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Menstruation and Menopause Flashcards

1
Q

How is the menstrual cycle controlled

A

Release of pituitary gonadotrophins, triggered by the hypothalmus - hypothalamic-pituitary-ovarian (HPO) axis
Also changes in ovarian hormones which are controlled by the HPO

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2
Q

Describe the follicular phase of the menstrual cycle

A

FSH released from the pituitary and stimulates the ovarian follicle development and the theca cells to secrete oestrogen
The granulosa cells secrete inhibin
The rise in oestrogen levels and inhibin produced by the developing follicles inhibit production of FSH
Fall in FSH cause atresia off all except the main follicle - dominant follicle
This will most likely be the one with the efficient aromatase activity and highest concentration of FSH-induced LH receptors

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3
Q

Describe ovulation

A

Production of oestrogen increases until it reaches the threshold to exert a positive feedback effort on the hypothalamus and pituitary to cause the LH surge.
The surge of LH from the pituitary triggers ovulation
The dominant follicle ruptures and releases the oocyte - around 12 hours after surge

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4
Q

Describe the luteal phase

A

The corpus luteum forms from the ruptured follicle - theca and granulosa cells
It starts producing progesterone - starts secretory phase of endometrium
If there is no conception and therefore no BHCG release then 14 days later luteolysis occurs and the corpus luteum breaks down

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5
Q

Describe what happens in the proliferative phase of the endometrium

A

The endometrial glands and stroma grow under the influence of oestrogen
It changes from a single layer of columnar cells to a pseudostratified epithelium with frequent mitoses.

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6
Q

Describe what happens in the luteal/secretory phase of the endometrium

A

Glands dilate, grow blood supply and start secreting under influence of progesterone
Decidualisation occurs in the late secretory phase - formation of a specialised glandular epithelium (irreversible)
Apoptosis of this layer occurs if no embryo implantation
Menstruation occurs

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7
Q

What happens to the endometrium during menstruation

A

The arterioles supplying it constrict and the apoptosed functional layer is shed
This is caused by falling hormone levels
Fibrinolysis inhibits clot and scar formation

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8
Q

What is normally lost during menstruation

A

Less than 80ml of blood and should be no clots

usually lasts 4-6 days with peak on day 1 or 2

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9
Q

How long is a normal menstrual cycle

A

The average is 28 days

between 21 and 35 is considered normal

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10
Q

What is meant by flooding

A

Blood leaking out onto clothes/surroundings when wearing sanitary products

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11
Q

What is menorrhagia

A

Prolonged and increased menstrual flow - heavy bleeding (>80ml per period)

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12
Q

What is metrorrhagia

A

Regular intermenstrual bleeding

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13
Q

What is polymenorrhea

A

Menstruation occurring at <21 day intervals

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14
Q

What is polymenorrhagia

A

Increased bleeding and a frequent cycle (<21 days)

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15
Q

What is menometrorrhagia

A

Prolonged menses and intermenstrual bleeding

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16
Q

What is secondary amenorrhea

A

Absence of menstruation for over 6 months in a woman who previously menstruated
Pregnancy is the most common cause

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17
Q

What is oligomenorrhea

A

Menses at intervals of over 35 days OR presence of five or fever menstrual cycles over a year.

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18
Q

If there is no organic cause of menorrhagia what is it called

A

Dysfunctional uterine bleeding

No organic pathology

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19
Q

List some local causes of menorrhagia

A 
Fibroids
Endocervical or Endometrial polyp
Cervical eversion
Endometrial hyperplasia
IUD - copper 
Pelvic inflammatory disease 
Endometriosis
Malignancy of the cervix or uterus
Hormone producing tumours
Trauma
Adenomyosis
Arteriovenous malformation
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20
Q

Which age group is endometrial cancer most commonly seen in

A

Usually only seen in the over 60s

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21
Q

Which age group is more likely to get cervical cancer

A

Younger women

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22
Q

What causes endometriosis

A

Ectopic endometrium out with the uterus
Will be under hormonal influence and bleeds each month
Bleeding leads to inflammation and pain

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23
Q

Which endocrine disorders can cause menorrhagia

A

Hyper/hypothyroidism
Diabetes mellitus
Adrenal disease
Prolactin disorders - more likely to cause amenorrhea

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24
Q

Which drugs can cause menorrhagia

A

Anticoagulants

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25
Q

When might menorrhagia occur as a result of pregnancy

A

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Postpartum haemorrhage

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26
Q

What are the two subtypes of dysfunctional uterine bleeding

A

Anovulatory

Ovulatory

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27
Q

Describe anovulatory dysfunctional uterine bleeding

A

Makes up 85% of DUB cases
Common in the 2 extremes of age – girls just starting periods and women just before the menopause
More common if obese
Will have an irregular cycle

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28
Q

Describe ovulatory dysfunctional uterine bleeding

A

Common in women aged 35-45
Will have regular but heavy periods
Caused by inadequate progesterone production by the corpus luteum

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29
Q

How do you investigate dysfunctional uterine bleeding

A 
Full blood count - looking for anaemia 
Cervical smear - if due 
TSH
Coagulation screen
Renal/Liver function tests
Transvaginal ultrasound scan - look for thickness of endo and for fibroids etc 
Endometiral sampling
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30
Q

List some examples of non-surgical management of dysfunctional uterine bleeding

A

Progestogens- synthetic analogue of progesterone
Combined oral contraceptive pill
GnRH analogues
Anti-fibrinolytics - tranexamic acid; taken during menstruation only
NSAIDs - e.g. mefenamic acid – taken during menstruation only
Mirena IUS
Capillary wall stabilisers

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31
Q

Which type of DUB is well treated with hormonal treatments

A

Irregular cycles

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32
Q

List some of the surgical managements of DUB

A

Endometrial ablation - burn the endometrium to reduce blood flow
Endometrial resection
Hysterectomy - sub-total or total

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33
Q

What is a sub-total hysterectomy

A

You leave the cervix behind and only take top 2/3 of uterus

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34
Q

What is the main contra-indication to surgical treatment of DUB

A

If someone still wants to have kids

Fertility is lost with both ablation and hysterectomy

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35
Q

Do you still need to have smear tests if you’ve had a sub-total hysterectomy

A

YES

The cervix is left behind so could still get cancer

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36
Q

What is the average age of menopause

A

51 years old

Normal from 46-53

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37
Q

What is considered early and premature menopause

A

Early menopause <45yrs

Premature menopause <40yrs

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38
Q

How do you diagnose menopause

A

Only diagnoses after a whole year of amenorrhea

Diagnosed based on symptoms and blood tests for FSH

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39
Q

What is considered late menopause

A

Late menopause >54yrs

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40
Q

What are the physical symptoms of menopause

A 
Hot flushes - 3-5 mins 
Night sweats
Palpitations
Insomnia
Joint aches
Headaches
Dry and itchy skin
Hair changes
Osteoporosis 
Recurrent UTI or urgency 
Most women say this is the worst part
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41
Q

Is a single high FSH diagnostic of the menopause

A

Nope
It is released in a pulsatile fashion so could get false positive
Need multiple measurements at least 2 weeks apart

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42
Q

What are the psychological symptoms of the menopause

A 
Mood swings
Irritability
Anxiety
Tearfullness 
Difficulty concentrating
Forgetfulness
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43
Q

What are the sexual symptoms of the menopause

A

Vaginal dryness - due to decrease in collagen in the vaginal tissue
Decreased libido

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44
Q

What symptoms can appear late in the menopause

A 
Frequency
Recurrent UTIs
Dysuria
Incontinence
Dry hair and skin
Atrophy of breast and genitals

Due to a loss of collagen

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45
Q

What conservative management is available for menopausal symptoms

A 
Diet
Weight loss
Exercise - good for joints, CV risk, bone density 
CBT - for mood symptoms 
Fans and avoid spicy food to help sweats
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46
Q

What treatments are available for menorrhagia in the menopause

A 
Mefenamic acid
Tranexamic acid
Progesterones
Intra-uterine system - Mirena is best as works as HRT and contraception  
Endometrial ablation
Hysterectomy
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47
Q

What causes the symptoms of the menopause

A

The decrease in oestrogen

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48
Q

What are the risks of HRT

A

HRT increases risk of stroke, heart disease, venous thromboembolism
Also increases risk of breast and endometrial cancer

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49
Q

Why cant you give oestrogen alone as HRT

A

Could cause endometrial cancer

Can be given to women without a uterus though

50
Q

What is given in HRT

A

Give oestrogen alongside progesterone
Can be continuous or sequential (still have a bleed)
Continuous is typically for post-menopausal and cyclical for peri-menopausal who still get periods
A 3rd hormone, testosterone, can be added in cases of reduced libido.

51
Q

What are the contraindications for HRT

A 
Absolute: 
Breast cancer
Endometrial cancer
Pregnancy
Active thrombo-embolic disorder 
Recent Myocardial infarction
Active liver disease with abnormal LFT
Porphyria cutanea tarda
Uncontrolled hypertension
Otosclerosis 
Relative
Undiagnosed abnormal vaginal bleeding
Large uterine fibroids
Past history of benign breast disease
Unconfirmed personal history or a strong family history of VTE
Chronic stable liver disease
Migraine with aura
52
Q

How long after the menopause can a women be on HRT

A

Safe up to 10 years after

53
Q

What is primary amenorrhea

A

Failure to menstruate by age 15 years in presence of secondary sexual characteristics
OR
13 years in absence of secondary sexual characteristics

54
Q

List physiological causes for amenorrhea

A

The person hasn’t reached puberty
Pregnancy - this is the cause until proven otherwise
Lactation
Menopause

55
Q

List hypothalamic causes of amenorrhea

A

Anorexia/bulimia - most common
Excessive exercise
Psychological stress
Idiopathic - hypogonadotropic hypogonadism)
Tumours - craniopharyngiomas, germinomas, gliomas and dermoid cysts)
Cranial irradiation
Head injury
Sarcoidosis
TB
Kallman’s syndrome - genetic syndrome which causes GnRH deficiency

56
Q

List pituitary causes of amenorrhea

A 
Hyperprolactinaemia - prolactinoma 
Tumours
Sheehan syndrome - damage to the pituitary following serious blood loss at childbirth (O2 deprivation)
Cranial irradiation
Head injury
Sarcoidosis
TB
57
Q

List ovarian causes of amenorrhea

A

PCOS
Premature ovarian failure - genetic i.e., Turner’s syndrome, XXX, autoimmune, infective, radio/chemotherapy
Congenital adrenal hyperplasia

58
Q

List outflow obstruction causes of amenorrhea

A 
Cervical stenosis
Asherman’s syndrome - adhesions
Imperforate hymen
Vaginal agenesis 
Mullerian aplasia (Kokitansky syndrome)- Mullerian ducts fail to develop resulting in absent uterus and variable malformations of the vagina -
59
Q

Which endocrine disorders can result in amenorrhea

A 
Thyroid disease - hyper or hypo
Cushing syndrome
Acromegaly
(will usually also present with other symptoms) 
PCOS

Testosterone secreting tumours
Congenital adrenal hyperplasia

60
Q

Which systematic disorders can result in amenorrhea

A

Many chronic debilitating disorders
Chronic renal failure
The body basically shuts down so menstruation stops

61
Q

Which drugs can result in amenorrhea

A

Oestrogen - COC etc.
Depo-Provera

Dopamine depleting drugs like metoclopramide, phenothiazides
This is because it usually negatively controls prolactin so depletion can cause hyperprolactinaemia

62
Q

All patients presenting with amenorrhea should be offered which test first

A

PREGNANCY TEST

63
Q

When taking a history for amenorrhea what should you focus on

A

primary and secondary sexual characteristics
Medical conditions
Family history
Drugs - especially contraception,
Diet, exercise and weight change
Stress
Hot/cold flushes (suggest premature menopause)
Galactorrhea (suggests hyperprolactinemia)
Acne/hirsutism (suggest PCOS)

64
Q

When would you do a visual field examination on a patient presenting with amenorrhea

A

If you suspect a brain tumour may be the cause

Would so optic disc and visual field exam

65
Q

When would you do a bimanual examination on a patient presenting with amenorrhea

A

Only when appropriate

e.g. when you think it may be an outflow obstruction

66
Q

Which examinations would you do on a patient presenting with amenorrhea

A

BMI
Examine sexual characteristics and external genitalia
Assessment of hirsutism, acne, galactorrhea

67
Q

Which hormone levels should be checked in a patient presenting with amenorrhea

A

HCG - urine and blood
LH, FSH, oestradiol, PRL, testosterone, TSH – these tests help differentiate between hypothalamic, pituitary and ovarian causes

68
Q

When would you perform a pelvic US in a patient with amenorrhea

A

If primary amenorrhea or PCOS

69
Q

When would you perform a CT or MRI pf the head in a patient with amenorrhea

A

If you suspect hyperprolactinaemia or a brain tumour is the cause

70
Q

When would you perform a genetic study in a patient with amenorrhea

A

If they have premature ovarian failure (<40 years old) as this could be a genetic thing
Turner’s or fragile X

71
Q

When would you perform a hysteroscopy in a patient with amenorrhea

A

If you suspect Ascherman’s syndrome - pelvic adhesions

72
Q

When would you perform a DEXA scan in a patient with amenorrhea

A

If they are found to have premature ovarian failure

This is because they lose the protective effect of oestrogen which can lead to osteoporosis

73
Q

How do you treat amenorrhea

A

• Correct underlying cause e.g. surgery to imperforate hymen, dopamine agonist if hyperprolactinaemia

Treat any side effects of cause such as endometrial hyperplasia in PCOS or osteoporosis in POF

Offer fertility treatment if required

74
Q

A raised PRL and testosterone is suggestive of which cause of amenorrhea

A

PCOS

75
Q

A raised FSH and LH is suggestive of which cause of amenorrhea

A

POF

Requires repeat blood tests to confirm the diagnosis - 4 months apart

76
Q

What hormonal changes would be seen in a woman going through the menopause

A

The cessation of oestradiol and progesterone production in the ovaries.

Due to this decrease, FSH and LH levels will often increase.

77
Q

List symptoms of Turner’s syndrome

A

Short stature.
Poor pubertal development.
Primary amenorrhoea
Raised FSH and LH

78
Q

List symptoms of an imperforate hymen

A

Cyclical abdominal pain
Sometimes urinary retention, constipation, and lower back pain.
A few cases have led to peritonitis due to retrograde menstruation

79
Q

What is Turner’s syndrome

A

aAcongenital disease caused by the partial or full absence of the second X chromosome in phenotypically female patients

80
Q

How would a prolactinoma cause amenorrhea in females

A

By inhibiting the secretion of GnRH which in turn results in low levels of oestrogen

81
Q

When is the menstrual cycle at its most irregular

A

Around the extremes of reproductive life- menarche and menopause
Due to anovulation and inadequate follicular development.

82
Q

Which part of the menstrual cycle is responsible for the variation in length

A

The follicular phase - can range from 10-16 days

The luteal phase has a constant duration of 14 days

83
Q

Which hormone is released by the hypothalamus to influence the menstrual cycle

A

Gonadotrophin-releasing hormone (GnRH)
Released in a pulsitile fashion
It triggers the pituitary to release FSH and LH

84
Q

What are ovulation predictor tests looking for

A

The LH surge

85
Q

When in the menstrual cycle do progesterone levels peak

A

7 days before the start of the next menses

This level is used for assessing infertility and checking for ovulation

86
Q

What triggers the menstrual cycle to restart if there is no pregnancy

A

A reduction in progesterone, oestrogen and inhibin feeding back to the pituitary cause an increase in gonadotrophin hormones and it starts again

87
Q

How does haemostasis in the endometrium differ from elsewhere in the body

A

it does not involve the process of clot formation and fibrosis.

88
Q

Why do NSAIDs work in the treatment of heavy peroids

A

They are prostagladin inhibitors so act by increasing the ratio of vasoconstrictor to the vasodilator.
Prostagladins are one of the vasodilators involved

89
Q

List some systemic disorders which can cause menorrhagia

A

Endocrine disorders - hyper/hypothyroism, diabetes mellitus, adrenal disease, prolactin disorders
Haematological diseases - Von willebrand’s disease, immune thrombocytopenic purpura (ITP), factor II, V, VII and XI deficiency
Liver disorders – cirrhosis
Renal disease
Drugs – anticoagulants

90
Q

Which examinations might you perform on a woman with menorrhagia

A

Look for signs of anemia
Abdominal and pelvic exam - look for masses
Speculum - visualize cervix, take swabs if necessary

91
Q

Which treatments for DUB are useful if the patient wants to conceive

A

Antifibrinolytics - tranexamic acid
NSAIDs

Many of the others are contraceptives

92
Q

List potential causes of intermenstrual bleeding

A

Cervical ectropion
Pelvic inflammatory disease (PID) and sexually transmitted disease
Endometrial or cervical polyps
Cervical cancer
Endometrial cancer
Undiagnosed pregnancy/ pregnancy complications
Hyatidiform molar disease.

93
Q

List causes of post-coital bleeding

A 
Cervical ectropion
Cervical carcinoma
Trauma
Atrophic vaginitis
Cervicitis secondary to sexual transmitted diseases.
Polyps
Idiopathic
94
Q

What is pre-menstrual syndrome

A

PMS
The occurrence of cyclical somatic, psychological and emotional symptoms that occur in the luteal (premenstrual) phase of the menstrual cycle and resolve by the time menstruation ceases

95
Q

What are the main features of PMS

A 
Bloating
Cyclical weight gain
Mastalgia
Abdominal cramps
Fatigue
Headache
Depression
Changes in appetite and increased craving
Irritability

Will occur in a cyclical pattern

96
Q

How can you treat PMS

A

Mild symptoms - lifestyle (stress reduction, more exercise etc.)
Severe symptoms - SSRIs
Psychological symptoms - CBT
Medical - COOP, short-term GnRH analogues, transdermal oestrogen

Last resort - hysterectomy with bilateral salpingo-oophorectomy

97
Q

What causes cervical ectropion

A

Most often hormonal changes due to high oestrogenic states in pregnancy or use of hormonal contraceptives, especially the combined pill.

98
Q

List potential causes of post-menstrual bleeding

A 
Atrophic vaginitis 
Endometrial polyps
Endometrial hyperplasia
Endometrial carcinoma 
Cervical carcinoma
Ovarian cancer – especially the oestrogen-secreting (theca cell) tumours
Vaginal cancer – rare
99
Q

When is post-menopausal bleeding ‘normal’

A

If they are on combined cyclical HRT which causes cyclical bleeding during the progesterone free period

100
Q

How should you investigate PMB

A

A thorough history and abdominal and pelvic examination
1st line is a TVUS
NICE guidelines state that women over the age of 55 with PMB should be investigated within 2 weeks by ultrasound for endometrial cancer

101
Q

What is atrophic vaginitis

A

A benign condition where the epithelium thins and breaks down in response to low oestrogen levels.

102
Q

What is the most common cause of menstrual irregularity

A

PCOS

103
Q

Which features are required for a diagnosis of PCOS

A

Clinical or biochemical evidence of hyperandrogenism (hirsutism, acne; high free testosterone, low sex hormone binding globulin, high free androgen index respectively)

Polycystic ovaries on ultrasound scan – defined as an increase in ovarian volume to >10cm3, at least 12 follicles in one ovary measuring 2-9mm in diameter.

Oligo/amenorrhea.

104
Q

List some of the features of PCOS

A

Obesity/overweight
Hypertension
Acanthosis nigricans (thickening and pigmentation of the skin of the neck, axillae and intertriginous areas)
Acne and hirsutism – due to increased testosterone
Alopecia
There is a link to insulin resistance, diabetes, lipid abnormalities therefore an increased cardiovascular risk.
irregular periods

105
Q

PCOS increased your risk of which cancer

A

Increased risk of endometrial hyperplasia and carcinoma

Due to oligo/amenorrhea in the presence of pre-menopausal levels of oestrogen.

106
Q

How do you manage the acne seen in PCOS

A

Co-cyrprindol (Dianette) - reduces acne and hirsutism

The COCP

107
Q

What is dysmenorrhea

A

Excessive pain during the menstrual period.

108
Q

What is primary dysmenorrhea

A

When there is no underlying pelvic pathology
It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.
Excessive endometrial prostaglandin production is thought to be partially responsible.

109
Q

What is secondary dysmenorrhea

A

Dysmenorrhea which develops many years after the menarche
It is the result of an underlying pathology.
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.

110
Q

What can cause secondary dysmenorrhea

A 
endometriosis 
adenomyosis 
Pelvic inflammatory disease
Intrauterine devices - copper coil
Fibroids – differs in terms of location within the uterus.
111
Q

What is adenomyosis

A

Presence of endometrium between the muscle layers of the uterus
Uterus will often appear large and globular.

112
Q

How do you manage dysmenorrhea

A

NSAIDs such as mefenamic acid
Combined oral contraceptive pills are used second line
Levonogestrel Intrauterine system (LNG-IUS) – when dysmenorrhea occurs with menorrhagia
GnRH analogues – they are the best to manage symptoms, especially due to fibroids, when awaiting for hysterectomy

113
Q

List causes of primary amenorrhea

A 
Genital tract abnormalities 
Mullerian agenesis 
Premature ovarian failure or insufficiency
Genetic disorders 
Hypothalamic disorders 
Iatrogenic - chemo or radiation 
Autoimmune desturction 
Endocrine causes 
Pituitary disorders
114
Q

Which genetic disorders can cause primary amenorrhea

A 
Turner’s syndrome
Pure gonadal agenesis
Androgen insensitivity syndrome
5-alpha reductase deficiency
Kallman’s syndrome - absence or failure of respond to GnRH
115
Q

Which endocrine disorders can cause primary amenorrhea

A 
Hypothyroidism
Constitutional delay
Congenital adrenal hyperplasia
PCOS
Androgen secreting tumour
116
Q

List causes of secondary amenorrhea

A

Hypothalamic disorders - stress, weight loss
Autoimmune conditions
Pituitary disorders
Iatrogenic - oophorectomy, radiation, chemotherapy, use of antidopaminergic drugs
Endocrine abnormalities – hypothyroidism/hyperthyroidism, PCOS
Ashermann’s syndrome
Other uterine problems – endometrial atrophy, cervical stenosis from aggressive treatment for cervical cancer.
Physiological causes – lactation, pregnancy.

117
Q

What is the main medical management for the menopause

A

Hormone replacement therapy
Oestrogen being the main hormone
Can be given as patches, gel, tablets or implants

118
Q

How long after starting HRT do women usually see improvement

A

Usually 4-6 weeks after starting HRT

Get a review at 3 months to assess effectiveness

119
Q

List oestrogen related side effects of HRT

A

Breast enlargement, leg cramps, dyspepsia, fluid retention, nausea, headaches
Usually dose-related and settle with time

120
Q

List progestrogen related side effects of HRT

A

luid retention, breast tenderness, headaches, acne, mood swings, depression, irritability, constipation, increased appetite

121
Q

Does HRT act as contraception

A

No
Women with premature menopause can occasionally ovulate so contraception will be needed for those who are sexually active and don’t wish to conceive

122
Q

How long after menopause should women continue on contraception

A

2 years after the last menstrual period in women under 50 and for a year in women over 50

Reproduction (16 decks)

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