Women’s Health Flashcards
Normal length of menstrual cycle
28 days
Phases of menstrual cycle
Follicular phase - follicles grow
Ovulation (1 day)
Luteal phase
Follicular phase hormone
FSH - causes growth of follicles
GnRH causes FSH release from anterior pituitary
Inhibin is later released to inhibit FSH
Name of follicle that ovulates (releases oocyte)
Mature/Grafian follicle
Hormone that causes ovulation
LH
Day 14 of 28 day cycle
Causes oocyte release
Corpus luteum
What the follicle turns into after ovulation
Produces oestrodiol and progesterone
Lasts for 2 weeks producing hormones unless egg is fertilised (stays for about 3 months until placenta takes over)
Degenerates into corpus albicans (doesn’t produce hormones)
Follicular phases
Primordial follicles Primary follicles Secondary follicles Tertiary follicles (most grown one is released into Fallopian tube) Corpus luteum Involution Corpus albicans Primordial follicles
HCG secreted by fertilised egg
Prevents corpus luteum undergoing involution
Uterine cycle phases
Menstrual phase Proliferation phase (grows) Secretory phase (continues growing + good vasculature, secretes more endometrium) If no fertilisation, endometrium breaks down
What happens during menstruated phase
Follicles grow
Menstration
Layer of endometrium always present
Stratum basalis
Layer of endometrium that breaks off
Stratum functionalis / functional layer
Layer below endometrium
Myometrium
Name of fertilised egg that starts mitosis
Blastocyst
Day fertilised egg will implant in uterine lining
About day 21
When uterine lining is at its thickest
Hormone responsible for blood vessels and increased secretion of stratum functionalis
Progesterone (+ oestradiol) secreted from corpus luteum
Time after which corpus luteum involutes if no blastocyst implantation
About 2 weeks
Reduces progestone levels
Menarche
The first menstrual cycle
Menopause
The cessation of menstruation for 12 consecutive months (not on hormonal contraception)
Diagnosed based on age + symptoms
Dysmenorrhoea
Painful menstruation
Menorrhagia
Abnormally heavy bleeding at menstruation
Metrorhagia
Period lasts for more than 7 days or spotting between periods
Not used very often
Oligomenorrhoea
Infrequent menstrual periods (less than 6-8 peer year)
Primary amenorrhea
Absence of menses at age 15 years in the presence of secondary sexual characteristics and normal growth
Secondary amenorrhea
Absence of 3 or more periods in a row by someone who has had periods in the past
Gynae cancers
Ovarian
Endometrial
Cervical
Vulval
Symptoms of cervical cancer - 2ww
On examination, appearance of cervix is consistent with cervical cancer
Endometrial cancer symptoms - ultrasound scan referral
High blood glucose levels with visible haematuria (age 55+)
Low haemoglobin levels with visible haematuria (age 55+)
Haematuria (visible) with low haemoglobin levels or thrombocytosis or high blood glucose levels or unexplained vaginal discharge (age 55+)
Thrombocytosis with visible haematuria or vaginal discharge (unexplained) (age 55+)
Vaginal discharge (unexplained) either at first presentation or with thrombocytosis or with haematuria (age 55+)
Endometrial cancer symptoms - 2ww
Post-menopausal bleeding (under or over 55)
Vulval cancer - 2ww
Unexplained vulval lump, ulceration, or bleeding
Vaginal cancer - 2ww
Unexplained palpable mass in or at the entrance to the vagina
Ovarian cancer symptoms
Appetite loss or early satiety Abdominal distension (persistent or more than 12/month) Ascites and/or pelvic or abdominal mass on physical examination Abdo pain IBS symptoms (age over 50) Unexplained change in bowel habit Unexplained fatigue Urinary urgency/frequency Unexplained weight loss
Ovarian cancer - 2ww
Ascites and/or a pelvic or abdominal mass identified by physical examination (which is not obviously uterine fibroids)
Abdominal or pelvic mass identified by physical examination
Ovarian cancer - blood test
Serum CA125
If greater then 35 IU/ml - USS of abdo + pelvis
‘Breakthrough bleeding’
Irregular bleeding with hormonal contraception
Intermenstrual bleeding (IMB)
Vaginal bleeding (not postcoital) at any time during the menstrual cycle other than during normal menstruation
Postcoital bleeding (PCB)
Non-menstruated bleeding that occurs immediately after sexual intercourse
Causes of PCB
Infection Cervical ectropion (esp COCP) Cervical or endometrial polyps Vaginal cancer Cervical cancer Trauma or sexual abuse Vaginal strophic change
% of PBC cases with no specific cause for bleeding found
50%
Causes of IMB
Pregnancy related - ectopic, gestational trophoblastic disease
Physiological - vaginal spotting around ovulation time, hormonal fluctuations in perimenopause
Vaginal - adenosis, vaginitis, tumours
Cervical - infection (chlamydia, gonorrhoea), cancer, cervical polyps, cervical ectropion, condylomata acuminata of the cervix
Uterine - fibroids, endometrial polyps, cancer, adenomyosis, endometritis
Oestrogen-secreting tumours
Iatrogenic - tamoxifen, following smear test, missed oral contraceptive pills, drugs altering clotting parameters (eg anticoags, SSRIs, corticosteroids)
Frequency of fibroids
Over 5% of women of reproductive age
Causes of breakthrough bleeding
Common when new type of contraception started
Pregnancy
Infection
More common with progesterone-only contraception
Smokers have increased risk
COCP, POP, contraceptive depot injections, IUS, implant, emergency hormonal contraception
Key menstruated changes history points
Last MP (normal?) Regularity + cycle length Duration fo abnormal bleeding Menorrhagia Timing of bleeding in cycle Associated symptoms (abdo pain, fever, vaginal discharge, dyspareunia) Exacerbating factors (eg intercourse, exercise) Previous pregnancies (delivery, miscarriage, termination) Currently breastfeeding Ectopic pregnancy RF Risk of current pregnancy Current use of contraception Smears Previous gynae investigations / surgery Med hx (bleeding disorders, diabetes) Sexual hx Current meds (+ OTC)
Dyspareunia
Difficult or painful sexual intercourse
Sexual history
Risk factors for STI
Those aged <25 or any age with new partner / more than 1 partner in last year
Past hx + treatment for STIs
High BMI is an independent risk factor for which gynae cancer
Endometrial cancer
Cervical ectropion (or erosion)
appears as a red ring around the external os due to extension of the endocervical columnar epithelium over the ectocervix
Cervical polyp
mass arising from the endocervix, usually protruding through the external os into the vagina. They can be avulsed and sent to histology. Occasionally, endometrial polyps can be seen extruding through the cervix
Cervicitis
the cervix appears red, congested and sometimes oedematous. There may be purulent discharge and the cervix is usually tender to palpation. The most common cause of infection currently is Chlamydia trachomatis. Neisseria gonorrhoeae as a cause of cervicitis should not be forgotten. A rarer cause is Trichomonas vaginalis where the cervix is friable, with prominent papillae and punctate haemorrhages, and is commonly described as a ‘strawberry cervix’. Herpetic cervicitis gives rise to multiple ulcerated regions
Key gynae investigations
Pregnancy test
Infection screen (STIs (esp chlamydia in IMB / PCB), N. gonorrhoea (depends on individuals sexual risk + local prevalence))
Cervical smears in those overdue regular screening
Menorrhagia summary
Excessive (heavy) menstrual blood loss which occurs regularly (every 24-35 days) and interferes with a women’s physical, emotional, social, and material quality of life
Excessive menstrual blood loss
80mL or more and/or a duration of more than 7 days
Peak age of women with menorrhagia
30-49
Name of menorrhagia with no underlying cause
Dysfunctional uterine bleeding
Almost 50% of menorrhagia cases
Causes of menorrhagia
Uterine and ovarian pathologies, such as uterine fibroids, endometriosis, and pelvic inflammatory disease.
Systemic diseases and disorders, such as coagulation disorders, hypothyroidism, diabetes mellitus, and liver or kidney disease.
Iatrogenic causes, such as anticoagulant treatment or chemotherapy.
Menorrhagia investigations
FBC to rule out iron deficiency anaemia
Presence of iron deficiency anaemia in menorrhagia
About 2/3
When should fibroids be referred to a specialist
More than 3cm in diameter
Less than 3cm with suspected / diagnoses adenomyosis
Adenomyosis
when the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus. The displaced tissue continues to act normally — thickening, breaking down and bleeding — during each menstrual cycle
Adenomyosis treatment
Hysterectomy
Causes of heavy periods
conditions affecting your womb, ovaries or hormones, such as polycystic ovary syndrome, fibroids, endometriosis and pelvic inflammatory disease
some medicines and treatments, including some anticoagulant medicines and chemotherapy medicines
stress and depression
Rarely, heavy periods can be a sign of womb cancer.
Menorrhagia treatment
IUS
COCP
Tranexamic acid
Anti-inflammatory painkillers - mefenamic acid, naproxen
Tramexamic acid
Helps the blood to clo
Side effects - nausea, diarrhoea, red itchy skin
Generally considered safe for breast feeding mothers
Don’t take whilst pregnant
Primary dysmenorrhagia
in young females in the absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain.
Secondary dysmorrhagia
caused by an underlying pelvic pathology (such as endometriosis, fibroids, or pelvic inflammatory disease [PID]) or by intrauterine device (IUD) insertion
Dysmenorrhagia prevalence
16-91% of women in reproductive age
Primary dysmenorrhea risk factors
earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea
Primary dysmenorrhoea onset
6–12 months after the menarche, once cycles are regular.
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
Features of primary dysmenorrhoea
The pain is usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynaecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain.
Pelvic examination is normal
Onset of secondary dysmenorrhoea
often starts after several years of painless periods.
The pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
Features of secondary dysmenorrhagia
Other gynaecological symptoms (such as dyspareunia) are often present.
Pelvic examination may be abnormal, but the absence of abnormal findings does not exclude secondary dysmenorrhoea.
Secondary dysmenorrhoea red flags
Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids).
Abnormal cervix on examination.
Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge.
Treatment of secondary dysmenorrhoea
Refer to secondary care - treat underlying cause
Treatment of primary dysmenorrhoea
A nonsteroidal anti-inflammatory drug (such as ibuprofen) and/or paracetamol will usually provide pain relief.
For women who do not wish to conceive, hormonal contraception is an alternative first-line treatment and has the additional advantage of providing contraception.
Local application of heat (for example, a hot water bottle or heat patch) and transcutaneous electrical nerve stimulation (TENS) may also help to reduce pain.
If symptoms are severe and have not responded to initial treatment within 3–6 months or if there is doubt about the diagnosis, referral to a gynaecologist should be arranged.
Primary amenorrhoea
No menses by age 14 in the absence of secondary sexual characteristics
No menses by 16 with secondary sexual characteristics
Secondary amenorrhoea
Menstruation has previously occurred but has stopped (at least 6 months, longer when menses previously infrequent)
Cause of primary amenorrhoea
Secondary sexual characteristics are present
Constitutional delay Genitourinary malformation Testicular feminisation Hyperprolactinaemia Pregnancy
Constitutional delay
there is no abnormality but she is a little later than her peers in reaching her menarche. Ask about the age of menarche in her mother and any older sisters. Reassure that the menarche is the last of the characteristics to develop
Genitourinary malformation
E.g. imperforate hymen, transverse vaginal septum or absence of the uterus or vagina (eg, Müllerian agenesis). Absence of a vagina may have previously gone unnoticed. If a uterus is present but there is no passage to the outside, there may be cyclical lower abdominal pains.
Testicular feminisation
also called androgen resistance syndrome, this occurs with an XY karyotype. There may be ambiguous genitalia.The external appearance is as a normal adolescent girl but there are no internal female organs. The gonads are testes that produce testosterone. There are no ovaries, Fallopian tubes, uterus or upper vagina. The clinical manifestation is variable according to the degree of androgen sensitivity.
Hyperprolactinaemia
can be due to many causes, including hypothyroidism and medication, especially phenothiazines. If it is due to a pituitary tumour, the level of prolactin (PRL) is usually very high.
Causes of primary amenorrhoea
Secondary sexual characteristics absent
Ovarian failure Hypothalamic failure Failure of hypothalamic-pituitary acid Congenital adrenal hyperplasia (CAH) Ambiguous genitalia
Ovarian failure
due to chemotherapy, irradiation, or chromosomal gonadal abnormality (eg, Turner syndrome).
Hypothalamic failure
this can be due to chronic illness, excessive exercise, stress or being significantly underweight. Anorexia nervosa usually develops after the menarche and represents a regression. Obesity is also more likely to cause secondary amenorrhoea.
Failure of hypothalamic-pituitary axis
Tumours, irradiation, infection or head injury involving the hypothalamus or pituitary.
Kallmann’s syndrome: characterised by failure of secretion of gonadotropin-releasing hormone (GnRH), tumours of the hypothalamus or pituitary gland along with other causes of hypopituitarism and hydrocephalus.
Other syndromes including empty sella syndrome, Prader-Willi syndrome and Laurence-Moon syndrome.
Congenital adrenal hyperplasia (CAH)
can cause precocious puberty or at least pseudoprecocious puberty as the development of sexual characteristics is not followed by menstruation
Causes of ambiguous genitalia
Eg androgen-secreting tumours
5 alpha-reductase deficiency
Precocious puberty
The appearance of signs of pubertal development at an abnormally early age
Before 8 in girls
Before 9 in boys
Most common cause of secondary amenorrhoea
Pregnancy (in women of childbearing age)
PCOS, hypothalamic amenorrhoea, hyperprolactinaemia, primary ovarian insufficiency
Secondary amenorrhea causes
No signs of androgen excess
pregnancy, lactation and the menopause Premature ovarian failure Depot and implant contraception Cervical stenosis and intrauterine adhesions (Asherman’s syndrome) Hypothalamic dysfunction Loss of weight Pituitary disease andhyperprol Thyroid disease Iatrogenic ‘Post-pill amenorrhoea’
No signs of androgen excess
Pregnancy, lactation and the menopause
physiological causes. Secondary amenorrhoea is due to pregnancy until proved otherwise. Even denial of sexual activity should be taken with a degree of circumspection.
No signs of androgen excess
Premature ovarian failure
physiological causes. Secondary amenorrhoea is due to pregnancy until proved otherwise. Even denial of sexual activity should be taken with a degree of circumspection.
No signs of androgen excess
Depot and implant contraception
often produces amenorrhoea and the progestogen-only contraceptive pill can do so less often. Intrauterine contraceptive devices usually increase menstrual flow but intrauterine contraceptive systems (Mirena® and to a lesser degree Jaydess®) reduce menstrual flow and may stop it.
No signs of androgen excess
Asherman’s syndrome
Cervical stenosis and intrauterine adhesions
No signs of androgen excess
Hypothalamic dysfunction
may cause menstruation to cease. Causes include: stress, excessive exercise, eating disorders, depression, chronic systemic illness and tumours.
No signs of androgen excess
Loss of weight
especially if rapid. Body mass index (BMI) is rarely above 19 where this is the case, and at least 10% of normal body weight has been lost. Anorexia nervosa and other eating disorders including bulimia nervosa should be considered. The female athlete triad is well recognised. It consists of eating disorder, amenorrhoea and osteoporosis, predisposing to stress fractures. The triad affects not just distance runners but gymnasts and dancers
No signs of androgen excess
Pituitary disease and hyperprolactinaemia
prolactinomas cause raised prolactin levels and subsequent amenorrhoea. Medication (for example, phenothiazines, methyldopa, cimetidine, opiates and metoclopramide) may raise prolactin levels. Recreational drugs may also cause this; prolonged amenorrhoea is very common in heroin abusers. They are usually underweight but there may also be a pharmacological effect. The pituitary gland may be damaged by tumours, trauma, cranial irradiation, sarcoidosis or tuberculosis. Sheehan’s syndrome is acute pituitary infarction due to postpartum haemorrhage.
Sheehan’s syndrome
acute pituitary infarction due to postpartum haemorrhage.
No signs of androgen excess
Thyroid disease
either hypothyroidism or hyperthyroidism may affect menstruation.
No signs of androgen excess
Iatrogenic
apart from medication discussed above (those which raise prolactin and hormonal medication), other iatrogenic causes include surgery (hysterectomy, endometrial ablation, ovarian surgery), irradiation and chemotherapy.
No signs of androgen excess
‘Post-pill amenorrhoea’
this occurs when stopping oral contraceptives does not lead to a resumption of a normal menstrual cycle. It usually settles spontaneously in around three months but, if not, it requires investigation. It may be that the cause of amenorrhoea started whilst taking the contraceptives which induced an artificial cycle, masking the issue until they were stopped.
Signs of androgen excess
Features
Eg hirsuism, acne, virilisation
Secondary amenorrhoea causes
Signs of androgen excess
Polycystic ovary syndrome (PCOS)
Cushing’s syndrome
Late-onset congenital adrenal hyperplasia
Adrenal or ovarian carcinoma
Androgen excess
PCOS
PCOS accounts for as many as 30% of cases of amenorrhoea. Both androgens and oestrogens may be normal or slightly raised so that, whilst there are signs of virilisation, there is no evidence of oestrogen deficiency. They are usually, but not always, overweight and may have insulin resistance. Fat is very important in the metabolism of the steroid sex hormones and it accounts for both the excess in PCOS and the deficiency in anorexia.
Androgen excess
Cushing’s syndrome
may be spontaneous or iatrogenic
Androgen excess
Late-onset congenital adrenal hyperplasia
Produces androgens
Androgen excess
Adrenal or ovarian carcinoma
Can produce androgens
Key amenorrhoea questions
Duration of amenorrhoea. Contraception, recent and current. Vasomotor symptoms. Galactorrhoea. Exercise habits. Stresses. Medication history. Past medical history.
Amenorrhoea investigations
Pregnancy test (if appropriate). Urinary or serum hCG is measured.
Follicle-stimulating hormone (FSH) and luteinising hormone (LH). FSH and LH are raised in ovarian failure; an FSH level ≥20 IU/l in a woman aged under 40 with secondary amenorrhoea indicates ovarian failure.
Prolactin. (Raised in 7.5% of women with amenorrhoea), measure at least twice
Total testosterone and sex hormone-binding globulin
TFTs - Low T4 with low thyroid-stimulating hormone (TSH) suggests pituitary failure.
Pelvic ultrasound
Some of the extra potential amenorrhoea investigations
Karyotyping may be required to exclude Turner syndrome, testicular feminisation and rarer conditions such as XXX
Where chronic illness is suspected, investigation follows clinical findings.
MRI or CT where pituitary tumour is suspected or for investigation of adrenal or ovarian tumours.
Hysteroscopy may be required for Asherman’s syndrome.
When do you need an FSH blood test to diagnose menopause
(Must not be taking combined oestrogen and progestogen contraception or high-dose progestogen as reduced accuracy of results)
Women aged over 45 years with atypical symptoms.
Women between 40–45 years with menopausal symptoms, including a change in their menstrual cycle.
Women younger than 40 years in whom premature menopause is suspected.
How is menopause clinically diagnosed normally
Age + symptoms
Symptoms of menopause
hot flushes/night sweats, cognitive impairment + mood disorders, urogenital symptoms, altered sexual function, sleep disturbance
What factor complicates the diagnosis of menopause
The use of oral contraception
Types of HRT available
Tablets: oestrogen-only or combined, higher risk of blood clots
Skin patches: oestrogen-only or combined, better if you don’t like taking tablets everyday, avoids some side effects (eg indigestion + increased clot risk)
Oestrogen gel
Implant (lasts for several months before needs to be replaced, small pellet-like implant inserted under skin (mostly tummy area), oestrogen only (so will need to take progesterone separately if you still have a womb), IUS (3-5 years + contraceptive)
Vaginal oestrogen cream(doesn’t increase risk of breast cancer, can use without progesterone even if still have womb)
When can you use oestrogen-only HRT
If you’ve had a hysterectomy
Anyone can use vaginal oestrogen only cream
Cyclical vs continuous HRT
Cyclical - monthly (women having regular periods), 3 monthly (irregular periods, every 3m)
monthly HRT – you take oestrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
3-monthly HRT – you take oestrogen every day, and take progestogen alongside it for around 14 days every 3 months
Continuous - postmenopausal (no period for 1 year), no breaks
Contraindications to taking HRT
No contraindications but may need to change type of HRT based on breast/gynae cancer history)
HRT side effects
Slightly increased risk of breast cancer - similar to background rate Blood clot risk higher with tablets Weight gain Bloating Breast tenderness Headaches Mood swings Vaginal bleeding
Perimenopause
the period before the menopause characterized by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period
Mean age of natural menopause in UK
51 years
Cervical cancer screening frequency
Offered to everyone with a cervix aged 25-64
Every 3 years aged 25-49
Every 5 years aged 50-64
Screens for HPV (increased risk of developing cervical cancer)
Proportion of women in UK diagnosed with breast cancer during their lifetime
About 1 in 8
Breast cancer screening frequency
Women aged 50-71
Every 3 years
Maybe eligible for screening before 50 if very high risk of developing breast cancer
Local vs systemic causes of menorrhagia
The range of causes is divided into local (e.g. adenomyosis, fibroids, endometrial polyps) and systemic (e.g. clotting problems, hypothyroidism)
