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3a > WH: Menstrual Disorders > Flashcards

WH: Menstrual Disorders Flashcards

1
Q

What is amenorrhoea

A

Lack of menstrual periods

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2
Q

what is primary amenorrhoea ? what age?

A

patient has never developed menstural periods
( not starting menstruation by 15 when there are other sings of puberty)

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3
Q

what could cause primary amenorrhoea ? (5)

A
  • Abnormal function of hypothalamus (hypogonadotorphic hypogonadism)
  • Abnormal function of gonads (hypergonadotrophic hypogonadism)
  • congenital structural abnormalities (imperforate hymen)
  • Congenital Adrenal hyperplasia
  • Androgen insensitivity syndrome
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4
Q

what is secondary amenorrhoea ?

A

patient has piously had periods that they stop

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5
Q

Causes of secondary amenorrhoea ? (7) most common ?

A
  • Pregnancy (most common)
  • menopause
  • Physiological stress
  • PCOS
  • Medications (hormonal)
  • Thyroid hormone abnormailites
  • Cushings
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6
Q

what physiological stress could cause secondary amenorrhoea ?

A
  • high exercise
  • low BMI
  • chronic disease
  • Physcosocial factors
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7
Q

What is irregular mesntruation

A

abrnomal uterine bleeding: abnormal
- Frequency
- Duration
- Volume of menses
- Regularity

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8
Q

What does irregular menstruation indicate? (2)

A
  • annovulation (lack of ovulation)
  • Irregular ovulation
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9
Q

what pathophysiology could cause irregular menstruation?

A
  • disruption of normal hormone levels
  • ovarian pathology
    (think HPG axis)
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10
Q

causes of irregular menstruation ? (6)

A
  • Extremes of reproductive age
  • PCOS
  • Psychosocial stress
  • eating disorder/chronic disease
  • Hormonal imbalance
  • thyroid disorder
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11
Q

What is intermenstural bleeding (IMB)

A

any bleeding that occurs between menstural periods

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12
Q

what is intermenstrual bleeding a red flag for?

A

red flag for cervical cancer but has more common causes

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13
Q

common causes of IMB?

A

intermenstrual bleeding
- hormone contraception
- Cervical ectropion/polyps
- STI
- pregnancy

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14
Q

What is dysmenorrhoea

A

Painful periods

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15
Q

What could cause dysmenorrhoea ?

A
  • Primary dysmenorrhoea (no underling pathology)
  • Endometriosis
  • Fibroids
  • PID
  • Copper coil
  • Cervical/endo cancer
  • PCOS
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16
Q

what is menorrhagia ?

A

heavy menstrual periods

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17
Q

What could cause menorrhagia ? (9)

A
  • Dysfunctional uterine bleeding
  • Extremes of reproductive age
  • fibroids
  • Endo
  • PID
  • Contraceptive (copper coil)
  • anticoags
  • Bleeding disorders
  • PCOS
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18
Q

What is post-coital bleeding a red flag for?

A

red flag for cervical cancer but other reasons more common

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19
Q

post coital bleeding causes? (4)

A
  • trauma
  • Atrophic vaginitis
  • cervical ectropion/polyps
  • endo/vaginal/cervical cancer
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20
Q

what could cause pelvic pain? (12)

A
  • UTI
  • Dysmenorrhoea
  • IBS
  • ovarian cysts
  • endo
  • PID
  • Ectopic pregnancy
  • Appendicitis
  • Mittelschmerz
  • Pelvic adhesions
  • Ovarian torsion
  • IBD
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21
Q

what vaginal discharge is concerning?

A

excessive
discoloured
foul smelling

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22
Q

what could cause abnormal vaginal discharge? (6)

A
  • BV
  • STI
  • foreign body
  • Pregnancy
  • Ovulation
  • Cervical ectropion
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23
Q

what is kallman syndrome ? what type of amenorrhoea does it cause?

A

Kallman syndrome
- genetic condition causing hypogonadotrophic hypogonadism with failure to start puberty (primary amenorrhoea)

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24
Q

Briefly describe hypogonadotrophic hypogonadism: defieicy in what ? due to abnormal functioning of what?

A

abnormal function of hypo/AP => deficiency in LH + FSH
- causes low oestrogen

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25
Q

Briefly describe hypergonadotrophic hypogonadism: defieicy in what ? due to abnormal functioning of what?

A

abnormal function of gonads
ovaries fil to respond to gonadotrophin (LH + FSH) => no oestrogen => high LH + FSH, low sex hormones

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26
Q

hypothalamic causes of amenorrhoea? (3)

A

(hypogonadotrophic hypogonadism)
- Functional disorders (eating disorders, exercise)
- Severe chronic conditions (psychiatric, thyroid disease)
- Kallmann syndrome

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27
Q

what type of inheritance is Kallmann syndrome ?

A

x-linked recessive disorder

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28
Q

Kallmann syndrome pathophysiology

A

underdevelopment of specific neurones in brain => filature of migration of GnRH cells => hypogonadotrophic hypogonadism => primary amenorrhoea

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29
Q

Pituitary causes of amenorrhoea ?

A

(hypogonadotrophic hypogonadism)
- Prolactinomas
- Other pituitary tumours
- Sheehans syndrome (post-partum)

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30
Q

Ovarian causes of amenorrhoea/oligomenorrhoa ? (3)

A
  • PCOS
  • Turners syndrome
  • Premature ovarian failure (early menopause - before 40)
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31
Q

Adrenal causes of amenorrhoea ?

A

congenital adrenal hyperplasia

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32
Q

physiological causes of amonorhoea ?

A

(secondary)
- Pregnancy
- lactation
- Menopause

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33
Q

What is congenital adrenal hyperplasia ?

A

congenital deficiency 21-hydroxylase enzyme => underproduction of cortisol + aldosterone + overproduction of androgens
(cause of primary amenorrhoea)

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34
Q

What type of inheritance is congenital adrenal hyperplasia ?

A

autosomal recessive

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35
Q

what is androgen insensitive syndrome ?

A

genetically males are unable to reopen to androgen hormones (testosterone) and excess converted to oestrogen => male genotype and female phenotype (female secondary characteristics)

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36
Q

Genetic abnormilaites causing primary amenorrhoea ?

A
  • Turnerss syndrome
  • Kallmanns syndrome
  • androgen insensitivity syndrome
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37
Q

definition of secondary amenorrhoea ?

A

no mesntruation for more than 3 months after previous regular menstrual periods

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38
Q

How does hyperprolactinaemia cause secondary amenorrhoea ? what type of amenorhhoea is this?

A

raised prolactin supresses GnRH release from hypothalamus (hypogonadotrophic hypogonadism)

39
Q

Hyperprolactinaemia treatment ?

A

dopamine agonist: cabergoline

40
Q

what investigations would you do for amenorrhoea ?

A
  • pregnancy test
  • LH + FSH
  • prolactin
  • TFT
41
Q

what are patient with amenorrhoea associated with low oestrogen at higher risk of?

A

osteoporosis risk

42
Q

What is PMS? during which phase?

A

premenstrual syndrome
- psychological, emotional +physical symptoms that occur during the luteal phase (days prior to menstruation)

43
Q

what is PMS caused by?

A

fluctuation of oestrogen + progesterone (not fully understood)

44
Q

PMS presentation

A
  • Low mood, anxiety, mood swings, irritability
  • bloating, fatigue, breast pain
  • Reduced confidence, cognitive difficulties, reduced libido
45
Q

what is severe PMS that affects QOL ?

A

premenstrual dysphoric disorder

46
Q

how is PMS diagnosed? when do symptoms improve ?

A

symptom diary shows cyclical changes
- symptoms improve after menstruation

47
Q

PMS management

A
  • general healthy lifestyle (diet, exercise, alcohol, stress, sleep)
  • COCP
  • SSRI
  • CBT
48
Q

What is menorrhagia?

A

heavy menstrual bleeding

49
Q

average blood loss during menstruation ?

A

40ml

50
Q

what counts as excessive blood loss? vol? symptom complaint?

A

> 80ml
- changing pad every 1-2 hours
- bleeding lasting >7days
- passing large clots

51
Q

Causes of menorrhagia ? (9)

A
  • dysfunctional uterine bleeding (no identifiable cause)
  • extremes of reproductive age
  • fibroids
  • PCOS
  • PID
  • Endo
  • Bleeding disorder
  • Anticoagulants
  • Copper coil
52
Q

what investigations might you to for menorrhagia ?

A
  • Pelvic exam + speculum + bimanual
  • consider hysteroscoy, TVUS
53
Q

menorrhagia management categories ? (3)

A
  • contraceptive
  • non-contraceptive
  • definitive
54
Q

what contraceptive management is there for menorrhagia ? (3)

A

1) mirena coil
2) COCP
3) cyclical oral progestogens

55
Q

what non-contraceptive managmetn is there for menorrhagia ?

A
  • Tranexamic acid
56
Q

what is a definitive management option for menorrhagia ? (2)

A
  • endometrial ablation
  • hysterectomy
57
Q

What is primary dysmenorrhoea ? secondary ?

A

primary: menstural pain occurring with no underlying pelvis pathology
secondary: menstrual pain that occurs with an oassocaietd pelvic pathology

58
Q

examples of secondary dysmenorrhoea causes ?

A
  • endometriosis
  • adenomyosis
  • PID
  • Adhesions
  • non gynae (IBD, IBS)
59
Q

what is the pathophysiology of parity dysmenorrhoea ? what chemical involved ?

A

thought to be due to excessive prostaglandin release by endometrial cells
- prosaglandins => serial artery vasospasm (=> ischaemic necrosis) + increase myometrial contractions

60
Q

features of primary dysmenorrhoea ? associated with ?

A

lower abdo or pelvic pain
- crampy, lasts 48-72 hrs
- associated with malaise/N+V/diarhoea/dizziness

61
Q

primary dysmorrhoea Mx ?

A

lifestyle: stop smoking
- pharmacological NSIADs (inhibits the production of prostaglandins)
- 2nd line: COCP, mirena coil

62
Q

What is HRT ? in who is it used ?

A

used I perimenopausal + PM women to alleviate symptoms of menopause

63
Q

what brings on the sx of the menopause ? associated with what ?

A

sx associate with decline in oestrogen
(so HRT: exogenous oestrogen)

64
Q

what hormones are in HRT ?

A

oestrogen
- plus progesterone given to women that have a uterus (to prevent endometrial hyperplasia/thicken of endo => endo cancer secondary to unopposed oestrogen)

65
Q

what is unopposed oestrogen ?

A

oestrogen without protection of progesterone

66
Q

Generally, what HRT recommended for: women that have periods ?

A

cyclical HRT with cyclical progesterone + regular breakthrough bleeds

67
Q

Generally, What HRT recommended for: PM women with uterus + more than 12 months without periods?

A

continuous HRT

68
Q

no hormonal Tc for menopause Sx ?

A
  • lifestyle change (diet, stop smoking, increase exercise, reduce alcohol, reduce caffein, reduce stress)
  • CBT
  • SSRI, venlafaxine
  • gabapentin
  • clonidine
69
Q

what is clonidine used for ?

A

redue BP + reduce HR => reduce hot flushes (vasomotor sx of menopause)

70
Q

indications for HRT ? (6)

A
  • replaying hormones in premature ovarian insufficiency (even without sx)
  • hot flushes, night sweats (sx of reduced vasomotor)
  • improve low mod
  • low libido
  • poor sleep
  • reduce osteoporosis risk
71
Q

benefits of HRT ? (3)

A
  • improved sx
  • improved QOL
  • reduce osteoporosis risk
72
Q

HRT risks ? (4)

A
  • increase breast cancer risk (combined HRT)
  • increase endo cancer risk (so add progestogen if have uterus)
  • increase VTE risk (so use patches rather than pill)
  • stroke
73
Q

HRT contraindications ? (7)

A
  • undiagnosed abnormal bleeding
  • endometrial hyperplasia/cancer
  • breast cancer
  • uncontrolled hypertension
  • VTE
  • liver disease
  • pregnancy
74
Q

does cyclical or continuous HRT have better endo protection ?

A

continuous HRT has better endo protection than cyclical HRT

75
Q

what different options for oestrogen are there for HRT ?

A

oral, transdermal (gel/patches)
-transdermal: better for poor oral Mx, increase VTE risk, CVD, headaches

76
Q

why is progesterone used in HRT ?

A

reduce risk of end-hyperplasia + cancer in women with uterus
(helpful for reduced libido, depression)

77
Q

what different types of progestogen are used in HRT ?

A

oral, transdermal, IUS (mirena)
- C19: derived from testosterone (helpful in low libido)
- C21: derived from progesterone (helpful in depression/acne)

78
Q

what can mirena be used for ? (3)

A
  • HRT
  • contracpetion
  • Menorrhagia
79
Q

are patches or pills typically better for HRT ?

A

patches tend to be better due to reduced VTE risk

80
Q

what HRT regime for woman with no uterus ?

A

oestrogen only pill or patch

81
Q

what HRT regime for premenopausal woman with periods ?

A

cyclical combined tablet/patch/mirena coil
PLUS oestrogen only pills/patches

82
Q

example regime for PM women with uterus?

A

continuous combine tablet/patch, mirena coil PLUS oestrogen only pills/patches

83
Q

additional HRT mx ? when check up ?

A

follow up 3 months after starting HRT
- SE usually settle with time, takes 3-6 months to get full effects

84
Q

is HRT contraception ?

A

nope
- but mirena or POP (in addition to HRT) is

85
Q

HRT SE ?

A

oestrogen: nausea, bloating, breast swelling, breast tenderness, headaches
- progesterone: mood swings, bloating, fluid retention, weight gain, acnei

86
Q

If you are getting HRT SE, what should you consider ?

A

changing pill => patch
different progestogen

87
Q

how to stop HRT ?

A

rescued gradually or stopped abruptly

88
Q

What is premature ovarian insufficiency ? due to what ?

A

It is menopause <40 yrs
- due to decline invariant activity => early menopause sx

89
Q

what are the hormone levels like in premature ovarian insufficiency ? what hyper/hypogonadotorphin things is this ?

A

hypergonadoprophic hypogonadism (under activity of ognads)
- high LH + high FSH
- Low estradiol

90
Q

causes of premature ovarian insufficiency ? (5) most common ?

A
  • idiopathic (50%)
  • iatrogenic (chemo, radiotherapy, oophorectomy)
  • autoimmune
  • genetic
  • infection (mumps, cytomegalovirus)
91
Q

premature ovarian insufficiency px ? (3)

A

oligomenorrhoea or secondary amenorrhea
- sx of low oestrogen (hot flushes, night seats, vaginal dryness)

92
Q

premature ovarian insufficiency dx ?

A

typical monpasual sx PLUS elevated FSH
(in a women <40 yrs)

93
Q

what conditions are associated with the reduced oestrogen in premature ovarian insufficiency ? (5)

A
  • CVD
  • Stroke
  • Osteoporosis
  • Cognitive impairment
  • Dementia
94
Q

premature ovarian insufficiency Mx ?

A

HRT
- traditional HRT
- or COCP

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