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OBGYN 4MB > The Menstrual Cycle and its Disorders > Flashcards

The Menstrual Cycle and its Disorders Flashcards

1
Q

Define menarche

A
  • Onset of menstruation

- Avg. age 13yrs

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2
Q

Describe the physiology of puberty

A
  • Controlled by the hypothalamic-pituitary axis
  • Hypothalamic GnRH pulses increase in amplitude and frequency
  • Leads to increase in pituitary FSH and LH which stimulate release of oestrogen from the ovary
  • Oestrogen is responsible for development of secondary sexual characteristics
  • Menarche is final stage
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3
Q

What happens on days 1-4 of the menstrual cycle?

A
  • Menstruation
  • Endometrium shed as hormonal support withdrawn
  • Myometrial contraction occurs
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4
Q

What happens on days 5-13 of the menstrual cycle?

A
  • Proliferative phase
  • Pulses of GnRH stimulate FSH and LH release which induce follicular growth
  • Follicles produce oestradiol and inhibin which suppress FSH secretion = only one follicle matures
  • Oestradiol levels reach maximum which has positive feedback on LH causing a surge in LH
  • Ovulation follows 36hrs after surge
  • Oestradiol causes endometrium to reform and become proliferative
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5
Q

What happens on days 14-28 of the menstrual cycle?

A
  • Luteal/secretory phase
  • Follicle from which oocyte was released becomes corpus luteum
  • Produces oestradiol, but mainly progesterone which peaks around 1wk later (day 21 of 28 day cycle)
  • Induces secretory changes in endometrium
  • Towards end corpus luteum starts to fail if egg not fertilised, causing progesterone and oestrogen levels to decrease
  • Endometrium breaks down, menstruation follows and cycle restarts
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6
Q

What are the characteristics of normal menstruation?

A
  1. Menarche <16
  2. Menopause >45
  3. Menstruation 3-8 days in length
  4. Blood loss <80ml
  5. Cycle length 24-38days
  6. No intermenstrual bleeding
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7
Q

Define abnormal uterine bleeding (AUB)

A

Any variation from the normal menstrual cycle which includes:

  • changes in regularity and frequency of menses
  • changes in duration of flow
  • changes in amount of blood loss
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8
Q

List the causes of AUB

A
  1. Structural causes:
    - Polyps
    - Adenomyosis
    - Leiomyomas
    - Malignancy and hyperplasia
  2. Non-structural causes:
    - Coagulopathy
    - Ovulatory dysfunction
    - Endometrial (primary disorder of mechanisms regulating local endometrial haemostasis)
    - Iatrogenic
    - Not yet specified

PALM COEIN

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9
Q

Define heavy menstrual bleeding (HMB)

A
  • Excessive menstrual blood loss that interferes with a woman’s quality of life (clinical)
  • Blood loss of >80ml in an otherwise normal menstrual cycle (objective)
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10
Q

Define irregular menstrual bleeding

A

Cycle-to-cycle variation >20days

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11
Q

Define amenorrhea

A

No bleeding in a 6mth interval (absent menstrual bleeding)

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12
Q

Define oligomenorrhea (infrequent menstrual bleeding)

A

Bleeding at intervals >38days apart

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13
Q

Define frequent menstrual bleeding

A

Bleeding at intervals <24days apart

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14
Q

Define prolonged menstrual bleeding

A

Bleeding >8days duration

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15
Q

Define shortened menstrual bleeding

A

Bleeding <3days duration

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16
Q

Define intermenstrual bleeding (IMB)

A

Irregular episodes of bleeding, often light and short, occurring between otherwise normal menstrual periods

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17
Q

Define postcoital bleeding (PCB)

A

Bleeding post intercourse

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18
Q

Define premenstrual and postmenstrual spotting

A

Bleeding for one or more days before or after the recognised menstrual period

19
Q

Define postmenopausal bleeding (PMB)

A

Bleeding occurring more than 1yr after the acknowledged menopause

20
Q

Define precocious menstruation

A

Bleeding before the age of 9yrs

21
Q

List the causes of HMB

A
  1. Uterine fibroids and polyps
  2. Chronic pelvic infection
  3. Ovarian tumours
  4. Endometrial and cervical malignancy
  5. Thyroid disease
  6. Haemostatic disorders
  7. Anticoagulant therapy

*5-7 = rare

22
Q

What factors should be assessed in a hx of HMB?

A
  1. Amount and timing of bleeding
  2. Flooding and passage of clots = excessive loss
  3. Any contraception?
23
Q

What features are present on exam in HMB?

A
  1. Anaemia
  2. Pelvic signs often absent
  3. Irregular enlargement of uterus (fibroids)
  4. Tenderness (adenomyosis)
  5. Ovarian mass or fibroids may be felt
24
Q

What investigations should be done for HMB?

A
  1. Check Hb
  2. Coagulation (only if hx suggestive)
  3. TFTs (only if hx suggestive)
  4. TVUS pelvis:
    - endometrial thickness
    - exclude fibroids or ovarian mass
    - detect polyps
  5. Endometrial biopsy done in:
    - >40yrs
    - bleeding not responsive to medical therapy
    - younger women with risk factors for endometrial cancer
25
Q

What is the medical management of HMB?

A
  1. Intrauterine system (firstline):
    - Progestogen impregnated
    - Decreases menstrual flow by >90%
    - Fewer SEs than systemic
    - Contraceptive
  2. Antifibrinolytics (Tranexamic acid):
    - Taken during menstruation only
    - Decrease blood loss by ~50%
    - Few SEs
    - Second line
  3. NSAIDs:
    - Inhibit prostaglandin synthesis
    - Decrease blood loss by ~30%
    - Useful for dysmenorrhea
    - SEs similar to aspirin
    - Second line
  4. COCP:
    - Induces lighter menstruation
    - Less effective if pelvic pathology
    - Contraceptive
    - Second line
  5. Progestogens:
    - High doses induce amenorrhea
    - Bleeding will follow withdrawal
    - Third line
  6. GnRH agonists:
    - Produce amenorrhea
    - Duration limited to 6mths unless add-back HRT given (osteoporosis)
    - Bleeding will follow withdrawal
    - Third line
26
Q

What is the surgical management of HMB?

A
  1. Hysteroscopic:
    - Polyp removal
    - Endometrial ablation (most appropriate in older women)
    - Transcervical resection of fibroid (submucosal fibroids up to 3cm)
  2. Radical:
    - Myomectomy (removal of fibroids; open or laparoscopic; GnRH agonists or ulipristal acetate used preoperatively to shrink)
    - Hysterectomy (last resort)
    - Uterine artery embolization (treats menorrhagia due to fibroids; want to retain uterus and avoid surgery)
27
Q

List the causes of irregular menstruation and intermenstrual bleeding

A
  1. Anovulatory cycles (common in early and late reproductive years)
  2. Pelvic pathology:
    - Non-malignant
    - Malignant
28
Q

What investigations should be done in cases of IMB?

A
  1. Check Hb
  2. Exclude malignancy
  3. Cervical smear
  4. US women >35yrs + younger women with failed medical tx
  5. Endometrial biopsy:
    - Focally or very thickened
    - Polyp suspected
    - Woman >40yrs
    - Significant IMB
    - Risk factors for endometrial cancer
    - Endometrial ablation surgery or IUS to be used
29
Q

What is the medical management of IMB?

A
  1. IUS or COCP = first line
  2. Progestogens - when given on a cyclical basis can mimic normal menstruation
  3. HRT - may regulate erratic uterine bleeding during perimenopause
  4. Other treatments that are second line tx for HMB
30
Q

What is the surgical management of IMB?

A
  • Same as for women with HMB

- Ablative techniques less helpful

31
Q

Define primary amenorrhea

A

Menstruation not started by 16yrs

32
Q

Define secondary amenorrhea

A

When previously normal menstruation ceases for 3mths or more

33
Q

List the causes of amenorrhea

A

Physiologial:

  1. Pregnancy
  2. After menopause
  3. During lactation
  4. Constitutional delay

Pathological:

  1. Hypothalamus
  2. Pituitary
  3. Thyroid
  4. Adrenals
  5. Ovary
  6. Uterus and outflow tract

Drugs:

  1. Progestogens
  2. GnRH analogues
  3. Antipsychotics (increase prolactin levels)
34
Q

What are the most common causes of amenorrhea?

A
  1. Premature menopause
  2. PCOS
  3. Hyperprolactinaemia
35
Q

What are the causes of amenorrhea that originate from the hypothalamus?

A
  1. Hypothalamic hypogonadism:
    - Usually due to physiological factors (low weight/ anorexia nervosa/excessive exercise)
    - Tumours uncommon
    - Treatment is supportive (oestrogen replacement)
36
Q

What are the causes of amenorrhea that originate from the pituitary?

A
  1. Hyperprolactinaemia:
    - Pituitary hyperplasia or benign adenomas
    - Tx = bromocriptine, cabergoline or surgery
    - Sheehan’s syndrome - severe PPH causes pituitary necrosis
37
Q

What are the causes of amenorrhea that originate from the adrenal or thyroid glands?

A
  1. Hyper or hypothyroidism

2. Congenital adrenal hyperplasia or virilising tumours

38
Q

What are the causes of amenorrhea that originate from the ovary?

A
  1. Acquired disorders:
    - PCOS (most common)
    - Premature menopause
    - Virilising tumours (rare)
  2. Congenital disorders:
    - Turner’s syndrome (most common)
    - Gonadal dysgenesis
39
Q

What are the causes of amenorrhea that originate from outflow tract problems?

A
  1. Congenital problems:
    - Imperforate hymen
    - Transverse vaginal septum
    (Tx of both above = surgical)
    - Absence of vagina with or without a functioning uterus (Rokitansky’s syndrome)
  2. Acquired problems:
    - Cervical stenosis
    - Asherman’s syndrome (uncommon consequence of excessive curettage at ERPC)
40
Q

What is postcoital bleeding (PCB)?

A
  • Vaginal bleeding following intercourse that is not menstrual loss
  • Always abnormal except for first intercourse
  • Must exclude cervical carcinoma
41
Q

List the causes of PCB

A
  1. Cervical:
    - Ectropions
    - Polyps
    - Invasive cervical cancer
  2. Occasionally from vaginal wall
42
Q

What is the management of PCB?

A
  • Cervix carefully inspected and smear taken
  • Polyp - removed and sent for histology
  • Ectropion - frozen with cryotherapy
  • Colposcopy to exclude malignant cause
43
Q

Define dysmenorrhea

A
  • Painful menstruation
  • High prostaglandin levels in endometrium
  • Due to contraction and uterine ischaemia
44
Q

Discuss the causes and management of dysmenorrhea

A
  1. Primary dysmenorrhea:
    - No organic cause
    - Coincides with start of menstruation
    - Usually responds to NSAIDs or ovulation suppression (COCP)
    - Pelvic pathology more likely if medical tx fails
  2. Secondary dysmenorrhea:
    - Pain due to pelvic pathology
    - Precedes and is relived by onset of menstruation
    - Deep dyspareunia + menorrhagia or irregular menstruation common
    - Pelvic US and laparoscopy useful

Most significant causes:

  • Fibroids
  • Adenomyosis
  • Endometriosis
  • PID
  • Ovarian tumours

OBGYN 4MB (25 decks)

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