Menstrual Disorders - Amenorrhea, Dysmenorrhea Flashcards
Folliculogenesis
-before birth
-puberty
-fertilization
Arrest points
Before birth - primordial follicle pool
-primary oocytes arrest at P1
Puberty
-primary oocytes atrese or mature into antral cells
-antral cells complete meiosis 1 => secondary oocyte + 1 polar body
-secondary oocyte arrest at M2
After ovulation
-secondary oocyte fertilised
-meiosis 2 complete + 2nd polar body
Follicular phase and ovulation
-days
-what happens
Menstrual and proliferative phase
-days
-what happens
Follicular phase - 1-10
-FSH and LH stimulate follicle development => O released from follicles
Ovulation - 11-14
-O increase => LH surge triggers ovulation
-basal body temp falls
-O, P, LH receptors increase
Menstrual phase - 1-5
Proliferative - 6-14
-endometrium builds up
-thick mucus plugs cervix
-before ovulation, wet mucus
Luteal phase
-days
-what happens
Secretory phase
-days
-what happens
Luteal - 15-28
-corpus hemorhagicum => CL releases P
-no implantation => corpus albicans => fall in P
Secretory - 15-28
- increased P => endometrial glands, spiral arteries build up
- secrete mucus, glycogen
- cervical mucus thickens
- basal body temp increases
Oestrogen function
Endometrial proliferation
Follicle growth
LH surge
Upregulates O, PO, LH receptors
Increases TBG levels
Genitalia development
Female fat distribution
Increases hepatic synthesis of transport proteins
Progesterone function
Maintain endometrium, pregnancy
Thicken cervical mucous
Decrease myometrial excitiability
Increases body temp
Spiral artery dev
Causes of primary amenorrhea
-definition
No period by
-13 + without 2ndary sexual characteristics
-15 + 2ndary sexual characteristics
Gonadal dysgenesis - Turners
Functional hypothalamic
CAH
Imperforate hymen
Causes of secondary amenorrhea
-definition
Past normal, regular - no period for 3-6months
Past oligomenorrhea - no period for 6-12months
Hypothalamic amenorrhea
PCOS
High PRL
POI
Thyrotoxicosis
Sheehan’s - postpartum bloodloss affecting pituitary function
Asherman’s - build up of scar tissue in uterus
Amenorrhea
-investigations
-management
Exclude pregnancy - urinary/serum bHCG
FBC, U&E, coeliac screen, TFT
FSH, LH
-high if ovarian problem
-low if hypothalamic problem
PRL
Androgens
-high in PCOS
O
For primary and secondary
-find underlying cause
PCOS
-pathophysiology
-presentation
-investigations
-management
High LH => high T
Hyperinsulinemia
Triad of
Reproductive disfunction
-sub/infertility
-oligo/amenorrhea
Hyperandrogenism
-hirsutism, acne
Metabolic syndrome
-obesity
-acanthosis nigricans
High LH:FSH ratio
PRL, T normal or high
Impaired glucose tolerance
Pelvic US - cysts
2 of the following 3 needed to make diagnosis
-oligo/amenirrhea
-clinical/biochemical signs of hyperandrogenism
-Polycystic ovaries found on US (12+ follicles in 1 or both ovaries, or increased ovarian volume
Hyperandrogenism
-COCP (co-cyprindol) can also regulate cycle
COCP increases VTE risk
Infertility
-weight reduction
-consider metformin, clomifene
Androgen insensitivity syndrome
-pathophysiology
-presentation
End organ resistance to testosterone => 46XY with female phenotype
Primary amenorrhea
Little/no axillary or pubic hair
Undescended testes => groin swellings
Breast development possible
Chromosomal analysis => 46XY
High T
Counselling - raise child as female
Bilateral orchidectomy
Oestrogen therapy
Endometriosis
-pathophysiology
-presentation
-investigations
-management
Growth of endometrial-like tissue outside uterine cavity
Pain
-chronic pelvic
-period
-dyspareunia
-dysuria, dyschezia
Subfertility
Hematuria, urgency
Definitive - laparoscopy
Pain relief
1st line - NSAIDS/paracetamol
2nd line - COCP/progesterone
3rd line - refer to specialist
-GnRH analogues
-laparoscopic excision of endo/adhesiolysis to improve conception likelihood
Dysmenorrhoea
-primary presentation and management
-secondary presentation and possible causes
Primary - no underlying pelvic pathology
-thought to be related to excess endometrial prostaglandin release
Pain just before/within hours of period starting
Suprapubic cramping => back, thigh
1st line - NSAIDS (mefenamic acid, ibuprofen)
2nd line - COCP
Secondary - many years after menarche
-3-4days before period
=> REFER TO GYNAE
Endo
Adenomyosis
PID
IUDs - copper (IUS Mirena can help)
Fibroids
PID
-pathophysiology
-causative organisms
-presentation
-investigations
-complications
Upper pelvic organ infection
Most common - chlamydia trachomatis
NGonorrhea
Lower abdo pain
Fever
Deep dyspareunia
Dysuria menstrual irregularities
Discharge
Cervical excitation
Pregnancy test => exclude ectopic
High vaginal swab
Chlamydia and Gonorrhea screen
1st line - PO ofloxacin + metronidazole OR
IM ceftriaxone + PO doxy and metronidazole
FItz-Hugh-Curtis Syndrome - adhesions between liver and peritoneum
-RUQ pain, cholecystitis-like
Infertility
Chronic pelvic pain
Ectopics
Fibroids
-pathophysiology
-presentation
-investigations
-management
Benign smooth muscle tumour in uterus
-develop in response to estrogen
Asymptomatic
Heavy periods
Bulk symptoms
-lower abdo pain, crampy with period
-bloating
-urinary symptoms
Subfertility
TVUS
Asymptomatic - periodic monitoring
Menorrhagia - contraception
LNG-IUS/COCP/PO P/injectable P
Reduce size
Medically - GnRH
Surgically - myomectomy/hysterectomy
Fibroid degeneration
-pathophysiology
-presentation
-management
Sensitive to O => grow during pregnancy
Growth outstrips blood supply => fibroid ischemia
Acute pain - local, tender, palpable
Fever
Conservative - self limiting in 1wk
-paracetamol for pain
-AVOID NSAIDS
