Mentruation

Question 1

What is classified as ‘normal menstruation’?

Answer 1

Lasting 4-6 days with heaviest days being 1 and 2.
<80ml per day and no clots passed
no intermenstrual or post-coital bleeding

Question 2

What is menorrhagia and metrorrhagia?

Answer 2

Menorrhagia - increased menstrual bleeding

Metrorrhagia - regular intermenstrual bleeding

Question 3

What is polymenorrhoea and polymenorrhagia?

Answer 3

Polymenorrhoea - cycle lasting <21 days

polymenorrhagia - increased frequency and menstrual bleeding

Question 4

What is menometrorrhagia?

Answer 4

increased menstrual loss with regular intermenstrual bleeding

Question 5

What is amenorrhoea and oligomenorrhoea?

Answer 5

Absensce of menstruation

Menstruation cycle lasting >35 days

Question 6

What is DUB?

Answer 6

Dysfunctional uterine bleeding (menorrhagia in the absence of pathology - 50% of cases)

Question 7

When does puberty usually start in females?

Answer 7

ages 9-11 with the start of breast development and pubic hair growth.

Question 8

What is the average age of menarche in the UK?

Answer 8

12.9 years

Question 9

What does LH act on in the ovary?

Answer 9

the thecal cells - to increase androgen production (and maturation of oocytes)

Question 10

What are the four structures involved in the regulation of ovulation and menstruation?

Answer 10

Hypothalamus
Anterior pituitary gland
ovary
uterus

Question 11

What is the definition of primary amenorrhoea?

Answer 11

No periods experienced before the age of 16 if no secondary characteristic present
if secondary characteristics present then investigate at 18

Question 12

List some causes of primary amenorrhoea

Answer 12

Hypothalmic (lack of GnRH) or hypogonadotrophic (lack of LH or FSH)

Question 13

List some organic causes of menorrhagia

Answer 13

tumours, fibroids, endometriosis, adenomyosis, IUCD, PID

Question 14

List some systemic causes of menorrhagia

Answer 14

hypothyroidism/hyperthyroidism, diabetes, adrenal disease, prolactin disorders and coagulopathies (VWF deficiency, ITP, factor deficiency) or on anti-coagulant

Question 15

List some causes of bleeding during pregnancy

Answer 15

Ectopic or miscarriage

Question 16

What investigations would you consider in someone with menorrhagia?

Answer 16

FBC
Coag screen
TSH
Endometrial sampling
transvag USS
cervical smear

Question 17

What are the different types of DUB? Explain.

Answer 17

Anovulatory - 85% and will occur in the extremes of age

Ovulatory - 15% and due to insufficient secretion of hormone by the corpus luteum

Question 18

What is the first line treatment of DUB?

Answer 18

IUD (mirena)

Question 19

What is the second line treatment of DUB?

Answer 19

OCP
Antifibrinolytic e.g. transexamic acid
Antiprostaglanding e.g. mefanamic acid

Question 20

What is the third line treatment of DUB?

Answer 20

GnRH analogues

Question 21

What is the surgical treatment of DUB?

Answer 21

endometrial ablation/resection

hysterectomy

Question 22

What are some physiological causes of amenorrhoea?

Answer 22

pre-menstrual
pregnancy
lactation
post-menopausal

Question 23

What are some pituitary causes of amenorrhoea?

Answer 23

pituitary adenoma (non-functioning)
prolactinoma (prolactin will inhibit GnRH production from hypothalamus and causes downstream decrease in FSH and LH levels)

Question 24

What are some ovarian causes of amenorrhoea?

Answer 24

Premature ovarian failure
PCOS - ineffective LH so ovum never released from ovary. must have 2 of: cystic ovaries on pelvic USS, evidence of androgen excess (hirsuitism, acne) and amenorrhoea

Question 25

What is menopause?

Answer 25

This is the normal cessation of menstruation due to reduced oestrogen production by the ovaries

Question 26

When does menopause usually occur?

Answer 26

> 45

Question 27

When is menopause abnormal?

Answer 27

<40 as this may signify POF

surgery, radiotherapy and chemotherapy all increase risk of this

Question 28

What are the symptoms of menopause?

Answer 28

hot flushes, night sweats, vaginal dryness, low mood/anxiety, decreased libido, difficulty sleeping

Question 29

If symptoms of menopause are severe what can be give (medical management)?

Answer 29

HRT - oestrogen +/- progesterone

Question 30

When is combine HRT (oestrogen and progesterone) given and why?

Answer 30

Given to women with symptoms of menopause who still have a uterus. If oestrogen is unopposed then this increases risk of uterine cancer.

Question 31

What other therapies can be used (apart from HRT) to treat menopause?

Answer 31

CBT
healthy diet and exercise
antidepressants

Question 32

What does FSH act on and what does this result in?

Answer 32

Acts on the granulosa cells of the ovary to increase the conversion of androgens (secreted by the thecal cells) into oestrogen via aromatase enzymes

Question 33

What happens to hormone axis during the menopause?

Answer 33

FSH levels are high - increased conversion of androgens to oestrogen by granulosa cells
LH low due to no formation of a leading follicle, so no ovum to be released (ovulation does not occur)
Progesterone low as no corpus luteum formation - increased FSH further to stimulate oocyte follicular development.