Women's health Flashcards
Ovarian cycle
Provide an environment for fertilisation
- Follicular phase
- Luteal phase
Uterine cycle
Receives fertilised oocyte and allows implantation
Proliferation phase - prior to ovulation
Secretory phase - after ovulation
Female HPG axis
- Pulsatile GnRH released from the hypothalamus
- Stimulates the anterior pituitary to release FSH and LH
- FSH stimulates granulocytes and theca interna and externa cells to proliferate
- FSH causes granulosa cells of the follicles to release oestrogen and inhubin and causes follicles to mature.
LH causes theca interna cells to release androgens which are aromatised to oestrogen under the influence of FSH.
- Oestrogen at low concentrations has a negative feedback on the hypothalamus. As follicles develop, oestrogen concentration increases and exerts a positive feedback
- Once the dominant follicle has been selected, inhibin causes negative feedback on the anterior pituitary so follicles stop maturing
- Oestrogen exerts a positive feedback on the hypothalamus, anterior pituitary and granulosa cells so oestrogen and inhibin are still produced.
- Once, LH conc is more than FSH, ovulation occurs
Male HPG axis
- Hypothalamus releases GnRH in pulsating manner as there is no ovarian hormone production and no negative feedback
- Stimulates the anterior pituitary to release FSH and LH
- FSH stimulates the sertolli cells to produce sperm and LH stimulates the Leydig cells to produce testosterone
Which phase of the ovarian cycle can be varied?
Follicular phase
Ovulation
Mature oocyte is extruded through the ovarian capsule into the peritoneal cavity where it is picked up by fimbrae and transported to the fallopian tube
Meiosis I is completed and Meiosis II starts
Endometrium
Stratum functionalis layer: Sheds during menstruation
Stratum basalis: contains stem cells and allows regrow the at the start of the cycle
Proliferates in response to oestrogen - thick and fat
Becomes more glandular and secretory in response to oestrogen and progesterone
Prevents blastocyst from implanting too far via the decidual reaction
Proliferation phase
Create a good environment for fertilisation
The functional layer proliferates and thickens
Simple straight glands coil
Secretory phase
Progesterone causes coiled glands to become secretory
Blood supply is established - spiral arteries
Oestrogen in the proliferative phase
Proliferation of the myometrium and endometrium
Increases fallopian tube motility
Thin, alkaline cervical mucous is produced
Normal menstrual cycle
21 - 35 days
Variation due to variation in follicular phase
Progesterone in the secretory phase
Create environment viable for pregnancy
Decreases myometrium motility
Further thickening of the endometrium
Thick, acid cervical mucus
Increased body temperature
Primary amenorrhoea
Absence of menstruation
Never had a period by the age of 16
Secondary amenorrhoea
Started periods but the periods have stopped for more than 6 months
Causes:
- pregnancy
- weight loss
- menopause
- birth control
- hypothyroidism
- hyperprolactinaemia
Oligomenorrhoea
Reduced menstruation
Cycle length is more than 35 days
Menorrhagia
Heavy menstrual bleeding
More than 80ml
Causes:
- benign or malignant growth in the endometrium
- clotting disorders
- anticoagulation therapy
- normal
Presentation:
- fatigue
- pallor
Ix:
Bloods - FBC
(anaemia)
Dysmenorrhea
Painful periods
Causes:
- endometriosis
Polycystic ovarian syndrome summary
Cause: idiopathic
Risks: COCP and obesity
Pathophysiology: Elevated LH causing hyperandrogenism
Presentation: Raised insulin resistance - T2DM Secondary amenorrhoea Infertility Hirsutism Obesity
Ix: USS and blood test
Treatment: remove uterus
How long should menses last
7 - 9 days
Endometriosis cks
Pathophysiology: Endometrial tissue that occurs outside the uterine cavity (Oestrogen dependent)
Presentation:
- early menarche
- menorrhagia
- dysmenorrhea
- AUB
- infertility
- dyspareunia
Management of dysmenorrhea
NSAIDs
COCP
Intrauterine device
GnRH analogues
Surgery - hysterectomy
Menopause
No menstruation periods for 12 consecutive months and no other biological or physiological cause identified
Due to loss of ovarian follicular activity
Ovaries can no longer produce follicles - oestrogen decreases
Early menopause
Menopause occurring before 45
Premature menopause (pathological)
Cessation of menopause as all ovarian follicles depleted before 40
(Premature ovarian failure)
Menopausal transition
Time between onset of irregular menses and permanent cessation of menstruation
Average - 4 years
What age does ovarian function decline
45 - 55 years old
Average - 50yrs old
Premenopause
Time before menopause
- less oestrogen secretion
- Reduced fertility
- cycle relatively unchanged
Perimenopause
Transitional phase Physiological changes: - mood swings - hot flushes - infrequent menstruation
Follicular phase shortens and ovulation is early or absent
Post menopause
Time after a women has experience amenorrhoea for over 12 months
No longer able to conceive
Hormone measured to diagnose physiological menopause
FSH - increases significantly
As oestrogen no longer secreted so no inhibition
Symptoms of menopause
Itchy - puritis Twitchy - restless limbs Sweaty Sleepy Bloated Moody Forgetful
Early signs of menopause
Hot flushes Sweating Insomnia Irregular menstruation Mood swings Depression
Intermediate menopause symptoms
Vaginal atrophy Dyspareunia Skin atrophy - breasts Urge stress continence Frequent UTIs - atrophy of urethra and bladder lining Reduced pubic hair
Late menopause symptoms
Osteoporosis - increased osteoclasts activity
Atherosclerosis - CHD, CVD - increased cholesterol and less HDLs
Hormone replacement therapy (for symptomatic relief only)
Oestrogen
- pill
- vaginal cream
- transdermally - patch
Red flags
Endometrial cancer
- haematuria + high blood glucose
- Post menopausal bleeding
Ovarian cancer - Ascites and abdominal distension
Vulval cancer - lump and bleeding
Oocyte maturation
- Germ cells colonise the gonadal cortex and differentiate into oogonia
- Oogonia proliferate by mitosis
- Arrange in clusters surrounded by squamous epithelial cells
- Some enter meiosis till prophase I forming primary oocytes
- Atresia
- Surviving primary oocytes surrounded by follicular cells - primordial follicles
- Preantral stage - from squamous to straitidied cuboidal - granulosa cells
- Granulosa cells secrete glycoprotein forming zona pellucida
- Antral stage - fluid filled spaces form between granulosa cells and coalesce forming antrum
- Preovulatory stage - induced by surge of LH, meiosis I complete and arrest in meiosis II (metaphase II)
Post coital bleeding
Causes:
- Infection - STI
- cervical or endometrial polyps
- vaginal or cervical cancer
- trauma
Ix:
- pregnancy test
- STI screen
- Blood tests - clotting, FSH (menopause)
- Trans- vaginal USS
- cancer screening
When to refer for menorrhagia
- ascites
- abdominal mass
- compression symptoms e.g. dyspareunia
- fibroids > 3cm
Mx of menorrhagia
- Iron tablets - if anaemia with iron deficiency
- Levonorgestrel intrauterine system
- Tranexamic acid or NSAID
- COCP or POP
- Surgery - remove fibroids if > 3cm or uterine artery embolisation
- Endometrial ablation
- Hysterectomy
Contraindications for tranexamic acid
Fibrinolytic conditions following DIC
Convulsions
Severe renal impairment
History of DVT/PE
Mx of menopausal symptoms
Conservative:
- hot flushes - wear thin layers
- Low mood - adequate sleep
Vasomotor symptom control
- SSRI
Mood disorders - antidepressants
Urogenital symptoms - moisturiser and lubricants
HRT
With uterus - oral or transdermal combined oestrogen - progesterone
Without uterus - oestrogen only pill or transdermal patch
Follow up after 3 months
Risks of HRT
VTE - greater in oral preparations
Combined HRT increases risk of breast cancer
Causes of post coital bleeding
- Infection
- Cervical or endometrial polyps
- Vaginal cancer
- Cervical cancer
- Trauma or sexual abuse
Investigations of post coital bleeding
- pregnancy test
- STI screen
- Blood tests - clotting, FSH (menopause suspected)
- Trans vagina ultrasound - structural abnormality
- Referral for cancer screening
Mx of post coital bleeding
- pregnancy test
- STI screen
- Blood tests - clotting, FSH (menopause suspected)
- Trans vagina ultrasound - structural abnormality
- Referral for cancer screening
Causes of inter menstrual bleeding:
• Ectopic pregnancy • Gestational trophoblastic disease • Vaginal spotting may occur during the time of ovulation • Vaginal adenosis - benign metaplastic endometrial/ cervical epithelium • Vaginal cancer • Cervical infection ◦ Chlamydia ◦ Gonorrhoea • Cervical cancer • Uterine Fibroids • Polyps • Iatrogenic ◦ Tamoxifen ◦ After smear ◦ Missed oral contraceptive pill
Causes of menorrhagia
- 50% idiopathic
- Uterine fibroids
- Endometriosis
- PID
- Polyps - endometrial
- PCOS
- Endometrial hyperplasia
- Coagulation disorders e.g. Von Willebrands disease
- Hypothyroidism
- Diabetes mellitus
- Hyperprolactinaemia
Ix for menorrhagia
- look for related symptoms
- Look for causative condition - Bloods FBC (iron deficiency anaemia), clotting, HbA1C, TSH
- Abdo exam - fibroids
- Bimanual pelvic examination
- Ultrasound - polyps
Causes of amenorrhoea
• constitutional delay - FHx • Structural defect - imperforate hymen • Androgen resistance syndrome • Hyperprolactinaemia- hypothyroidism or pituitary tumour • Pregnancy • Chemotherapy • Hypothalamic failure ◦ Anorexia ◦ Stress ◦ Chronic illness ◦ Excessive exercise • PCOS • Cushing’s syndrome
Ix of amenorrhoea
• BMI • Abdo exam • Pelvic examination • Blood test ◦ Androgens ◦ Cortisol ◦ FSH ◦ Prolactin ◦ TSH • Pregnancy test • Pelvic ultrasound • Karyotyping - exclude Turners • MRI head - pituitary tumour
Cyclical HRT
monthly or trimonthly with break in between so know when period has stopped
Continuous HRT
Given when periods have stopped for at least 12 months or over 51 yo
Endometriosis presentation
Vague pelvic pain
Deep dyspareunia
Pain on defecation
Dysuria
Haematuria
Urgency
Adenomyosis presentation
Dysmenorrhoea
Dyspareunia
Menorrhagia
PID presentation
Chronic pelvic pain
Deep dyspareunia
Fibroids presentation
Pelvic pain
Menorrhagia
Endometriosis Ix and Mx
- refer to secondary care for laparoscopy
Mx:
- NSAIDs +/- paracetamol
- COCP/POP
- refer to secondary care for: GnRH analogues, surgery
