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Reproductive Medicine > Menstrual problems and the menopause > Flashcards

Menstrual problems and the menopause Flashcards

1
Q

What is menorrhagia?

A

Heavy periods - >80 mls per cycle

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2
Q

What is dysmenorrhoea?

A

Painful periods

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3
Q

What is intermenstrual bleeding?

A

Bleeding between periods not caused by coitus

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4
Q

What is psot coital bleeding?

A

Vaginal bleeding after sex

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5
Q

What is oligomenorrhoea?

A

Infrequent periods

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6
Q

What is amenorrhoea?

A

No periods (can be primary or secondary)

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7
Q

What would you want to ask about in a menstrual history?

A

MR FLOPPI DICS

  • Menopause
  • Regularity
  • Flow - light/heavy, flooding, clots
  • Last menstrual period
  • Odd bleeding - Post coital, post menopausal, intermenstrual
  • Dysmenorrhoa
  • Initiation - menarche
  • Cycle - days on, days off, Contraception
  • Smear history
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8
Q

What is regarded as normal menstrual cycle length?

A

4-5 days on/21-35 days off

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9
Q

What is the mean blood loss from menstruation?

A

30-40 mls

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10
Q

What are features of normal menstruation?

A
  • Duration between two and seven days
  • Flow less than 80 mL
  • Occurring in cycles of 24 to 35 days
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11
Q

What are symptoms of normal menstruation?

A
  • Abdominal pain and cramps
  • Vaginal bleeding
  • Nausea
  • Diarrhoea
  • Sweating
  • Fatigue
  • Irritability
  • Dysphoria (unhappiness)
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12
Q

What is primary amenorrhoea?

A

Menstruation has not occured yet - pre-menarche

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13
Q

When does primary amenorrhoea need investigation?

A

16 year old or 14 year old with no breast development

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14
Q

What is secondary amenorrhoea?

A

When periods stop for >6 months other than due to pregnancy

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15
Q

What is primary dysmenorrhoea?

A

Pain without organ pathology - often starting with anovulatory cycles after menarche. It is crampy with ache in the back or groin, worse during the first day or two

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16
Q

What are options for managing primary dysmoenorrhoea?

A
  • NSAIDs - mefenamic acid - during menstruation
  • Paracetamol
  • COCP
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17
Q

What is secondary dysmenorrhoea?

A

Dysmenorrhoea with pathology - e.g. adenomyosis, endometriosis, PID, fibroids

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18
Q

What are causes of secondary dysmenorrhoea?

A
  • Adenomyosis
  • Endometriosis
  • PID
  • Fibroids
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19
Q

What should you always screen for in a woman with post-coital bleeding?

A

Chlamydia

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20
Q

What are causes of post-menopausal bleeding?

A

!!Endometrail cancer until proven otherwise!!

  • Vaginitis (often atrophic)
  • Foreign bodies - pessaries, tampons
  • Carcinoma of cervix/vulva
  • Endometrial/cervical polyps
  • Oestrogen withdrawal
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21
Q

What should you always test for in secondary amenorrhoea?

A

PREGNANCY!! - most common cause of amenorrhoea in woman of childbearing age

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22
Q

What is the most likely cause of primary amenorrhoea if secondary sexual characteristics are absent?

A

Most likely delayed puberty. Should also consider genetic causes - turner’s syndrome, androgen insensitivity

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23
Q

What is the most likely cause of primary amenorrhoea if secondary sexual characteristics are present?

A

Can just be normal variant

Anatomical causes:

  • Congenital absence of uterus
  • Imperforate hymen
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24
Q

Can exercise cause priamry amenorrhoea?

A

Yes - if excessive

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25
Q

Can low body weight cause primary amenorrhoea?

A

Yes

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26
Q

What can cause primary amenorrhoea?

A
  • Chromosomal problem - turner’s etc.
  • Hypothlalamic - Physiological delay, weight loss/anorexia, heavy exercise, GnRH deficiency
  • Pituitary - partial/total hypopituitarism, hyperprolactinaemia, adenoma, trauma
  • Ovarian - True agenesis, prem. ovarian failure, PCOS
  • Primary hypothyroid
  • Adrenal hyperplasia
  • Imperforate hymen
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27
Q

What are causes of secondary amenorrhoea?

A
  • Physiological - pregnancy, lactation, menopause
  • Hypothalamic - weight loss, heavy exercise, stress
  • Pituitary - hyperprolactinaemia, hypopituitarism
  • Ovarian - PCOS, prem. ovarian failure, surgery/radio/chemo, virilising ovarian tumours
  • Primary hypothyoridism
  • Adrenal hyperplasia/tumour
  • Hysterectomy
  • Endometrial ablation
  • Minera IUS
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28
Q

What is premature ovarian failure?

A

Cessation of ovarian function before the age of 40 - usually due to depletion of primordial follicles

29
Q

How would you investigate someone presenting with amenorrhoea?

A
  • Bedside - urinary pregnancy test, dipstick
  • Bloods - FSH/LH, Serum free androgen, Prolcatin, TFTs, Testosterone, oestrogen
  • Imaging - TVUSS/TAUSS, MRI
30
Q

Why might you look at serum ostrogen in someone with primary amenorrhoea?

A

Low in primary ovarian failure

31
Q

Why might you do serum prolactin levels in amenorrhoeic individuals?

A

Look for hyperprolactinaemia

32
Q

Why might you do TFTs in someone with amenorrheoa?

A

Look for primary hypothyroidism

33
Q

When might you do an MRI head in someone with amenorrhoea?

A

If serum prolactin levels are high - look for pituitary tumour causing hyperprolactinaemia

34
Q

What are causes of menorrhagia?

A
  • Dyfunctional uterine bleeding
  • IUCD
  • Fibroids
  • Endometriosis
  • Adenomyosis
  • Pelvic infection
  • Polyps - endometrial, cervical
  • Hypothyroidism
  • Coagulation disorders
  • Endometrial carcinoma - post menopausal
35
Q

What investigations would you consider doing in someone with menorrhagia?

A
  • Bedside - pregnancy test
  • Bloods - FBC, TFTs, Testosterone, coagulation screen
  • Imaging - Pelvic USS
  • Other - biopsy, hysteroscopy
36
Q

Why might you do an FBC in someone with menorrhagia?

A

Look for signs of anaemia

37
Q

Why might you do TFTs in someone with menorrhagia?

A

Look for Hypothyroidism

38
Q

What should be considered as first line treatment for menorrhagia?

A

Mirena IUS

39
Q

How does the mirena IUS help with menorrhagia?

A

Releases levonogestral into the endometrial cavity, leading to atrophy

40
Q

What medications can be used to manage menorrhagia?

A
  • Mirena IUS
  • Taken during bleeding
    • Antifibrinolytics - Tranexamic acid
    • NSAIDs
  • COCP
  • Progestogen injection
41
Q

Why are NSAIDS/tranexamic acid used during bleeding in menorrhagic patients?

A

Reduce blood loss

42
Q

What surgical options are available for managing menorrhagia?

A

Consider benefits and risk of each - reserved for non-responders to medication

  • Endometrial ablation - thermal balloon, microwave, electrical impedence
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
43
Q

What is premenstrual syndrome?

A

A condition which manifests with distressing physical, behavioural, and psychological symptoms in the absence of organic or psychiatric disease, regularly occurring during the luteal phase of the menstrual cycle and with significant improvement by the end of menstruation

44
Q

What are symptoms of PMS?

A
  • Mood swings
  • Irritability
  • Depression
  • Bloating
  • Breast tenderness
  • Headache
  • Reduced visuospatial ability
  • Increase in accidents
45
Q

What is the menopause?

A

Time of waning fertility leading up to the last period. It is a retrospective diagnosis, having said to occurered 12 months after the last period

46
Q

What is the average age of menopause in the UK?

A

52

47
Q

What is peri-menopause?

A

Transition from cyclic menstrual bleeding to a total cessation of menses happens over about 4 years. It is marked irregularity and periods of amenorrhoea ue to declining progesterone and oestradial levels

48
Q

What are features of the menopause?

A
  • Menstrual irregularity
  • Vasomotor disturbance - sweats, palpitations, flushes, palpitations
  • Atrophy of oestrogen dependent tissues - breast, genitalia, skin
  • Vaginal dryness -> UTIs, dyspareunia, trarumatic bleeding
  • Stress incontinence
  • Osteoporosis
49
Q

What happens to levels of LH/FSH in the menopause?

A

Increase due to reduced oestrogen negative feedback

50
Q

What are features of hot flushes experienced in menopause?

A

Last about 3 minutes

  • Feeling of warmth
  • Nausea
  • Palpitations
  • Sweating
51
Q

Why are menopausal women at increased risk of UTI?

A

Due to vaginal glycogen depletion, leading to increased vaginal pH

52
Q

When do atrophic changes tend to appear in menopausal women?

A

Years after menopause

53
Q

How would you manage someone going through the menopause?

A
  • Diet and exercise
  • Mirena coil - if menorrhagic
  • Contraception - until 1 year amenorrhoeic
  • Oestrogen cream - vginal dryness
  • HRT
  • Osteoporosis prevention - weight bearing exercise, Vit D and calcium, bisphosphonates
54
Q

What should those without a uterus going through the menopause be given in terms of hormonal replacement therapy?

A

Oestrogen only HRT

55
Q

What are examples of vaginal HRT preparations?

A
  • Oestradiol tablets
  • Ring pessaries
  • Vaginal cream
56
Q

What HRT preparations should be used in women with a uterus?

A

Oestrogen and progesterone (combined) HRT

57
Q

What regimen of HRT should be used in women who are still having (irregular) periods or are within 12 months of their last period?

A

Oestrogen and cylical progestogen - usually results in regular withdrawal bleeding

58
Q

When is continuous combined HRT used?

A

In women who are post-menopausal for more than 2 years

59
Q

How long after their last menstrual period is a woman considered fertile?

A

About 2 years

60
Q

What are contraindications to HRT?

A
  • Oestrogen dependent cancer
  • Past PE
  • Undiagnosed PV bleeding
  • Deranged LFTs
  • Pregnancy
  • Breastfeeding
  • Phlebitis
61
Q

What are side effects to HRT?

A
  • Fluid retention
  • Bloating breast tenderness
  • Nausea
  • Headaches
  • Leg cramps
  • Dyspepsia
  • Mood swings
  • Depression
  • Acne
  • Backache
62
Q

What should be done at annual check up in someone going through menopause?

A
  • Breasts
  • BP
  • Weight
  • Abnormal bleeding
63
Q

How would you manage/prevent osteoporosis in someone going through the menopause?

A
  • Calcium supplementation
  • Vit D supplementation
  • Bisphosphonates
  • Strontium
  • SERMS
64
Q

What should not be used as first line treatment for osteoporosis in menopausal women?

A

HRT - unless treating menopausal symtpoms

65
Q

What are risks fo HRT?

A
  • Increased breast cancer risk
  • Increased endometrial cancer risk
  • Double risk of VTE
  • Increased risk of stroke
66
Q

How long is HRT normally continued for?

A

Ususally 2-3 years - decision to extend beyond this dependent on circumstances

67
Q

What should you consider as differential diangosis for someone presenting with features of menopause?

A
  • Pregnancy
  • Hyperthyroidism
  • Hypothyroidism
  • Anorexia
  • Medications
68
Q

What are causes of post-coital bleeding?

A
  • Trauma
  • Ectropian
  • Cervicitis
  • Cervical/endometrial polyp
  • Cervical cancer
  • Vaginitis
  • Vaginal cancer
  • Vulval dermatitis
  • Vulval cancer
  • STI’s - gonorrhoea, chlamydia
69
Q

What are causes of intermenstrual bleeding?

A
  • Physiological
  • Trauma
  • Ovarian tumour
  • Uterus - endometritis/PID, polyp, hyperplasia, fibroids, cancer
  • Cervix - cervicitis, polyp, cancer
  • Vagina - vaginitis, cancer
  • Vulva - dermatitis, dystrophy, cancer
  • Pregnancy - miscarriage, ectopic, molar pregnancy
  • Systemic - bleeding disorder, metastatic cancer
  • Iatrogenic - IUCD, HRT, POP, depoprovera
  • STI’s - gonorrhoea, chlamydia
  • Bleeding from somewhere else - urethra, bladder, anus, rectum

Reproductive Medicine (43 decks)

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