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menstrual cycle and abnormalities Flashcards

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1
Q

define menstruation

A

process of the endometrium being discharged each month if pregnancy fails to occur

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2
Q

basic physiology of menstruation

A

sloughing of the endometrium of pver a period of days

bleeding and subsequent repair so that the uterus is receptive to an implanting embryo in the next cycle

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3
Q

state the phases of the menstural cycle

A

follicular phase

luteal phase

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4
Q

define the follicular phase

A

from start of menstruation to moment of ovulation (first 14 days in 28 day cycle )

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5
Q

define the luteal phase

A

from moment of ovulation to start of mensturation (final 14 days of the cycle)

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6
Q

define the cells that develop into eggs
-what happens to them

A

oocytes
-surounded by granulosa cells foroming structures called follicles

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7
Q

define how a follicle changes during the menstural cycle

A

PRIMORDIAL FOLLICLES mature into primary and secondary follicles
-this is always occurring and happens independently of the menstrual cycle

once they reach the secondary follicle stage they develop FSH receptso

at the start of the menstural cycle FSH stimulates secondary follicles to grow and the granulosa cells surrounding them secrete oestrogen

one of the follicles will develop further than oterhrs and become the dominant follicle

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8
Q

how does oestrogen released from the granulosa cells impact the menstrual cycle

A

oestrogen negatively feedback on FSH and LH in the ant pit gland

also causes cervical mucus to become more permeable-> allows sper to penetrate the cervix at time of ovulation

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9
Q

how does LH affect the menstural cycle

A

LH spikes just before ovulation cuasing the dominant follicle to realse the ovum (unfertilitsed egg) from the ovary
-this happens 14 DAYS BEFORE THE END OF THE MENSTURAL CYCLE

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10
Q

Descibre the intial parts of teh luteal phase

A

follicle that released the ovum collapses and become shte corpus luteum

-this releases high levels of progesterone
-and a small amount od oestrogen

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11
Q

impact of progesterone at the start of the luteal phase

A

maintains the endometrial lingin

also causes cervical mucus to become thick and no longer permeable

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12
Q

what ahppens at fertilitsaiont

A

syncytiotrophoblasts of the embryo secrete hCG

hCG maintains the corpus leuteum
-whitou it the corpus leutuem degenerates

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13
Q

what happens if tehres no fertilisation

A

no production of hCG
corpus leutuem degenerates and stiops producing oestrogen and progesterone

-fall in both causes the endometruium to break down and mensturation occurs

-ve feedback from porgesterone and oestrogen stops and this allows FSH and LH to rise again and the cycle restat

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14
Q

what does the endometrium release when no fertilation occurs

A

stromal cells of the endometrium release rpostaglandins

prostaglainsn encourage the dnometrium to break down and the uterus to contract

mensturation starts on day 1 of the menstural cycle

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15
Q

which parts of the endometrium are involved in menstration

-what else happens

A

superficial and middle layers of the endometrium separate from the basal layer

-tissue is broken down inside the uterus and released via the cervix and vagina

-can last for 1-8 day s

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16
Q

define heavy menstrual bleeding

A

bleeding that has an adverse impact on woman QoL

-commonest causes of IDA in women in affluent world

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17
Q

average age of menarche in uk

A

13 yo

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18
Q

average age of menopause in uk

A

51
ranges from 45-55

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19
Q

on average how much blood do women loose during menstruation

A

40ml

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20
Q

what value of blood loss defines heavy menstural bleeding
-how is this quantified for diagnosis

A

over 80ml (although this is rarely measured)
-based on symptoms
-changing pads every 1-2hours
-bleeding lasting more than 7 days
-passing large clots

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21
Q

how can causes of heavy menstrual bleeding be classified 3

A

uterine pathology

HMB in absence of pathology (previously DUB (dysfunctional uterine bleeding))

medical disorders

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22
Q

uterine pathology that can cause heavy menstrual bleeding 5
-incidence of this type

A

fibroids

endometrial polyps

andeomyosis

pelvic infection

endometrial malignancy

-incidence- common

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23
Q

causes of heavy menstrual bleeding in abscence of pathology 2
-incidnce

A

anovulatory

ovulatory

-incidence - v common

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24
Q

medical disorder causes of heavy menstrual bleeding 1
-incidence 1

A

clotting disorders

-incidence - very rare

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25
investigations for heavy menstrual bleeding 8
pelvic examination - with a speculum and bimanual -assess for fibroids, ascites, cancer FBC- look for IDA outpatient hysteroscopy if fibroids, cancer or persistetn intermenstrual bleeding pelvic an dtransvaginal ultrasound Swabs coagulation screen- if FHx ferritin If clinically anaemic TFTs if features of hypotrhydoisim
26
when would a biopsy be used in investigations for heavy menstrual bleeding 3
peristent menstural bleeding women aged over 45 treatment failure or ineffective treatment
27
how does managemnt of heavy menstrual bleeding differ
if patient willing/accepts use of contraception -* remember to exclude serious underlying patholgies
28
management of heavy menstrual bleeding if patient denies contraception 2
if patient does not want contraception -transexamic acid - if no assoc pain -mefenamic acid- if assoc pain
29
managemnt of heavy menstural bleeding if patient accepts contraception 3
if contraception wanted/accepted -mirea coil- first line -combined OCP -cyclical oral progestogens
30
how doe progesterone receptor modulators work
agonist and antagonistic effects of progesterone -bind to progesterone receptors -little effect on ovarian function act directly on endometrium -induce amenorrhea -shrink biroids by 20-40% -well tolerated, oral medication
31
what is important regarding biospy of the endometrum
must indicate time in cycle and any hormonal preparations the patient is taking -this may influence interpretation by pathologist
32
anotehr name for mirena coil
LNG-IUS
33
describe endometrial ablation
local or general anaesthetic -ablation of enodmetirum to border with myometrium -PREGNANCY CONTRAINDICATED POST PROCEDURE -must ensure tissue sampling pre procedure 20-50% amenorrhea 70-80% satisfaction
34
assoicated morbiitidy and mortality of hysterectomy
mortatlity 1/1000-2000 major complication 3% minor complciation 15-30% *-level of satifaction high amenorrhea guaranteed
35
define amenorrhoea
absent menses
36
describe the two types of amenorrhoea
primary - fialure to menstruate by age of 15 -may be associated w normal or delayed/absent development of secondary sexual characteristics secondary -established menses stop for ≥6mnths in absence of pregnancy
37
define oligomenorrhoea
cycle which is persistently greater than 35 days in length
38
how can medical hormonal management of heavy menstrual bleeding be split
pseudo-pregnancy -pesudo-menopause
39
options for psuedo-regnacy medical hormonal management of heavy menstrual bleeding 3
COCP progestogens local - (coil)
40
what is the pseudo-menopause treatment for medical hormonal management of heavy menstrual bleeding called
GnRH analouges
41
how do GnRH analouges work for medical hormonal management of heavy menstrual bleeding
pusaltile release fo GnRH from hypothalamus continous levels 'switch off' FSH and LH release form pituitary (FSH and LH become desensitized to GnRH) useful for short term (6mnths-2yrs) can shrink fibroids by up to 40% imrpve haemoglobin can be combined w HRT administer by injection
42
describe the two types of hypogonadism
hypogonaodotropic hypogonadism - -deficiency of LH and FSH hypergonadotropic hypogonadism -lack of response to LH and FSH by the gonads (testes and ovaries)
43
causes of hypogonadotropic hypogonadism
hypopituitarism damage to hypothalamus or pituitary significant chronic conditions eg CF or IBD excesvie ecervise or dieting consitituaila delay in growth and development endocrine- hypothryoidm, cushings, hyperprolcatinaemia kallman syndrome
44
cuases of hpyergonadotropic hypogonadism
previous damge to gonads -torsion, cacner, infections (mumps) congential absence of the ovaries turners syndrome (XO)
45
what is kallmans syndrome assocaited with
hypogonadotrophic hypogonadism and a reduced or absent sense of smell
46
common causes of primary ammenrorhea 4
physiolgoical delay weight loss/ anorexia/ heavy exercise polycystic ovaries imperforate hymen
47
compoents of history for primary amernorhea
FHx weight excersie stresss/exams/ family sexual activity
48
compoentnes of exmaination for primary amenorrhoea 2
secondary sexual cahractereitstcs tanner staging
49
investgations for primary amenroreha 4
plasma FSH,LH oestradiol, prolactin, TFTs karyotype X-ray for bone age cranial imaging
50
first line invesitgation in primary amernorrhea if patient has normal secondary sexual characteristics -what is looked for
ultrasound scan -if uterus is present
51
after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics -if the uterus is present what happens next
check for outflow tract obstruction -imperforate hymen -transverse vaginal septum if normal anatomy-> hormone profile
52
after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics -if normal hymen and vaginal canal what happens next
karyotype -XX-> MRKH Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that mainly affects the female reproductive system. This condition causes the vagina and uterus to be underdeveloped or absent, although external genitalia are normal. Affected individuals usually do not have menstrual periods due to the absence of a uterus -XY- >androgen insensitivity
53
common causes of secondary amenorrrhoea 6
pregnacy lactaion menopause weight loos/stress/anoerxia PCOS surgery -hysterectomy, endometrial ablation, IUD
54
criteria for PCOS diagnosis
Rotterdam Criteria for diagnosis Requires 2 of the 3 features: Clinical or biochemical evidence of hyperandrogenism (high Free androgen index) Oligomenorrhoea/amenorrhoea Ultrasound features of PCO
55
consequences of PCOS 6
Reduced fertility Insulin resistance and diabetes Hypertension Endometrial cancer ‘unopposed oestrogen’ Ensure progesterone protection or withdrawal bleeding Depression and mood swings Snoring and daytime drowsiness
56
PCOS managemnt 5
Education WEIGHT LOSS AND EXERCISE Endometrial protection Progesterone or withdrawal bleed Fertility assistance Lifetime awareness +/- screening for complications
57
define the tanner staging criteria for girls regarding pubic hair (works for males aswell)
Stage 1: No hair Stage 2: Downy hair Stage 3: Scant terminal hair Stage 4: Terminal hair that fills the entire triangle overlying the pubic region Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh
58
describe the tanner staging criteria for girls regarding breast development scale
Stage 1: No glandular breast tissue palpable Stage 2: Breast bud palpable under the areola (1st pubertal sign in females) Stage 3: Breast tissue palpable outside areola; no areolar development Stage 4: Areola elevated above the contour of the breast, forming a “double scoop” appearance Stage 5: Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion
59
define dysmenorrohea
excessive menstural pain -usualy involves cramping lower abdo pain that may radiate to lower back and legs assoc w GI symptoms or malaise -affects 30-50%
60
split the causes of dysmeorrhoea
primary -idiiopathic secondary - pelvic pathology
61
charactertistics for primary dysmenorrhoea
begins w onset of ovaulatory cycles -usuallyw within first 2 years of menarche pain most sever on day of or day prior to starting menstruation
62
cuase of primary dysmenorrhoea
prostaglandins are involved PGF2å increases the contractility of the myometrium adn can lead to dysmenorrhoea
63
managment of primary dysmneorrhoea
pelvic exam may not be appropriate when dealing with an adolecsent transandbominal US scna to reveal normal pevlic organs and provide reassurance discussion and reassurance essential part of management if dysmenorrhea unresponsive to standard treatment - consider possibility of underlying pathology
64
treatment for primary dysmenorrhea
prostaglandin synthesis inhibitors -NSAIDs reduce uterine production of PGF2å COC- suppression of ovulation is highly effective depot progestogens -injectable progesogen-only contraceptive suppresses ovulation - mirena coil
65
what is secondary dysmenorrheoa usually assocaited with 4
endometriosis adenomyosisi pelvic infection fibroids -can also be assoc w precesnce of IUD
66
managemnt of secondary dysmenorrhoea
swabs from genital tract to exclude active pevlic infection if pelvic massess- US laparoscopy for endometriosis -treatement dependent on underlying pathology
67
define intrermenstual bleeeding
bleeding (incl brown discharge) in between periods
68
define post-coital bleeding
bleeding after intercousre
69
define post menopausal bleeding
bleeding occuring >12 months after last menstural period
70
some general casues of post-coital, post-menpausal and intermenstrual bleeding 7
infection truama polyps cervical ectorpion neoplasia/cancer contraception pregnancy
71
assessemnt and investigations for intermensturl and post coital bleeding 4
cervical smear history -should have had negative smear ≤3yr -DO NOT TAKE IF NOT DUE A SMEAR speculum and bimanual examination -urgent colposcopy if sus of cancer STD screen + treat Urine pregnancy test
72
describe the urgetn gynaecologcy referral pathway
women OVER 35 w persistent (over 4 weeks) post coital or intermensrual bleeding
73
describe the routine gynaecology referral pathway
women UNDER 35 w PCB or intermenstrual bleeding persistenitng over 12 weeks or - singel eheavy episode of postcoital or intermenstual bleeeding AT ANY AGE
74
describe reassurance given for intermenstual or post coital bleeding
in women uner 35 w normal findings and results -most will resolve within 6 months if on hormonal contraception or coil consider changing or stopping
75
for post menopausal bleedin what is the investigation of choice -when should it be biopsed
transvaginal USS -Biopsy if ET>3mm (non-HRT and CC-HRT users) Biopsy if ET>5mm (Sequential HRT users) Hysteroscopy/biopsy in Tamoxifen users

Obs & Gyn (23 decks)

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