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Menstrual Cycle Flashcards

(60 cards)

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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
Investigations in PCOS diagnosis
* Total testerone * Sex-hormone binding globulin * Free androgen index * +/- pelvic ultrasound * Rule out: LH and FSH, prolactin levels, thyroid stimulating hormone
26
Differential diagnoses for PCOS
* 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
Treatment of oligomenorrhoea in PCOS
``` • 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
Treatment of hirsutism in PCOS
* Spironolactone as androgen receptor antagonist for hirsutism * Cyproterone acetate (progestogen with with anti-androgen properties) * Flutamide (androgen receptor antagonist)
29
Treatment of anovulatory infertility in PCOS
* 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
Define 1º and 2º amenorrhoea
1º amenorrhoea is lack of menstruation by the age of 16 | 2º amenorrhoea is absence of menstruation for 6 months
31
Physiological causes of amenorrhoea
Physiological causes: • Pregnancy • Lactation • Menopause
32
Iatrogenic causes of amenorrhoea
* Progestagenic contraceptives (POP, depo-porvera, Mirena IUS, implanon) * Therapeutic progestagens, continuous COCP, GnRH analogues
33
Pathological causes of amenorrhoea
* 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
What do you ask about in someone presenting with amenorrhoea?
* 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
What do you look for on examination of a pt with amenorrhoea?
* 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
What investigations would you carry out in a pt with amenorrhoea
* 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
How do you manage a pt with amenorrhoea
* 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
Define premenstrual syndrome
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
Define PMTS
Pre-menstrual tension syndrome is more severe and is in the ICD-10. Indescribable tension, depression, hostility
40
Pathophysiology of premenstrual syndrome
* Unknown * Serotonin deficiency? * Mg and Ca deficiency? * Exaggerated response to normal hormonal changes? * Experience of abuse in early life?
41
Risk factors for premenstrual syndrome
Obesity | Smoking
42
Common symptoms of premenstrual syndrome
* 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
Treatments of premenstrual syndrome
* 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
Define menopause
Last spontaneous menstrual period, ovarian follicular inactivity Diagnosis made in retrospect after 12 months of amenorrhoea. Usually age 52-54.
45
Categories of menopause
Early<45 (usually familial pattern, consider FSH testing if menopausal symptoms and irregular periods) Premature<40 (need to investigate to find cause)
46
Hormonal changes in menopause
High FSH and LH with low oestrogen and progesterone | Ovarian failure
47
Give 6 oestrogen withdrawal symptoms
* 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
Give 2 major long term complications of menopause
``` Osteoporosis (DEXA scan) Cardiovascular disease (increased body weight, redistribution of body fat, adverse lipid profile, stiffening of arteries and plaques) ```
49
Describe the physiology of the menopause
* 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
What can predict age of menopause?
Smokers enter menopause earlier | Age of mother's menopause onset
51
Non HRT treatment of menopausal symptoms
* 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
Define HRT
Replacement of oestrogen after the menopause
53
When do the benefit of HRT outweigh the risks?
Benefits outweigh risks in first 10yrs after menopause in symptomatic women (vaginal and urinary atrophy symptoms, vasomotor symptoms, CVD risk) until aged 60
54
Instead of oral HRT, how can vaginal and urinary atrophy be treated?
Vaginal and urinary atrophy symptoms can be controlled using low dose oestrogen topical cream +/- pessary
55
What is involved in HRT?
* 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
When is HRT contraindicated?
* 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
Causes of premature ovarian failure | Treatment
• 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
HRT in VTE risk patients
For those at slightly higher risk of VTE, consider transdermal oestrogen or anticoagulate + HRT if thrombophilic
59
Why do fibroids increase menstrual blood loss?
They enlarge the uterine cavity (increased surface area) | They produce prostaglandins
60
Name 5 classes of drugs that can cause hyperprolactinaemia (and therefore amennorhoea)
``` Antipsychotics (haloperidol) TCAs Antihypertensives (methyldopa) Oestrogens (COCP) H2 antagonists (cimetidine, ranitidine, metoclopramide) ```

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