gynae - menstrual disorders Flashcards
(86 cards)
1
Q
stages
Menstrual cycle
A
- follicular phase - start of menstruation to moment of ovulation - first 14 days
- luteal phase - moment of ovulation to the start of menstruation - final 14 days
2
Q
What is primary dysmenorrhoea?
A
Painful periods without underlying pelvic pathology.
3
Q
How does primary dysmenorrhoea differ from secondary dysmenorrhoea?
A
Secondary dysmenorrhoea is associated with pelvic pathology.
4
Q
What is the pathophysiology of primary dysmenorrhoea?
A
Due to prostaglandin release following progesterone decline, leading to spinal artery vasospasm, ischemic necrosis, and increased myometrial contractions.
5
Q
What are the risk factors for primary dysmenorrhoea?
A
- Early menarche
- long menstrual phase
- smoking
- nulliparity
6
Q
What are the clinical features of primary dysmenorrhoea?
A
Crampy lower abdominal/pelvic pain radiating to the back/thigh, lasts 48-72 hours, may include nausea, vomiting, diarrhoea, dizziness.
7
Q
What are the differential diagnoses for primary dysmenorrhoea?
A
- Endometriosis
- adenomyosis
- PID
- adhesions
- IBD/IBS.
8
Q
What investigations are used for primary dysmenorrhoea?
A
- Swabs for infection
- transvaginal ultrasound if pelvic mass suspected.
9
Q
How is primary dysmenorrhoea managed?
A
- Lifestyle changes (stop smoking)
- NSAIDs
- paracetamol
- hormonal contraception
- heat application
- TENS.
10
Q
What defines heavy menstrual bleeding?
A
Excess menstrual loss that interferes with a woman’s quality of life.
11
Q
What is abnormal uterine bleeding?
A
Bleeding not attributed to uterine, endocrine, haematological, or infective pathology.
12
Q
What is the PALM-COEIN classification?
A
Aetiologies for AUB:
PALM (structural):
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy
COEIN (non-structural):
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
13
Q
What are risk factors for HMB?
A
Menarche or perimenopause, obesity, caesarean section (for adenomyosis).
14
Q
What are clinical features of HMB?
A
Excessive menstrual bleeding, fatigue, shortness of breath.
15
Q
What investigations are done for HMB?
A
Pregnancy test, blood tests (FBC, TFTs, coag screen), ultrasound, smear, swabs, endometrial biopsy, hysteroscopy.
16
Q
How is HMB managed?
A
Pharmacological: LNG-IUS, TXA, NSAIDs, COCP, progesterone;
Surgical: Endometrial ablation, hysterectomy.
17
Q
What is amenorrhoea?
A
Absence of menstrual periods.
18
Q
What is the difference between primary and secondary amenorrhoea?
A
- Primary: No menarche by age 16 (with 2o characteristics) or 14 (without);
- Secondary: Periods stop >6 months after starting.
19
Q
What is oligomenorrhoea?
A
Irregular periods >35 days apart or <9 periods/year.
20
Q
What are causes of amenorrhoea?
A
- Hypothalamic: eating disorders, chronic illness, Kallmann’s; Pituitary: prolactinomas, tumours, Sheehan’s;
- Ovarian: PCOS, Turner’s, premature failure;
- Adrenal: congenital adrenal hyperplasia;
- Genital tract: Asherman’s, imperforate hymen, MRKH syndrome.
21
Q
What are causes of oligomenorrhoea?
A
- PCOS
- hormonal treatments
- perimenopause
- thyroid disease
- eating disorders
- medications
22
Q
What investigations are used for amenorrhoea/oligomenorrhoea?
A
- Pregnancy test
- hormone panel (TSH, prolactin, FSH/LH, testosterone)
- ultrasound
- karyotyping
- progesterone challenge
23
Q
How is amenorrhoea/oligomenorrhoea managed?
A
Depends on cause:
- Regulate cycles (COCP, IUS)
- HRT for ovarian insufficiency
- Symptom control (acne, hirsutism)
- Lifestyle changes
- Treat underlying disorder (e.g. thyroid)
- Fertility: clomifene, metformin, IVF
- Surgery for anatomical issues
24
Q
What is PCOS?
A
An endocrine disorder characterised by excess androgen production and multiple immature ovarian follicles (“cysts”).
25
What causes PCOS?
Multifactorial aetiology with two key hormonal abnormalities:
- Excess LH: Increased GnRH pulse frequency → more LH from anterior pituitary → stimulates ovarian androgen production.
- Insulin resistance: Elevated insulin → reduced SHBG production → increased free androgens.
26
What are the risk factors for PCOS?
* Diabetes
* irregular menstruation
* family history of PCOS
27
What are the clinical features of PCOS?
- Symptoms: Oligo/amenorrhoea, infertility, hirsutism, obesity, chronic pelvic pain, depression.
- On examination: Hirsutism, acne, acanthosis nigricans, male pattern hair loss, obesity, hypertension.
28
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What are differentials for PCOS?
* Hypothyroidism
* hyperprolactinaemia
* Cushing's disease
29
What investigations diagnose PCOS?
* Rotterdam criteria (2 of 3): Oligo/anovulation, hyperandrogenism (clinical/biochemical), polycystic ovaries on imaging.
* Bloods: Raised testosterone, low SHBG, raised LH, normal FSH, elevated LH:FSH ratio, persistently low progesterone.
* Others: TSH, prolactin, oral glucose tolerance test.
* Imaging: Ultrasound showing multiple peripheral follicles or ovarian volume >10cm³.
30
How is PCOS managed?
* Underlying conditions: Treat diabetes, hypertension.
* Oligo/amenorrhoea: COCP or cyclical progesterone (e.g. dydrogesterone) to induce withdrawal bleeds.
* Obesity: Diet, exercise, possibly orlistat.
* Infertility: Clomifene ± metformin, laparoscopic ovarian drilling if normal BMI.
* Hirsutism: Cosmetic options, anti-androgens (cyproterone, spironolactone, finasteride), eflornithine cream (avoid in pregnancy).
31
What are fibroids?
Benign smooth muscle tumors of the uterus, also known as leiomyomas.
32
Where do fibroids arise from?
From the myometrium (muscular layer of the uterus).
33
What are the 3 main types of fibroids by location?
- Intramural – within the myometrium (most common)
- Submucosal – beneath the endometrium, protrudes into the uterine cavity
- Subserosal – protrudes from the uterine surface; may be pedunculated
34
What is thought to stimulate fibroid growth?
Oestrogen.
35
Name 5 risk factors for fibroids.
Obesity, early menarche, increasing age, family history, African-American ethnicity.
36
Are most fibroids symptomatic or asymptomatic?
Asymptomatic.
37
List 4 possible symptoms of fibroids.
Heavy menstrual bleeding, pressure symptoms (e.g. urinary frequency), subfertility, acute pelvic pain (rare).
38
What is red degeneration in fibroids?
Necrosis and hemorrhage of a rapidly growing fibroid, often during pregnancy.
39
How might fibroids be found on examination?
A solid, enlarged, non-tender uterus on abdominal or bimanual exam.
40
List 4 differential diagnoses for fibroids.
Endometrial polyp, ovarian tumour, leiomyosarcoma, adenomyosis.
41
What are 2 key imaging tests for fibroids?
Pelvic ultrasound and MRI (if malignancy suspected).
42
Name 3 medical treatments for fibroids.
TXA or mefenamic acid, hormonal contraceptives, GnRH analogues or Ulipristal acetate.
43
What are the surgical options for fibroids?
Hysteroscopic resection, myomectomy, uterine artery embolisation, hysterectomy.
44
Name 4 complications of fibroids.
Iron-deficiency anemia, urinary retention, hydronephrosis, infertility.
45
What is endometriosis?
Presence of endometrial tissue outside the uterine cavity.
46
What are common sites of endometriosis?
Ovaries, pouch of Douglas, uterosacral ligaments, peritoneum, bladder, lungs, umbilicus.
47
What is a proposed mechanism for endometriosis?
Retrograde menstruation.
48
What causes pain in endometriosis?
Bleeding from ectopic tissue and resulting inflammation and adhesions.
49
List 5 risk factors for endometriosis.
Early menarche, family history, short cycles, long periods, heavy bleeding.
50
Name 4 symptoms of endometriosis.
Cyclical pelvic pain, dysmenorrhoea, dyspareunia, subfertility.
51
What signs may be found on bimanual exam in endometriosis?
Fixed retroverted uterus, uterosacral nodules, tenderness.
52
What is the gold standard diagnostic test for endometriosis?
Laparoscopy.
53
What might be seen during laparoscopy in endometriosis?
Chocolate cysts, adhesions, peritoneal deposits.
54
Name 3 pain relief options in endometriosis.
NSAIDs, COCP, norethisterone.
55
How do GnRH agonists help in endometriosis?
They suppress ovulation and oestrogen production, mimicking menopause.
56
What are the surgical options for endometriosis?
Excision, ablation, or hysterectomy with oophorectomy (definitive).
57
What are cervical polyps?
Benign growths on the endocervical surface.
58
What causes cervical polyps?
Focal hyperplasia, possibly due to oestrogen or chronic inflammation.
59
Who is most likely to get cervical polyps?
Multigravida women aged 50–60.
60
What are symptoms of cervical polyps?
Often asymptomatic; can cause abnormal bleeding or discharge.
61
What may be seen on speculum exam for cervical polyps?
Polypoid growths protruding through the external os.
62
Name 4 differential diagnoses of cervical polyps.
Cervical cancer, ectropion, fibroids, STIs.
63
How are cervical polyps diagnosed?
Histological examination after removal.
64
When should further investigations (e.g. USS) be considered after polyp removal?
If symptoms persist or patient is postmenopausal.
65
How are cervical polyps treated?
Removal with polypectomy forceps, loop excision, or under GA.
66
Name 3 complications of cervical polyp removal.
Infection, bleeding, uterine perforation (rare).
67
What are endometrial polyps?
Benign growths on the inner uterine lining, composed of endometrial tissue.
68
What factors contribute to endometrial polyps?
Oestrogen, chronic inflammation, risk factors like obesity and tamoxifen use.
69
What are symptoms of endometrial polyps?
Irregular bleeding (menorrhagia, IMB, PMB), infertility, rarely pain.
70
How are endometrial polyps diagnosed?
Transvaginal ultrasound, hysteroscopy (most definitive), endometrial biopsy.
71
What is the treatment for endometrial polyps?
Watchful waiting, polypectomy via hysteroscopy, hormonal treatments (e.g. progestins, GnRH).
72
What are complications of endometrial polyps?
Infertility, risk of malignancy (0.5–3%, higher in postmenopausal women).
73
What is endometrial hyperplasia?
Abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle.
74
What are the types of endometrial hyperplasia?
* Simple
* complex
* simple atypical (precancerous state)
* complex atypical
75
What are the features of endometrial hyperplasia?
Abnormal vaginal bleeding, e.g. intermenstrual bleeding.
76
How is endometrial hyperplasia managed?
Simple without atypia → high dose progestogens with repeat sampling in 3–4 months.
Atypia → hysterectomy usually advised.
77
What is PMDD?
A severe form of PMS involving extreme mood disturbances and physical symptoms during the luteal phase.
78
PMDD symptoms
emotional and psychological:
* Severe mood swings
* irritability
* anger
* anxiety
* sadness
* hopelessness
* difficulty concentrating
* sleep problems
* fatigue
physical:
* Bloating
* breast tenderness
* headaches
* joint or muscle pain
* changes in appetite
* digestive issues
79
PMDD diagnosis and Mx
diagnosis:
- By tracking symptoms over several menstrual cycles to confirm they appear in the luteal phase.
Mx:
* Lifestyle: Exercise, yoga, balanced diet, avoid caffeine/alcohol/sugar, good sleep.
* Medications: SSRIs (for severe symptoms), COCPs (moderate), GnRH agonists.
* CBT
* Supplements: Calcium, magnesium, vitamin B6.
80
What is menopause?
Retrospective diagnosis made after 12 months without menstruation.
- Perimenopause: Time around menopause with symptoms and irregular periods.
- Premature menopause: Menopause before age 40.
81
menopause/perimenopause Sx
* Hot flushes
* emotional changes
* irregular or heavy periods
* joint pain
* vaginal dryness
* reduced libido
82
What risks are associated with menopause?
Increased risk of:
* Cardiovascular disease
* Stroke
* Osteoporosis
* Pelvic organ prolapse
* Urinary incontinence
83
how is menopause diagnosed?
- Clinical diagnosis in women >45 with symptoms.
- FSH test if < 40 (suspect premature) or 40–45 with symptoms.
84
role of contraception in menopausal women
- Required for 2 years after LMP if <50, 1 year if >50.
- Options: Barrier methods, Mirena/copper coil, POP, implant, injection (<45), sterilisation
85
management options for menopause
* No treatment
* HRT
* Tibolone
* Clonidine
* CBT
* SSRIs
* Testosterone (low libido)
* Vaginal oestrogen creams/tablets
* Vaginal moisturisers
86
what are the risks associated with HRT?
- Breast cancer: Slightly increased with combined HRT, especially if used >5 years.
- Blood clots (VTE): Increased risk with oral HRT; no added risk with transdermal (patch/gel).
- Stroke: Small increased risk, mainly with oral HRT in older women.
- Endometrial cancer: Risk increased with oestrogen-only HRT in women with a uterus; progestogen needed to reduce this risk.
