menopause?

A

51 yo

37
Q

When is menopause diagnosed?

A

12 months of amenorrhoea

38
Q

How long do menopausal symptoms normally last?

A

7 years

39
Q

What is climacteric/perimenopause?

A

Period prior to menopause where women experience symptoms such as ovarian function start to fail

From age 45

40
Q

What hormonal changes occur in menopause?

A

!!Reduction in follicle!! number - also less inhibin
Decrease in available binding sites
!!Reduced sensitivity!! of ovary to circulating LH and FSH
!!Reduced oestrogen secretion!!
Negative feedback reduced
Circulating LH and !!FSH increase!!

41
Q

How is menopause diagnosed?

A

Clinical diagnosis - hormone levels not normally necessary

Raised FSH not diagnostic but indicate reduced ovarian response

Investigate differentials

42
Q

How long do women need to use contraception around menopause?

A

<50 yeas old = 2 years after last period

>50 years old = 1 year after last period

43
Q

What are some psychological symptoms associated with menopause?

A 
Dizzy
Interrupted sleep
Anxiety
Poor memory/concentration
Depressive mood
Irritable
Reduced libido
44
Q

What happens to menstruation in menopause?

A

Abnormal cycle length - could be shorter or longer

Oestrogen breakthrough bleeding

45
Q

What changes are seen in the vagina in menopause?

A

Dryness

Painful intercourse

46
Q

What urinary symptoms may be present in menopause?

A

Incontinence
Urgency

Atrophy - share embryological origin with vagina so affected by low oestrogen

47
Q

What musculoskeletal problems may women suffer from in menopause?

A

Joint soreness
Joint stiffness
Back pain

48
Q

What skin changes are seen in menopause?

A 
Hot flush - spread from face down to neck and chest
Dry
Itching
Thinning
Tingling
49
Q

How do breasts change in menopause?

A

Enlargement

Pain

50
Q

What are some systemic symptoms of menopause?

A

Weight gain

Night sweats

51
Q

Why can you get breakthrough bleeding in menopause?

A

Progesterone req. to support endometrium

If no ovulation then endometrial lining break down

52
Q

What diseases are associated with menopause?

A

Vascular - ischaemic heart disease, stroke, peripheral artery disease
Osteoporosis
Alzheimers

53
Q

Why is menopause associated with IHD, stroke and peripheral artery disease?

A

Oestrogen lower LDL and raise HDL

Redistribution of body fat to abdomen

54
Q

How is menopause managed?

A

Lifestyle modification

HRT

55
Q

What lifestyle changes can be made to help reduce menopause symptoms?

A

Stop smoking
Reduce alcohol and caffeine intake
Regular exercise and weight loss
Calcium supplements

56
Q

How are vasomotor symptoms of menopause managed?

A

fluoxetine

or citalopram or clonidine

57
Q

How are psychological symptoms of menopause managed?

A

HRT and CBT

58
Q

How is a low sexual desire in menopause managed?

A

HRT

Testosterone supplementation

59
Q

How is vaginal dryness in menopause managed?

A

Lubrication

Estriol (vaginal oestrogen)

60
Q

Who is HRT used in?

A

Menopausal women where benefits will outweigh risks

61
Q

What are the types of HRT?

A

Oestrogen and progesterone or oestrogen alone

Cyclical (progesterone for last 14 days) or continuous

Oral or transdermal

62
Q

What must women with a uterus who request only oestrogen replacement therapy also have?

A

Mirena coil to provide progesterone

63
Q

What are the side effects of HRT?

A

Erratic bleeding for first 3 months

Progesterone - fluid retention, weight gain, mood swings, pelvic pain

Oestrogen - breast tenderness, leg cramps, bloating

64
Q

What are the risks of HRT?

A

VTE - much higher risk if combined and oral. Reduced risk with transdermal patch

Breast cancer - much higher risk if combined and continual not cyclical

Stroke

Endometrial cancer - oestrogen only

Ovarian cancer

IHD

65
Q

How is HRT stopped?

A

Gradually reduced or stopped immediately

If stopped immediately, may get short term symptom recurrence

66
Q

What are the cautions and contraindications for HRT?

A

Breast cancer

Oestrogen sensitive cancers

Undiagnosed vaginal bleeding

Untreated endometrial hyperplasia

67
Q

What are the benefits of HRT?

A

Improved symptoms - esp. vasomotor, mood and urogenital

Reduced risk of CVD and osteoporosis

Reduced risk of colorectal cancer

68
Q

In perimenopausal women would you use cyclical or continuous HRT preparations? Why?

A

Use cyclical as they get a predictable withdrawal bleed whereas in continuous they get unpredictable bleeds

Obstetrics and Gynaecology (21 decks)

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