Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gyneacology > Menstruation > Flashcards

Menstruation Flashcards

1
Q

What is the first phase of the menstrual cycle

A

Follicular/proliferative: Oestrogen dominant
Hypothalamus secretes GnRH, anterior pituitary secretes FSH and LH
FSH matures several primary follicles into secondary follicles (with theca and granulosa cells)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What do theca cells do

A

Theca cells produce testosterone which is aromatised to oestrogen in the granulosa
This thickens the endometrium by proliferation of basal cells and thins the cervical mucus
Oestrogen also supresses FSH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the second phase of the menstrual cycle

A

Luteal/secretory phase: Progesterone dominant

Follicle that has just released an oocyte undergoes lutenisation to form CL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What does the corpus luteum do?

A

Secretes oestrogen and progesterone, with progesterone causing a secretory change in the endometrium
Negative feedback then occurs to lower LH and FSH levels in response to high progesterone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What happens if fertilisation has occurred?

A

It is signalled back to the ovary by the release of hCG, maintaining the corpus luteum
CL continues to secrete progesterone until the placenta takes over progesterone production
CL degenerates into Corpus Albicans at this point

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What happens if fertilisation has not occurred

A

If after around 12 days there has been no hCG production from the embryo, luteolysis occurs (degradation of corpus luteum into corpus albicans)
Progesterone and oestrogen levels fall
Menstruation results

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How does the menstruation (period) come about?

A

Shedding occurs due to ischaemia as there is spasm of the spiral arterioles supplying it
PGE causes vasoconstriction and PGF causes vasodilation
Fibrinolysis degrades fibrinogen to prevent clotting and ensures loss of the endometrium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How is primary amenorrhoea defined?

A

Menarche should occur before the age of 16, where this does not occur it is known as primary amenorrhoea (or 14 without additional secondary sexual characteristics)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Causes of delayed menarche?

A

Always exclude pregnancy
Other common cause is constitutional (diagnosis of exclusion)
Isolated delayed menarche with other normal features indicates an anatomical problem: imperforate hymen, vaginal agenesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Causes of delayed menarche where other features of puberty are affected?

A

Low gonadotrophin secretion: physiological stress (over-exercise, low weight, chronic disease), prolactinomas
High gonadotroph secretion: Turner’s syndrome, acquired gonadal damage, gonadal dysgenesis, steroid hormone enzyme deficiencies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How is secondary amenorrhoea defined?

A

Secondary amenorrhoea is absence of menstruation for 6 months
- Physiological causes include pregnancy, lactation, and menopause. Always exclude pregnancy
Other causes are similar to primary amenorrhoea; excluding chromosomal causes and gonadal dysgenesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Causes of post coital bleeding

A
  • Infection
  • Cervical ectropion
    o This is where there is eversion of the cervical canal under the influence of oestrogen
    o The COC is a risk factor for this, alongside pregnancy and puberty
    o It can occasionally present with bleeding and/or excessive discharge, but is normally asymptomatic
    o Management options include stopping the COCP, if ectropion persists there can be cautery
  • Benign growths e.g. cervical and endometrial polyps
  • Malignancy of the vagina or cervix
  • Trauma e.g. coital laceration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Causes of intermenstrual bleeding

A

Vaginal causes: Vaginitis, malignant tumours
Cervical causes: Infection (TV, chlamydia, gonorrhoea), malignant tumours, ectropion, polyps
Uterine causes: Fibroids, polyps, malignant tumours, endometritis, adenomyosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How is menorrhagia defined?

A

Blood loss more than 80mls

Blood loss that interferes with a woman’s quality of life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is dysfunctional uterine bleeding

A

Abnormal uterine bleeding without any obvious pathology, usually presenting as menorrhagia, this is a diagnosis of exclusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Causes of menorrhagia

A 
Local causes:
benign/malignant tumours
PID
Endometriosis 
Systemic causes:
Thyroid disease
vWD
ITP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Key features to explore in a history of menorrhagia

A

Duration of bleeding and how much of that time it is heavy
Heavy flow: passage of clots, simultaneous use of tampons and towels
Symptoms of anaemia
Symptoms of clotting disorders e.g. bruising, bleeding gums
Sudden change in blood loss, intermenstrual and post-coital bleeding
Local pressure effects and pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Investigating menorrhagia

A 
FBC
TFTs (generally not recommended)
Clotting (look at platelets first)
Transvaginal USS
All women should have a cervical smear if due
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are fibroids

A

Also known as leiomyomata
Commonest tumour of the female genital tract
Typically occur if women under 35

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Types of fibroids

A

Intramural-within uterine wall
Subserous project from peritoneal surface
Submucous project from uterine cavity
Intraligamentary-between layers of the broad ligament
Most are asymptomatic, however some women will present with menorrhagia and local pressure effectsq

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Investigations for fibroids

A

All should have a pregnancy test and FBC

TVUS

22
Q

Complications of fibroids

A

Subfertility
Complications on pregnancy- preterm labour, obstructed labour
Hyaline degeneration-painful enlarged soft fibroids
Red degeneration-occurs in pregnancy due to infarction of the fibroid
Calcification of fibroids-post menopausal women
Sarcomatous change to malignancy-rare
Infection leading to abscess

23
Q

Management of fibroids

A

Anti-fibrinolytic agents
Hormonal contraceptives e.g. COCP, IUS
Progesterone receptor inhibitors, GnRH agonists
Surgical management indicated where there are pressure symptoms or medical management has not worked
Hysterectomy is definitive
Myomectomy in patients who wish to preserve their fertility
Uterine artery embolization

24
Q

Anovular Dysfunctional Uterine Bleeding

A

Prolonged irregular cycle-many days of bleeding following 6-8 weeks of amenorrhoea
Bleeding is heavy and persistent until the end of cycle often with clots
Occurs due to failure of ovulation resulting in excessive oestrogen production from unruptured follicle leading to endometrial hyperplasia
Manage with progestogens in 2nd half of the cycle -noresthhisterone from day5 to day26

25
Q

Ovular Dysfunctional Uterine Bleeding

A

Commoner than anovular
Failure of spiral artery constriction and prostaglandin dysfunction
Patient who needs contraception alongside treatment use the COC or mirena coil
If patient doesn’t require then use mefenamic acid and tranexamic acid
Surgical therapy will cause fertility loss but include endometrial ablation and hysterectomy

26
Q

Dysmenorrhoea

A

Low anterior pelvic pain occurring in association with periods
Key features to explore in a history of a patient with dysmenorrhoea include
- Length and regularity of cycle, including duration of bleeding
- Timing of pain in relation to period, location of pain
- Vaginal discharge, intermenstrual bleeding, dyspareunia, rectal pain or bleeding
It may be indicated to perform an abdominal, vaginal and/or speculum examination. Common investigations include STI screen and USS

27
Q

Primary dysmenorrhoae

A

Primary dysmenorrhoea develops soon after menarche, no organic or psychological cause can be found
- It is thought to be due to the local release of prostaglandins resulting in uterine spasm and colicky abdominal pain
- Pain usually begins with the onset of the period and lasts for 24 – 72 hours
Management centres around reassurance of patients, usually the symptoms will improve with age or following pregnancy. There are some treatment options however
- Smoking cessation should be advised where appropriate
- Simple analgesia, particularly with NSAIDs
- Prostaglandin synthetase inhibitors e.g. mefenamic acid 500mg TDS
- COC to suppress ovulation

28
Q

Secondary Dysmenorrhoea

A

Painful periods for which an organic or psychosexual cause is demonstrated
This typically commences several years after menarche
- The pain usually begins several days before menses and can last for the whole period
There are several common causes
- Endometriosis
- Adenomyosis
- Chronic PID
- Pelvic adhesions, including Asherman’s syndrome

29
Q

What is endometriosis

A

oestrogen-dependent condition, characterised by the growth of endometrial tissues outside of the uterine cavity
- Common sites include pelvic peritoneum (uterosacral ligaments, pouch of Douglas, rectosigmoid colon), ovary (endometriomas/ chocolate cysts), fallopian tubes
o Stage and extent of disease does not correlate with symptom severity
This condition typically affects nulliparous women, generally between 30 – 40 years’ old.

30
Q

Aetiology of endometriosis

A

This condition typically affects nulliparous women, generally between 30 – 40 years’ old. The aetiology is unknown, but there are several theories

  • Retrograde menstruation with adherence, invasion and growth of the tissue is the most popular theory
  • Other causes include mechanical transplantation of tissue at time of surgery, venous/lymphatic ‘metastasis’, immunological factors
31
Q

How does endometriosis present

A

Clinical presentation is variable, but typical features include dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and subfertility
- Menses are often heavy and irregular
- Other symptoms can include bloating, lethargy, low back pain, and rectal bleeding
Diagnosis is highly suggested by the presence of tender nodules on the uterosacral ligaments at bimanual examination. Other features on examination include bluish haemorrhagic nodules visible in the posterior fornix

32
Q

How do you investigate endometriosis

A

Key investigations should take place to exclude differential diagnoses. This can include routine blood tests, urinalysis and MC&S, and cervical swabs
For a definitive diagnosis of endometriosis, laparoscopy (with histological biopsy) is the gold standard investigation
- Transvaginal USS (and MRI, but not as first line) can also be used as they can demonstrate ovarian endometrioma and subperitoneal deposits of tissue (extensive disease), but will not identify stage I/II disease
- Laparoscopy is usually only indicated in resistant cases where there is therapeutic intention, or as part of infertility investigation

33
Q

Medical Management of Endometriosis

A

Treatment of endometriosis is on an individual basis dependent on the nature of symptoms, severity of symptoms, and desire for future fertility
- Simple analgesics are best if symptoms are mild, NSAIDs seem to be most effective
In younger women wishing to preserve fertility, the best option is hormonal treatment to supress ovarian function as a trial for 6 – 9 months. This should be continued indefinitely (until the patient wishes to conceive) if it is effective.
- COC/ POP used continuously to induce amenorrhoea
- Danazol is an alternative, however this is associated with virilisation in some
- GnRH agonists such as zoladex and gestrinone can also be used

34
Q

Surgical Management of Endometriosis

A

Surgical management can include CO2 laser vaporisation or diathermy of small deposits; however these have a risk of disease recurrence. Surgical intervention should only occur in patients that have been demonstrated to be sub-fertile

  • Large cysts and deposits require excision
  • Hysterectomy and BSO may be required, and is usually reserved as a last resort
35
Q

Adenomyosis

A

Adenomyosis is endometrial tissue found deep in uterine muscle (myometrium). This typically occurs in older, multiparous women
- It presents with increasing severe menorrhagia, secondary dysmenorrhoea, and a gradually enlarging tender uterus
Diagnosis requires histology, and therefore is usually made clinically and confirmed following hysterectomy

36
Q

Menopause

A

The menopause is a natural phenomenon that results in the end of the fertile period for women
- As the finite number of ovarian follicles becomes depleted, oestrogen and progesterone levels fall. Negative feedback increases LH and FSH levels in response
- These hormonal changes result in erratic menstruation and menopausal symptoms
Women are still potentially fertile for two years after their last menstrual period if <50, and one year if >50. They should be advised to continue contraception for this period.

37
Q

Two stages to menopause

A
  • The climacteric (menopausal transition stage/perimenopause) is the period of change leading up to the last period
    o This generally starts in the mid-to-late 40s
  • The menopause itself is a retrospective diagnosis of the time when menstruation permanently ceases, defined after 12 months’ amenorrhoea
    o This usually occurs between the age of 45 – 55
38
Q

What conditions can post menopausal women become more susceptible to?

A
  • CVD
  • Osteoporosis
  • Urogenital atrophy
  • Alzheimer’s disease
39
Q

How does menopause present?

A

Most women will notice menstrual irregularity, which can include a lengthening or shortening of the cycle as well as an increase in flow
- This can last for up to four years before the cessation of periods
80% of women will experience symptoms of menopause, which may last for over seven years. The combination of different symptoms below may be experienced to different extents, and can be from mild to very severe
- Hot flushes and sweats occur due to a loss of homeostasis by the thermoregulatory centre, often affecting the head and chest
- Urinary and vaginal symptoms occur to a loss of trophic effects of oestrogen
o Dyspareunia, vaginal dryness, UTIs, urinary incontinence
- Sleep disturbance
- Mood changes
- Loss of libido

40
Q

Investigations in Menopause

A

Investigations are not required in healthy women aged >45 with perimenopausal symptoms and irregular periods
- Consider measurement of lipids, and ensure the woman is up to date with her cervical and breast screening
In other women, there may be a need for investigation
- FSH levels are raised in climacteric and menopause (2 consecutive FSH >30 IU/L), but are not diagnostic alone
- TFTs
- Blood glucose

41
Q

Management of Menopause: Non HRT

A
  • SSRIs can be used for vasomotor symptoms, but only have a short acting effect
  • SERMs e.g. tibolone
  • Herbal or complementary therapies can be used, and many women find them effective. It is important to stress to patients that these have not been subject to the same research and regulations as prescribed medications and there may be variability between products
    o Phyto-oestrogens in certain foods and supplements are commonly used e.g. soy, nuts, wholegrains
42
Q

HRT

A

most effective treatment to relieve the symptoms of menopause; particularly vasomotor, vaginal and bladder, and mood symptoms. It also decreases the risk of long-term health problems associated with the menopause
- HRT is recommended in the following situations
o Women with troublesome vasomotor symptoms where the risk:benefit ratio is favourable
o Women with early menopause, until the age of natural menopause (~51)
o Women <60 at risk of osteoporotic fracture in which other treatments are unsuitable

43
Q

Contraindications to HRT

A

o Oestrogen-dependent cancer
o Past VTE
o Undiagnosed PV bleeding
o Raised LFTs

44
Q

Benefits of HRT

A

Reduction in vasomotor symptoms
Improvement in quality of sleep and mood changes
Decreased urinary symptoms and vaginal dryness
Reduced osteoporosis risk
Reduced CVD risk
Reduced colorectal cancer risk (combined only)

45
Q

Riks of HRT

A

VTE
Ischaemic stroke
Endometrial cancer (oestrogen alone)
Breast cancer (returns to baseline after stopping)

46
Q

Personalisation of HRT

A
  • For women who have had a hysterectomy, oestrogen-only HRT is preferred
  • For women with combined HRT there are many options, micronized progesterone is preferred
    o Sequential combined HRT is used where the woman’s LMP was <1 year ago. This involves taking continuous oestrogen, and taking progesterone in two-week cycles
    o Continuous combined HRT is prescribed to other women
47
Q

Different preparations of HRT

A

oral, topical (patches and gels) and local devices (Mirena IUS, oestrogen-releasing vaginal ring)
- Generally, non-oral preparations are preferred as they have less effect on clotting factors

48
Q

Side Effects of HRT

A
  • Fluid retention and bloating, breast tenderness, leg cramps, headaches
  • Continuous combined HRT is associated with breakthrough bleeding for <6 months
49
Q

Prescribing HRT

A

HRT should be prescribed as an initial 3-month trial, followed by annual review

  • Check for side effects
  • Blood pressure and weight
  • Encouragement of self-examination of breasts and attendance at screening
  • Discussion of risk:benefit ratio; trial withdrawal should be suggested when a woman is been asymptomatic for 1 – 2 years, or has been on HRT for >5 years
50
Q

HRT Counselling

A

Take a thorough history, including whether the uterus is intact and to establish the risk factors for osteoporosis, breast cancer, and CVD
- Examination should include BP, height and weight, and other as indicated by history
Discuss risks, benefits, alternative management, side-effects, and the need for contraception

51
Q

Early menopause

A

Early menopause occurs between 40 – 45
- These women are at a higher risk of osteoporosis, CVD, and dementia if they are not given HRT appropriately
Premature ovarian insufficiency is different (<40) and requires investigation

Gyneacology (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions