The menstrual cycle and its disorders Flashcards

1
Q

Puberty TAM

A

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

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2
Q

Day 1-4 menstruation

A

endometrium shed

hormonal support withdrawn

myometrial contract (can be painful)

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3
Q

Day 5-13 proliferative phase

A

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)

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4
Q

Days 14-28 luteal/secretory phase

A

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

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5
Q

Definition of AUB

A

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

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6
Q

Abnormal uterine bleeding and definitions of terms (FIGO)

A
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7
Q

Normal menstruation ranges

A
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8
Q

PALM COEIN for AUB

A
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9
Q

HMB definition: clinical and objective

A

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

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10
Q

HMB Aetiology

A

mainly fibroids (30%) and polyps (30%)

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11
Q

HMB Hx and O/E

A

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
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12
Q

HMB Ix

A

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
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13
Q

HMB Mx

A
  1. IUS
  2. Tranexamic acid/mefanamic acid OR -> COCP
  3. progestogens
  4. GnRH analogues
  5. Hysteroscopic (polyp removal, endometrial ablation,TRCE an old way)/hysterectomy
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14
Q

Irregular and intermenstrual bleeding DDx

A

same as HMB

increased cancer risk for older women

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15
Q

irregular and intermenstrual bleeding Ix

A

Hb

Exclude malignancy

Cervical smear

USS

  • over 35 y/o
  • if NRT under 35 y/o

Endometrial buipsy

  • similar indications for HMB
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16
Q

Irregular and intermenstrual bleeding Mx

A

Drugs

  • for anovulatory/apathological
  • 1 = IUS/COCP
  • 2 = Progestogens

Surgery

  • polyp for gistology
  • similar to HMB
17
Q

amenorrhoea/oligomenorrhoea: 1o and 2o and oligo

A

1o amen = no menstruation before 14 y/0

2o amen = menstruation stops more than 3 months

oligo = menstruation every 35 days - 6 months

18
Q

physiological causes of amen/oligo

A

1o = constituional delay, drugs

2o = pregnancy, lactation, menopause, drugs

19
Q

pathological causes of amen/oligo

A

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
20
Q

Postcoital bleeding aetiology

A

cervical ectropions

benign polyps

invasive cervical cancer

cervicitis/vaginitis

21
Q

postcoital bleeding mx

A

inspect and smear

polyp histology

colposcopy = look at cervix

22
Q

Dysmennorhoea physiology

A

due to contraction and uterine ischaemia

high PG levels

23
Q

Dysmenorrhoea primary vs secondary

A

Primary

  • no organic cause
  • very common
  • pain on menstruation
  • Mx: NSAIDS, COCP, reassure

Secondary

  • pelvic US + laparascopy
  • fibroids, adenomyosis, PID
  • pain relieved on menstruation
24
Q

Precocious puberty features

A

<8 y/o menstruating, reduction in secondary sexual characteristics

low height

25
Q

precocious puberty aetiology

A

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)
26
Q

Ambiguous development and intersex (female and male aetiology)

A

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
27
Q

PMS definition

A

Psych/behavioural/physica; sx rregularly in luteal phase, resolved by end of menstruation

28
Q

PMS Hx and O/E

A

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
29
Q

PMS Mx

A

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
30
Q

Menstrual cycle disorders at a glance