Menstruation and Abnormalities Flashcards
What is the normal process of menstruation
Process by which the endometrium is discarded each month.
LH, FSH and oestrogen rise during ovulation. Then there is a rise in progesterone. When there is no implantation the hormones drop and the endometrium sheds.
When is emnstrauation investigated?
If it begins before age 8 or after 16
Describe features of heavy menstrual bleeding
It is defined as bleeding which has an adverse impact on a womans QoL
What are the causes of heavy menstrual bleeding?
Uterine pathology - Fibroids, endometrial polyps, adenomyosis, pelvic infection, endometrial malignancy
HMB in the absence of pathology.
Medical disorders - clotting disorders
What is the assessment and investigations of all HMB
History and exam - abdominal and bimanual
Blood testing - Coagulation disorders, FBC and thyroid testing
Biopsy - To exclude endometrial cancer eg, age >45 with treatment failure or ineffective treatment.
Ultrasound - structural abnormalities
What is the pharmacological management of heavy menstrual bleeding
Mefanamic acid and/or TXA (taken during menses).
COCP,
Progesterone contraception,
LNG-IUS
GnRH analogues (switches off FSH and LH release).
Progesterone receptor modulatiors - induces amenorrhoea
What is the surgical management for heavy menstrual bleeding?
Endometrial ablation - Can use heated baloon, bipolar radiofrequency or direct vision with resection. Pregnancy contraindicated post-procedure.
Hysterctomy - Laparoscopic or laparotomy. Amenorrhoea guarenteed
Describe features of primary and secondary amenorrhoea?
Primary - Failure to menstruate by age 15. May have absent secondary sexual characteristics.
Secondary - Menses stop for 6+ months
What is oligomenorrhoea?
Cycle which is persistently greater than 35 days.
What are the causes of amenorrhoea?
Secondary:
Uterine eg, Ashermans syndrome (adhesions)
Ovarian eg, PCOS or premature ovarian failure,
Pituitary eg Prolactinoma or pituitary tumour,
Hypothalamic eg, weight loss, stress, or drugs
Primary:
Genitourinary abnormalities (for example, congenital absence of uterus, cervix or vagina eg Rokitansky syndrome or androgen insensitivity syndrome)
Chromosomal abnormalities, eg turner’s syndrome
Secondary hypogonadism (pituitary cause) eg, Kallmann syndrome, pituitary disease or hypothalamic amenorrhoea.
What are the investigations for amenorrhoea?
History
Examination - look for secondary sexual characteristics and use Tanner staging.
Ix - Plasma FSH, LH, oestradiol, prolactin and TFTs, karyotyping, X-ray for bone age and cranial imaging.
What is the Rotterdam criteria for PCOS?
Diagnosis of PCOS can be made if has two of following in adults and all three in teens:
1. Infrequent or no ovulation,
2. Clinical/biochemical signs of hyperandrogenism
3. Polycystic ovaries on US (>12 follicles sized 2-9mm in one or both ovaries or ovarial voume > 10mm3)
What are the consequences for PCOS?
Reduced fertility,
Insulin resistence and diabetes,
HTN,
Endometrial cancer,
Depression and mood swings,
Snoring and daytime sleepiness
What is the management of PCOS?
Education,
Weight loss and exercise,
Endometrial protection with progesterone,
Fetility awareness,
Lifetime awareness with screening for complications.
Describe features of primary dysmenorrhoea
Typically begins within first 2 years of menarche. Pain most severe on day of/day before start of period.
Treatment - NSAIDs, COC, depot injection, LNG-IUS. If no improvement then consider underlying pathology.
