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Obstetrics & Gynaecology > Menstruation and Menstrual Disorders > Flashcards

Menstruation and Menstrual Disorders Flashcards

1
Q

Causes of primary amenorrhoea

A

Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)

Abnormal functioning of the gonads (hypergonadotropic hypogonadism)

Imperforate hymen or other structural pathology

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2
Q

Causes of secondary amenorrhoea

A

Pregnancy (the most common cause)

Menopause

Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors

Polycystic ovarian syndrome

Medications, such as hormonal contraceptives

Premature ovarian insufficiency (menopause before 40 years)

Thyroid hormone abnormalities (hyper or hypothyroid)

Excessive prolactin, from a prolactinoma

Cushing’s syndrome

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3
Q

Causes of irregular periods

A

Extremes of reproductive age (early periods or perimenopause)

Polycystic ovarian syndrome

Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)

Medications, particularly progesterone only contraception, antidepressants and antipsychotics

Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin

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4
Q

Causes of intermenstrual bleeding

A

Hormonal contraception

Cervical ectropion, polyps or cancer

Sexually transmitted infection

Endometrial polyps or cancer

Vaginal pathology, including cancers

Pregnancy

Ovulation can cause spotting in some women

Medications, such as SSRIs and anticoagulants

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5
Q

Intermenstrual bleeding is a red flag for…

A

Cervical cancer

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6
Q

Causes of dysmenorrhoea

A

Primary dysmenorrhoea (no underlying pathology)

Endometriosis or adenomyosis

Fibroids

Pelvic inflammatory disease

Copper coil

Cervical or ovarian cancer

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7
Q

Causes of menorrhagia

A

Dysfunctional uterine bleeding (no identifiable cause)

Extremes of reproductive age

Fibroids

Endometriosis and adenomyosis

Pelvic inflammatory disease (infection)

Contraceptives, particularly the copper coil

Anticoagulant medications

Bleeding disorders (e.g. Von Willebrand disease)

Endocrine disorders (diabetes and hypothyroidism)

Connective tissue disorders

Endometrial hyperplasia or cancer

Polycystic ovarian syndrome

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8
Q

What are the two phases of the menstrual cycle?

A

Follicular phase

Luteal phase

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9
Q

When is the follicular phase?

A

Start of menstruation to the moment of ovulation

first 14 days in a 28-day cycle

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10
Q

When is the luteal phase?

A

The moment of ovulation to the start of menstruation

final 14 days of the cycle

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11
Q

What stages do the follicles go through in the follicular phase?

A

Primordial follicles

Primary follicles

Secondary follicles

Antral follicles (also known as Graafian follicles)

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12
Q

Outline the follicular phase

A

Primary follicles grow into secondary follicles

Secondary follicles have FSH receptor

FSH stimulates further development and begin secreting oestrogen

Oestrogen has negative effect on pituitary gland so less FHS and LH produced

One follicle will develop furthest and become dominant follicle

LH spikes just before ovulation, causing dominant follicle to release ovum

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13
Q

Outline the luteal phase

A

After ovulation, the follicle that released the ovum becomes the corpus lutem

Corpus lutem secretes high levels of progesterone which maintains endometrial lining

No fertilisation -> corpus lutem degenerates and stops producing oestrogen and progesterone

This causes endometrium to break down and menstruation occurs

Negative feedback from oestrogen and progesterone on hypothalamus and pituitary ceases, allowing LH and FSH levels to rise and cycle to restart

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14
Q

What is menstruation?

A

Superficial and middle layers of endometrium separating from basal layer

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15
Q

Definition of primary amenorrhoea

A

Not starting menstruation:

By 13 years when there is no other evidence of pubertal development

By 15 years of age where there are other signs of puberty, such as breast bud development

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16
Q

What is hypogonadism?

A

Lack of the sex hormones (oestrogen and testosterone) that normally rise before and during puberty

Causes a delay in puberty

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17
Q

What is hypogonadotropic hypogonadism?

A

Deficiency of LH and FSH, leading to deficiency of sex hormones (oestrogen)

LH and FSH are gonadotrophins produced by anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus

No gonadotrophins simulating the ovaries -> ovaries do not produce sex hormones (oestrogen)

Therefore, “hypogonadotropism” causes “hypogonadism”

18
Q

What is hypergondaotropic hypogonadism?

A

Gonads fail to respond to stimulation from the gonadotrophins (LH and FSH)

Without negative feedback from the sex hormones (oestrogen), anterior pituitary produces increasing amounts of LH and FSH

Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”)

19
Q

What is Kallman syndrome?

What is it associated with?

A

Genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty

Associated with anosmia

20
Q

What is congenital adrenal hyperplasia?

A

Congenital deficiency of the 21-hydroxylase enzyme

Causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth

Autosomal recessive

21
Q

Presentation of congenital adrenal hyperplasia

A

Tall for their age

Facial hair

Absent periods (primary amenorrhoea)

Deep voice

Early puberty

22
Q

What is androgen insensitivity syndrome?

A

Condition where tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop

Results in a female phenotype, other than the internal pelvic organs

Normal female external genitalia and breast tissue

Internally there are testes in the abdomen or inguinal canal

Absent uterus, upper vagina, fallopian tubes and ovaries

23
Q

Structural pathology causing primary amenorrhoea

A

Imperforate hymen

Transverse vaginal septae

Vaginal agenesis

Absent uterus

Female genital mutilation

24
Q

Initial investigations in primary amenorrhoea

A

FBC and ferritin for anaemia

U&E for chronic kidney disease

Anti-TTG or anti-EMA antibodies for coeliac disease

25
Q

Hormonal blood tests in primary amenorrhoea

A

FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism

TFTs

Insulin-like growth factor I is used as a screening test for GH deficiency

Prolactin is raised in hyperprolactinaemia

Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia

26
Q

Management of primary amenorrhoea

A

Treat underlying cause

Replacement hormones can induce menstruation and improve symptoms

27
Q

What conditions can pulsatile GnRH treat?

A

Hypogonadotrophic hypogonadism e.g.

Hypopituitarism

Kallman syndrome

28
Q

Define ‘secondary amenorrhoea’

A

No menstruation for more than three months after previous regular menstrual periods

29
Q

Causes of secondary amenorrhoea

A

Pregnancy is the most common cause

Menopause and premature ovarian failure

Hormonal contraception (e.g. IUS or POP)

Hypothalamic or pituitary pathology

Ovarian causes such as polycystic ovarian syndrome

Uterine pathology such as Asherman’s syndrome

Thyroid pathology

Hyperprolactinaemia

30
Q

Pituitary causes of secondary amenorrhoea

A

Pituitary tumours, such as a prolactin-secreting prolactinoma

Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome

31
Q

Assessment of secondary amenorrhoea

A

Detailed history and examination to assess for potential causes

Hormonal blood tests

Ultrasound of the pelvis to diagnose polycystic ovarian syndrome

32
Q

Hormone tests in secondary amenorrhoea

A

bHCG urine or blood tests to diagnose or rule out pregnancy

High FSH suggests primary ovarian failure

High LH, or LH:FSH ratio, suggests PCOS

Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour

TSH can screen for thyroid pathology

T3 and T4 when the TSH is abnormal

Raised TSH and low T3 and T4 indicate hypothyroidism

Low TSH and raised T3 and T4 indicate hyperthyroidism

Raised testosterone indicates PCOS, androgen insensitivity syndrome or congenital adrenal hyperplasia

33
Q

Osteoporosis and secondary amenorrhoea

A

Low oestrogen = risk of osteoporosis

Amenorrhoea >12 months requires risk mitigation

Ensure adequate vitamin D and calcium intake

HRT or COCP

34
Q

What is premenstrual syndrome?

A

Psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

35
Q

Management of PMS

A

General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep

COCP

SSRI antidepressants

CBT

36
Q

Define menorrhagia

A

Blood loss >80mls

37
Q

How do we quantify blood loss in practice?

A

Based on symptoms

Changing pads every 1- 2 hours

Bleeding lasting more than seven days

Passing large clots

38
Q

Causes of menorrhagia

A

Dysfunctional uterine bleeding (no identifiable cause)

Extremes of reproductive age

Fibroids

Endometriosis and adenomyosis

PID (infection)

Contraceptives, particularly the copper coil

Anticoagulant medications

Bleeding disorders (e.g. Von Willebrand disease)

Endocrine disorders (diabetes and hypothyroidism)

Connective tissue disorders

Endometrial hyperplasia or cancer

PCOS

39
Q

Investigations in menorrhagia

A

Speculum + bimanual

FBC - iron deficiency anaemia

Hysteroscopy if suspected fibroids/endometriosis

Swabs (infection)

Coagulation screen (Fix clotting disorders)

Ferritin if clinically anaemic

TFTs

40
Q

Management of menorrhagia

A

Treat underlying cause

Mirena coil (first line)

COCP

Cyclical oral progestogens, such as norethisterone

If woman does not want contraception:
Tranexamic acid when no associated pain (antifibrinolytic - reduces bleeding)
Mefenamic acid when there is associated pain (NSAID - reduces bleeding and pain)

41
Q

Outline the Rotterdam criteria for PCOS

A

Must have TWO of:

Oligoovulation or anovulation, presenting with irregular or absent menstrual periods

Hyperandrogenism, characterised by hirsutism and acne

Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Obstetrics & Gynaecology (13 decks)

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