The Menstrual Cycle & Abnormalities

Question 1

Menstruation

Answer 1

• The precess by which the endometrium is discarded each month if pregnancy fails to occur
• Involves sloughing of the endometrium over a period of days, bleeding and subsequent repair so tht the uterus is receptive to an implanting embryo in the next cycle

Question 2

Hormonal control

Answer 2

Question 3

Heavy menstrual bleeding (previously called menorrhagia)

Answer 3

• Bleeding that has an adverse impact on womans QoL
• Commonest cause of IDA in women in affluent world

Question 4

Causes of heavy menstrual bleeding

Answer 4

• Anovulatory (absence of pathology - very common)
• Ovulatory (absence of pathology - very common)
• Fibroids
• Adenmyosis
• Pelvicinfection
• Endometrial malignancy
• Clotting disorders (very rare)

Question 5

Assessment of heavy menstrual bleeding

Answer 5

• History and examination
• FBC
• Coagulation tests
• Serum ferritin
• Female hormone testing
• Thyroid testing
• Biopsy if appropriate
• US or imaging if pelvic mass or enlarged uterus

Question 6

Management of heavy menstrual bleeding

Answer 6

• Pharmacological
  
  • Mefenamic acid (prostaglandin synthase inhibitor)
  • TXA (antifibrinolytic)
  • COCP
  • Progestogens
  • LNG-IUS (Mirena coil)
  • GnRH analogues
• Endometrial ablation (endometrium to border with myometrium)
  
  • Pregnancy contraindicated post procedure
• Hysterectomy

Question 7

Amenorrhoea & Oligomenorrhoea

Answer 7

• Amenorrhoea - absent menses
  
  • Primary - failure to menstruate by 15 years
  • Secondary - established menses stop for ≥6 months in absence of pregnancy
• Oligomenorrhoea - cycle persistently greater then 35 days in length

Question 8

Causes of primary amenorrhoea

Answer 8

• Physiological delay
• Weight loss/anorexia/heavy exercise
• Polycystic ovaries
• Imperforate hymen

Question 9

Assessment of primary amenorrhoea

Answer 9

• History (FHx, weight, exercise, stress, sexual activity)
• Examination (secondary sexual characteristics, tanner staging)
• Plasma FSH, LH, oestradiol, prolactin, TFTs
• Karyotype
• X-ray for bone age
• Cranial imaging

Question 10

Causes of secondary amenorrhoea

Answer 10

• Pregnancy
• Lactation
• Menopause
• Weight loss/anorexia
• Heavy exercise
• PCOS
• Stress
• Surgery - hysterectomy
• Endometrial ablation
• Progestogen IUD

Question 11

PCOS

Answer 11

• Most common cause of anovulatory infertility
• Rotterdam criteria for diagnosis - requires 2/3 of:
  
  • Clinical of biochemical evidence of hyperandrogenism
  • Oligomenorrhoea/amenorrhoea
  • US features of PCOS

Question 12

Consequences of PCOS

Answer 12

• Reduced fertility
• Insulin resistance and diabetes
• HTN
• Endometrial cancer
• Depression and mood swings
• Snoring and daytime drowsiness

Question 13

Management of PCOS

Answer 13

• Education
• Weight loss and exercise (most important)
• Endometrial protection (progesterone or withdrawal bleed)
• Fertility assistance
• Lifetime awarness +/- screening for complications

Question 14

Definitions of IMB/PCB/PMB

Answer 14

• Intermenstrual bleeding (IMB)
  
  • Bleeding in between periods
• Post-coital bleeding (PCB)
  
  • Bleeding after intercourse
• Post menopausal bleeding (PMB)
  
  • Bleeding occurring >12 months after LMP

Question 15

Assessment of IMB and PCB

Answer 15

• Cervical smear history - should have negative smear <3 years
• Speculum and bimanual examination - urgent colopscopy if suspicious of cancer
• STD screen and treat
• Urine pregnancy test

Question 16

IMB and PCB pathways

Answer 16

• Urgent gynaecology referral
  
  • Women >35 with >4 weeks PCB/IMB
• Routine gynaecology referral
  
  • Women <35 with PCB/IMB >12 weeks
  • Single heavy episode at any age
• Reassurance
  
  • Women <35 with normal findings and results
  • Most resolve within 6 months

Question 17

Investigation of PMB

Answer 17

• 5% risk of cancer
• TVS
  
  • Biopsy if ET >3mm (non-HRT and CC-HRT users)
  • Biopsuy if ET >5mm (sequential HRT users)
  • Hysteroscopy/biopsy in Tamoxifen users