The menstrual cycle and its disorders Flashcards
Puberty TAM
Thelarche (9-11) = breasts
Adrenarche (11-12) = pubic hair
Menarche (13+) = menstruation (may be irregular at first but becomes regular as oestrogen rises)
Most growth finishes at 16 years
Day 1-4 menstruation
endometrium shed
hormonal support withdrawn
myometrial contract (can be painful)
Day 5-13 proliferative phase
GnRH from hypothalamus to pituitary
pituitary release LH+FSH for follicular growth
Follices produce oestradiol and inhibin -> negative feedback so only 1 follice and 1 oocute mature
oestrodiol increases -> positive feedback -> LH levels rise -> ovulation 36 hours after LH surge
oestradiol -> endometrium re-forms and becomes proliferative (thickens as stromal cells proliferate and glands elongate)
Days 14-28 luteal/secretory phase
Follices become CL
CL produces oestrodiol but MORE progesterone (peaks at day 21)
progesterone -> secretory changed in endometrium (stromal cells enlarge and glands swell and blood supply increases)
CL starts to fail if egg not fertilised -> P+O levels fall -> menstruation
Definition of AUB
any variation from normal menstrual cycle, and includes changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss
HMB most common complaint of AUB
Abnormal uterine bleeding and definitions of terms (FIGO)
Normal menstruation ranges
PALM COEIN for AUB
HMB definition: clinical and objective
clinical = excessivew menstrual blood loss that interferes with woman’s physical, emotional, social and material quality of life, and which can occur alone or in a combination with other symptoms
objective = blood loss >80mL in an otherwise normal menstrual cycle. Max amount woman can los per cycle without becoming iron deficient
HMB Aetiology
mainly fibroids (30%) and polyps (30%)
HMB Hx and O/E
Hx:
- contraception
- amount and timing
- anaemia (fatigue, weight loss, dizziness, dyspnoea, CP)
- FHx
- thyroid (hypothyroidism)
- anticoagulation
O/E:
- anaemia signs
- irregular enlargement of uterus = fibroids
- tenderness with/without enlargement = adenomyosis
HMB Ix
Hb
Coag
TFT
TVUSS (+saline)
Endometrial biopsy (pipelle/hysteroscopy)
- HMB and over 40 y/o
- bleeding NRT
- RF for cancer (young women) -> PCOS, nulliparity, HNPCC, obesity, diabetes
- Acute admission
- If USS suggest polyp or focal endometrial thickening
HMB Mx
- IUS
- Tranexamic acid/mefanamic acid OR -> COCP
- progestogens
- GnRH analogues
- Hysteroscopic (polyp removal, endometrial ablation,TRCE an old way)/hysterectomy
Irregular and intermenstrual bleeding DDx
same as HMB
increased cancer risk for older women
irregular and intermenstrual bleeding Ix
Hb
Exclude malignancy
Cervical smear
USS
- over 35 y/o
- if NRT under 35 y/o
Endometrial buipsy
- similar indications for HMB
Irregular and intermenstrual bleeding Mx
Drugs
- for anovulatory/apathological
- 1 = IUS/COCP
- 2 = Progestogens
Surgery
- polyp for gistology
- similar to HMB
amenorrhoea/oligomenorrhoea: 1o and 2o and oligo
1o amen = no menstruation before 14 y/0
2o amen = menstruation stops more than 3 months
oligo = menstruation every 35 days - 6 months
physiological causes of amen/oligo
1o = constituional delay, drugs
2o = pregnancy, lactation, menopause, drugs
pathological causes of amen/oligo
Hypothalamus
- hypothalamic hypogonadism (low BMI, exercise, Sheehan’s syndrome) MX: COCP
- anorexia nervosa
Pituitary
- hyperprolactinameia MX: cabergoline, bromocriptine
Adrenal/thyroid
- hypothyrodisim (incereased prolactin)
- CAH
Ovary
- PCOS
- Turners (45 XO)
- Asherman’s syndrome
Outflow tract
- Imperforate hymen
- Transverse vaginal septum
- Rokitansky’s syndrome
Postcoital bleeding aetiology
cervical ectropions
benign polyps
invasive cervical cancer
cervicitis/vaginitis
postcoital bleeding mx
inspect and smear
polyp histology
colposcopy = look at cervix
Dysmennorhoea physiology
due to contraction and uterine ischaemia
high PG levels
Dysmenorrhoea primary vs secondary
Primary
- no organic cause
- very common
- pain on menstruation
- Mx: NSAIDS, COCP, reassure
Secondary
- pelvic US + laparascopy
- fibroids, adenomyosis, PID
- pain relieved on menstruation
Precocious puberty features
<8 y/o menstruating, reduction in secondary sexual characteristics
low height
precocious puberty aetiology
80% apathological
central (increased GnRH) = meningitis, ewncephalitis, CNS tumours, hydrocephalus, hypothyroid
ovarian/adrenal (increased oestrogen) = hormone producing tumours
- McCune-Albright syndrome = bone and ovarian cysts, cafe au lait spots, precocious pubert. Mx: cyproterone acetare (antiandrogenic progestogen)
Ambiguous development and intersex (female and male aetiology)
increased androgen in female (CAH)
- high ACTH, high androgens
- low GC, Addisonian crisis
- Ambiguous genitals
- Enlarged clitoris + amenorrhoea
- Mx: cortisol and MR replacement
decreased androgen in male (Androgen Insensitivity Syndrome)
- androgen converted to oestrogen (appears female)
- amenorrhoea, uterus absent, rudimentary testes present
- Mx: testes removed (can be malignant), oestrogen replacement started
PMS definition
Psych/behavioural/physica; sx rregularly in luteal phase, resolved by end of menstruation
PMS Hx and O/E
cyclical
behavioural and psych
- tension, irritable, aggression, depression, loss of control
physical
- bloated, minor GI upset, breast pain
O/E
- psych eval (depression and neurosis)
- menstrual diaries for at at least 2 cycles
PMS Mx
Drugs:
- SSRIs (second half of cycle)
- continuous oral contraceptives (100 ug HRT patch)
- GnRH agonist and add-back orestrogen therapy
- bilateral oophectomy
Other:
- evening primrose oil (breast tenderness)
- pyridoxine (vit B6) 50 mg BD (mild PMS, can cause neuropathy ine excessive doses)
- Vitex agnus-castus extract (can help)
- CBT
Menstrual cycle disorders at a glance
