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Menstrual Cycle Flashcards

1
Q

What is the life span of a sperm?

A

5 days

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2
Q

How long do eggs last once ovulated?

A

24-48hrs

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3
Q

What are the 2 ovarian stages of the menstrual cycle?

A

Luteal and follicular

Luteal phase is fixed, follicular phase is variable and can be elongated

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4
Q

What is oligomenorrhoea?

A

Less regular cycles (eg 34 day cycle)

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5
Q

What happens in the follicular phase?

A

Primordial->primary->secondary->tertiary follicle

Ovulation

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6
Q

What happens in the luteal phase?

A

Corpus luteum produces progesterone and degrades->albicans

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7
Q

What are the phases of the uterine cycle?

A

Menses, proliferative phase, secretory phase

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8
Q

When does LH peak?

A

Day 13-14 of cycle, end of follicular phase, at ovulation

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9
Q

When does oestrogen peak?

A

As tertiary follicle forms and at ovulation (day 14)

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10
Q

When does progesterone peak?

A

Day 21-22 of cycle

During secretory phase

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11
Q

During menses, why is there cramping pain?

A

As functional layer of endometrium breaks down, uterus contracts to reduce blood loss from spiral arteries

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12
Q

Function of 3 different prostaglandins in menses?

A
  • PGF2 alpha: vasoconstriction the endometrial vessels and contracts myometrium
  • PGE2 vasodilates vessels of myometrium
  • PGI2 relaxes smooth muscle, vasodilates vessels and inhibits thrombocyte aggregation
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13
Q

Define menorrhagia

A

Excessive menstrual blood loss over several consecutive cycles which interferes with a woman’s physical, emotional, social and material quality of life (>80ml)

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14
Q

Causes of menorrhagia

A
  • 40-60% unknown (imbalance of prostaglandins)
  • Pelvic pathology (fibroids, endometrial polyps, endometriosis)
  • Systemic disorders (coagulation disorders, vW disease, hypothyroidism)
  • Iatrogenic (anticoagulant treatment, IUCD copper coil)
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15
Q

What Qs do you ask when someone presents with menorrhagia?

A 
•	Age at menarche
•	Number of days of menstruation / Length of cycle 
•	How long she considers periods to be heavy
•	What they were like previously
•	Impact on life
•	Intermenstrual or postcoital bleeding
•	Smear status 
•	Contraceptive use
Anaemia symptoms? (2/3 anaemic)
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16
Q

What features would you be worried about in a pt with menorrhagia?

A

Pelvic pain/pressure symptoms on bladder/bowel: large fibroid/ovarian cyst
Post coital bleeding: Genital tract, cervical cancer? STI?
Intermenstrual bleeding: polyps/fibroids
Dyspareunia: endometriosis/PID
Vaginal discharge: fibroids, polyps, STI
Fever: PID

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17
Q

What do you look for in a pt with menorrhagia

A
  • Abdominal (palpable fibroid?)
  • Pelvic: speculum +/- swabs, smear test
  • Bimanual palpation: uterine or adnexal enlargement or tenderness
  • Systemic signs: anaemia, endocrine (hirsutism, striae, goitre, skin pigmentation)
  • Coagulation disorders (bruises/petechiae)
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18
Q

Investigations in a pt with menorrhagia

A

• FBC
• Thyroid function tests
• Coagulation screen if clinical suspicion
• Trans-vaginal pelvic ultrasound scan (pelvic mass?)
; Endometrial biopsy if over 45/suspicious USS

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19
Q

Treatment of menorrhagia

A
  • Most is undertaken in primary care
  • 1st line is mirena coil (LNG-IUS)
  • 2nd line is tranexamic acid (antifibrinolytic, taken only during menstruation, good for women who want to conceive, avoid if previous PE/DVT)
  • 2nd line: NSAIDs (prostaglandin synthetase inhibitor and pain relief, INDOMETHACIN, MEFENAMIC ACID)
  • 2nd line: COC pill (stops FSH being produced, no ovarian stimulation)
  • 3rd line: Oral noristhisterone (synthetic progesterone, may inhibit ovulation but is not a contraceptive) Use Mirena coil instead as acts in a similar way but also is contraceptive)
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20
Q

What is done in secondary care if 1st treatment fails for menorrgagia?

A

Endometrial biopsy
• Exclude endometrial cancer or atypical hyperplasia
• If persistent intermestrual bleeding

GnRH analogues
•	Profound hypo-gonadal effect
•	Menopausal symptoms
•	No ovulation, no menses
•	Vaginal dryness
•	Temporary measure to do investigations

Endometrial resection:
• Shave lining of womb via hysteroscopy

Endometrial ablation:
• Simpler, burns endometrium up until myometrium, stops build up of endometrium in menstrual cycle, lighter periods, risk of pregnancy after, leads to ectopic pregnancy or miscarriage

Hysterectomy
• Laparoscopic
• Vaginal
• Abdominal

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21
Q

Define PCOS

A

Complex endocrine disorder with clinical features that include acne, hirsutism (excess androgens), oligomenorrhoea or amenorrhoea and multiple follicles in the ovary.
Ovary doesn’t respond well to hypothalmo-pituitary axis. No primary follicle/ovulation.

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22
Q

How is PCOS diagnosed

A

Rotterdam Diagnostic Criteria (2 of 3)
• Oligo-anovulation/anovulation
• Hyper-androgenism (clinical or biochemical testosterone levels)
• Polycystic ovaries (12 or more follicles/increased ovarian volume >10ml)

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23
Q

Aetiology of PCOS?

A
  • Unknown (genetic and environmental)
  • The theca cells of the ovary produce excess androgens
  • Decreased peripheral insulin sensitivity (insulin resistance) and consequent compensatory hyper-insulinaemia
  • Insulin has growth factor like effect-> increased lipid
  • Lipid can produce some oestrogen
  • Could be ovarian problem first or obesity problem first
  • Androgen secretion is increased due to too many thecal cells being produced.
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24
Q

Complications of PCOS

A
  • Impaired glucose tolerance and type 2 diabetes
  • Cardiovascular disease
  • Dyslipidaemia
  • Infertility (random periods/don’t know when ovulation occurs)
  • Sleep apnoea
  • Endometrial cancer (unopposed proliferation, should have at least 4 periods per year)
  • In pregnancy: higher rates of gestational diabetes, pregnancy induced hypertension, pre-eclampisia, pre-term delivery
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25
Q

Investigations in PCOS diagnosis

A
  • Total testerone
  • Sex-hormone binding globulin
  • Free androgen index
  • +/- pelvic ultrasound
  • Rule out: LH and FSH, prolactin levels, thyroid stimulating hormone
26
Q

Differential diagnoses for PCOS

A
  • Simple obesity
  • Primary hypothyroidism
  • Premature ovarian failure
  • Hyperprolactinaemia
  • Non classical congenital adrenal hyperplasia
  • Cushing’s syndrome
  • Androgen secreting neoplasm
  • Hypogonadotrophic hypogonadism
  • High does exogenous androgens
  • Acromegaly
27
Q

Treatment of oligomenorrhoea in PCOS

A 
•	Lose 10% body weight
•	Reduce cardiovascular risk
•	Early diagnosis of diabetes
•	Try and induce 4 withdrawl bleeds every 3-4 months (cyclical progestogens, COC pill, Mirena coil)
Metformin?
28
Q

Treatment of hirsutism in PCOS

A
  • Spironolactone as androgen receptor antagonist for hirsutism
  • Cyproterone acetate (progestogen with with anti-androgen properties)
  • Flutamide (androgen receptor antagonist)
29
Q

Treatment of anovulatory infertility in PCOS

A
  • Weight loss if BMI>30
  • Clomiphene citrate (inhibits negative feedback of oestrogen on gonadotropin release, regulates axis)
  • Gonadotropins
  • Ovarian drilling (destroys ovarian androgen producing tissues, recruitment of new follicles and return to normal ovarian function)
  • Aromatase inhibitors
30
Q

Define 1º and 2º amenorrhoea

A

1º amenorrhoea is lack of menstruation by the age of 16

2º amenorrhoea is absence of menstruation for 6 months

31
Q

Physiological causes of amenorrhoea

A

Physiological causes:
• Pregnancy
• Lactation
• Menopause

32
Q

Iatrogenic causes of amenorrhoea

A
  • Progestagenic contraceptives (POP, depo-porvera, Mirena IUS, implanon)
  • Therapeutic progestagens, continuous COCP, GnRH analogues
33
Q

Pathological causes of amenorrhoea

A
  • Hypothalmic (functional stress, excessive exercise)
  • Hypothalmic non functional (space occupying lesion, surgery, radiotherapy, 1º GnRH deficiency)
  • Anterior pituitary (prolactinoma, SOL, surgery, Sheehan syndrome)
  • Ovarian (PCOS, POF, resistant ovary syndrome, Turner’s)
  • Genital tract outflow obstruction (imperforate hymen, transverse vaginal septum, cervical stenosis, Asherman’s adhesions)
  • Agenesis of uterus and Mallerian duct structures
  • Endocrinopathies (Cushing’s, hyperprolactinaemia, hper/hypothyroidism, CAH)
  • Oestrogen/androgen secreting tumours
34
Q

What do you ask about in someone presenting with amenorrhoea?

A
  • Risk of pregnancy? Contraception used
  • Galactorrhoea?
  • Androgenic symptoms (weight gain, acne, hirsutism)
  • Previous genital tract surgery (Iintrauterine instrumentation/LLETZ)
  • Issues with eating or excessive exercise
  • Drug use (dopamine agonist antipsychotics)
35
Q

What do you look for on examination of a pt with amenorrhoea?

A
  • BMI (<17 or >30)
  • Hirsutism
  • 2º female characteristics
  • Endocrinopathies? Cushing’s, hyperprolactinaemia, thyroid, CAH)
  • Turner’s syndrome?
  • Evidence of virilisation (deep voice, male pattern balding, cliteromegaly)
  • Abdo masses-> genital tract obstruction
  • Pelvic: imperforate hymen, blind ending vaginal septum, absence of cervix and uterus
36
Q

What investigations would you carry out in a pt with amenorrhoea

A
  • Pregnancy test
  • FSH/LH levels (raised in premature ovarian failure POF)
  • Testosterone and sex-hormone binding globulin (SHBG) for PCOS
  • Prolactin
  • TFTs
  • USS (congenital abnormalities? PCOS, ovarian activity)
  • Karyotype if suggestive of Turner’s
  • Endocrinopoathy tests
37
Q

How do you manage a pt with amenorrhoea

A
  • Guided by diagnosis and fertility wishes
  • Attain normal BMI
  • Cabergoline/surgery/cessation of causative drugs for hyperprolactinaemia
  • Cyclical withdrawl bleeds on COCP for PCOS
  • HRT for PremOvFailure
  • Relief of genital tract obstruction (cervical dilation, hysteroscopic resection, incision in hymen)
38
Q

Define premenstrual syndrome

A

Recurrent luteal-phase condition characterised by physical, psychological and behaviour changes of sufficient severity to result in deterioration of interpersonal relationships and normal activity.

39
Q

Define PMTS

A

Pre-menstrual tension syndrome is more severe and is in the ICD-10. Indescribable tension, depression, hostility

40
Q

Pathophysiology of premenstrual syndrome

A
  • Unknown
  • Serotonin deficiency?
  • Mg and Ca deficiency?
  • Exaggerated response to normal hormonal changes?
  • Experience of abuse in early life?
41
Q

Risk factors for premenstrual syndrome

A

Obesity

Smoking

42
Q

Common symptoms of premenstrual syndrome

A
  • Mood swings
  • Feeling depressed, irritable or bad-tempered
  • Feeling upset, anxious or emotional
  • Tiredness or trouble sleeping
  • Headaches
  • Changes in appetite and food cravings
  • Feeling clumsy, possibly leading to increased accidents
  • Fluid retention and feeling bloated
  • Changes to skin or hair
  • Having sore or tender breasts
43
Q

Treatments of premenstrual syndrome

A
  • Weight loss and increased exercise
  • Lifestyle (balanced diet, reduce stress, talking with partner)
  • CBT
  • SSRIs & SNRIs
  • COCP
  • HRT
  • DANAZOL (leads to virilisation)
  • GnRH analogues (if severe, use for 6 months)
44
Q

Define menopause

A

Last spontaneous menstrual period, ovarian follicular inactivity
Diagnosis made in retrospect after 12 months of amenorrhoea. Usually age 52-54.

45
Q

Categories of menopause

A

Early<45 (usually familial pattern, consider FSH testing if menopausal symptoms and irregular periods)
Premature<40 (need to investigate to find cause)

46
Q

Hormonal changes in menopause

A

High FSH and LH with low oestrogen and progesterone

Ovarian failure

47
Q

Give 6 oestrogen withdrawal symptoms

A
  • Loss of menstruation
  • Hot flashes and night sweats
  • Insomnia (changes in melatonin secretion)
  • Vaginal atrophy (vaginal dryness, discomfort, itching, dyspareunia)
  • Decreased breast size
  • Reduced skin elasticity, hair loss, brittle nails
48
Q

Give 2 major long term complications of menopause

A 
Osteoporosis (DEXA scan)
Cardiovascular disease (increased body weight, redistribution of body fat, adverse lipid profile, stiffening of arteries and plaques)
49
Q

Describe the physiology of the menopause

A
  • Atrophy of ovary, no follicles
  • Ovarian failure
  • FSH rises subtly
  • Ovarian oestrogen, anti-Mullarian hormone, inhibin and progesterone falls
  • Follicular phase of menstrual cycle shortens
  • Changes in ovary and in pituitary/adrenal axis
50
Q

What can predict age of menopause?

A

Smokers enter menopause earlier

Age of mother’s menopause onset

51
Q

Non HRT treatment of menopausal symptoms

A
  • CBT
  • Herbal? (black cohosin, red clover, evening primrose oil, dong quai) Efficacy and safety unknown
  • SNRI, SSRI: used for vasomotor symptoms and depression
  • Gabapentin (vasomotor)
  • Clonidine (alpha agonist, vasomotor)
  • Propranolol (not NICE guideline, for palpitations)
  • Calcium and vitamin D, bisphosphonates
52
Q

Define HRT

A

Replacement of oestrogen after the menopause

53
Q

When do the benefit of HRT outweigh the risks?

A

Benefits outweigh risks in first 10yrs after menopause in symptomatic women (vaginal and urinary atrophy symptoms, vasomotor symptoms, CVD risk) until aged 60

54
Q

Instead of oral HRT, how can vaginal and urinary atrophy be treated?

A

Vaginal and urinary atrophy symptoms can be controlled using low dose oestrogen topical cream +/- pessary

55
Q

What is involved in HRT?

A
  • In patients that haven’t had a total hysterectomy, progesterone is also needed for endometrial protection
  • If perimenopausal can use mirena coil as contraception and progesterone part of HRT
56
Q

When is HRT contraindicated?

A
  • Unexplained vaginal bleeding
  • Pregnancy
  • Oestrogen sensitive cancer/breast cancer
  • Untreated endometrial hyperplasia
  • Active or recent VTE/MI/angina
  • Untreated hypertension
  • Abnormal LFTs due to active liver disease
57
Q

Causes of premature ovarian failure

Treatment

A

• Genetic: Turner’s, Fragile X
• Autoimmune: hypothyroidism, Addison’s, diabetes mellitus
• Prolactinoma/brain tumours
• Infection: mumps, TB, CMV, rubella
• Iatrogenic: radiotherapy, chemo, oophorectomy
Give HRT until average age of natural menopause

58
Q

HRT in VTE risk patients

A

For those at slightly higher risk of VTE, consider transdermal oestrogen or anticoagulate + HRT if thrombophilic

59
Q

Why do fibroids increase menstrual blood loss?

A

They enlarge the uterine cavity (increased surface area)

They produce prostaglandins

60
Q

Name 5 classes of drugs that can cause hyperprolactinaemia (and therefore amennorhoea)

A 
Antipsychotics (haloperidol)
TCAs
Antihypertensives (methyldopa)
Oestrogens (COCP)
H2 antagonists (cimetidine, ranitidine, metoclopramide)

O&G (12 decks)

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