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Gynaecology > Menstrual cycle and its disorders > Flashcards

Menstrual cycle and its disorders Flashcards

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1
Q

1st

A

1st

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2
Q

How do you ask about prolapse?

A

Does you ever get a dragging sesnation or feel a mass in or at the vagina?

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3
Q

Average age for menarche in the west?

A

13 years

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4
Q

What stimulates puberty?

A

Hypothalamic-pituitary axis
GnRH pulses increase in frequency and amplitude from age 8 - increases FSH and LH release from pituitary
These stimulate oestrogen release from ovary

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5
Q

What is thelarche and when does it happen?

A

Beginning of breast development

Occurs first at 9-11 years

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6
Q

What is adrenarche and when does it happen?

A

Growth of pubic hair - starts at age 11-12 years

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7
Q

3 phases of menstrual cycle

A

Day 1-4: menstruation
Day 5-13: proliferative phase
Day 14-28: luteal/secretory phase

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8
Q

Details of 2nd phase of menstrual cycle

A

Day 5-13: proliferative phase (follicle grows, releases oestradiol causing endometrium to reform - thickens, LH surge leads to ovulation)

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9
Q

Details of 3rd phase of menstrual cycle

A

Day 14-28: Luteal/secretory phase - egg released, corpus luteum remains, secretes oestradiol and progesterone - secretory changes in endometrium - no fertilisation, corpus luteum fails, hormones drop and endometrium breaks down

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10
Q

How do oestrogen and progesterone levels change during the menstrual cycle?

A

Progesterone levels raise slowly from phase 1 until reaches max in middle of luteal phase - then drops back to lowest in mid luteal
Oestrogen levels raise more quickly and reach max at ovulation - then drop steadily through luteal phase

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11
Q

How do LH and FSH levels change during menstrual cycle?

A

LH and FSH surge at ovulation

Also slight increase in FSH at end/beginning of cycle

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12
Q

What is menorrhagia?

A

Heavy menstrual bleeding

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13
Q

What is clinical definition of menorrhagia?

A

Excessive menstrual blood loss that interferes with womans physical, emotional, social and material quality of life

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14
Q

What is the objective definition of menorrhagia?

A

Blood loss of >80ml in otherwise normal menstrual cycle

But actual blood loss is rarely measured

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15
Q

What are the two most common pathological causes of menorrhagia?

A

Fibroids (30% of HMB)

Polyps (10% of HMB)

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16
Q

What pathological causes are most likely to cause irregular bleeding? x4

A

Chronic pelvic infection
Ovarian tumours
Endometrial and
Cervical malignancy

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17
Q

What are rare systemic causes of menorrhagia? x3

A

Thyroid disease
Haemostatic disorders such as von Willebrands disease
Anticoagulant therapy

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18
Q

What are two signs of excessive blood loss in menorrhagia?

A

Flooding

Passage of large clots

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19
Q

Investigations in menorrhagia? x4

A

FBC and Hb - anaemia
Coag and TFTs - systemic cause
Transvaginal US - local pathology

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20
Q

What are clinical indicators for endometrial biopsy with menorrhagia? x5

A 
Endometrial thickness >10mm
Polyp suspected 
Woman >40 years old with recent onset menorrhagia 
IMB 
Not responded to treatment
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21
Q

Further investigation which can be done in menorrhagia

A

Hysteroscopy

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22
Q

What is the first line treatment for menorrhagia?

A

IUS - not good if want to conceive

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23
Q

Second line treatments for menorrhagia? x3

A

Antifibrinolytics taken during menstruation - tranexamic acid (few side effects and available without prescription)
NSAIDs - also good for dysmennorhoea
COC - less effective if pelvic pathology

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24
Q

Third line treatments for menorrhagia x2

A

Progestogens - work but bleeding will follow withdrawal

GnRH agonists - duration limited to 6 months unless HRT taken - risks and concerns associated

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25
What are the hysteroscopic surgical treatments for menorrhagia? x3
Polyp removal Endometrial ablation (reduces fertility but not sterilising) Transcervical resection of fibroid (up to 3cm in diameter)
26
More radical surgical options for menorrhagia? x3
Myomectomy (removal of fibroids from myometrium) open or laparoscopic surgery (GnRH agonists used to reduce fibroid size first) Hysterectomy - last resort Uterine artery embolisation - effects on fertility not clear
27
When are irregular bleeding and intermenstrual bleeding most common?
At extremes of reproductive age
28
What are pathological non-malignant causes of irregular menstruation and intermenstrual bleeding? x5
Fibroids, uterine and cervical polyps, adenomyosis, ovarian cysts and chronic pelvic infection
29
When are malignant causes more likely to be cause of irregular bleeding?
Older women, esp. if a recent change
30
Which malignancies can cause irregular bleeding? x3
Endometrial Ovarian Cervical
31
Investigations in irregular bleeding x4
Hb to check anaemia Cervical smear US exam if >35 Endometrial biopsy if endometrium thickened, polyp suspected, woman >40 or if surgery/IUS will be used
32
First line treatment for irregular bleeding with no anatomical cause
IUS or COC
33
Second line treatment for irregular bleeding
Progestogens but irregular bleeding will follow withdrawal
34
What is amenorrhoea
Absence of menstruation
35
What is difference between primary and secondary amenorrhoea?
Primary is when periods haven't started by age 16, secondary is when previous menstruation ceases for 6 months or more
36
What is definition of delayed puberty?
Secondary sex characteristics not present by age 14
37
What is oligomenorrhoea
Menstruation which occurs every 35days to 6 months
38
What drugs can cause amenorrhoea?
GnRH analogues Progestogens Sometimes antipsychotics (increase prolactin levels)
39
What are the most common causes of secondary amenorrhoea or oligomenorrhoea? x3
Premature menopause Polycystic ovary syndrome Hyperprolactinaemia
40
What can lead to hypothalamic hypogonadism and subsequent amenorrhoea?
Psychological factors, low weight/AN or excessive exercise
41
What is the cause of pituitary related amenorrhoea?
Hyperprolactinaemia - cause by pituitary hyperplasia or benign adenomas (rarely pit tumours or Sheehans syndrome)
42
What is Sheehans syndrome
Rare severe post-partum haemorrhage causing pituitary necrosis and varying degrees of hypopituitarism
43
Treatment of hyperprolactinaemia causing amenorrheoa
Bromocriptine, cabergoline - occasionally surgery
44
What thyroid problems can cause amenorrhoea
Over-activity or under-activity of the thyroid can cause it | Hypothyroid leads to raised prolactin levels and amenorrhoea
45
What sort of amenorrhoea can PCOS cause?
Primary or secondary amenorrhoea | But oligomenorrhoea is more common
46
What are congenital causes of amennorhoea? x4
Turners syndrome Gonadal dysgenesis (ovary imperfectly formed due to mosaiic abnormalities of X chromosome) Gonadal agenesis Androgen insensitivity
47
What can outflow tract problems leading to amenorrhoea cause?
Eg. imperforate hymen or transverse vaginal septum - obstruct menstrual flow - therefore accumulates over months in the vagina (haematocolpos) or uterus (haematometra) - may be palpable abdominally
48
What is Ashermans syndrome?
Uncommon consequence of excessive curettage at evacuation of retained products of conception
49
Causes of post-coital bleeding? x4
Cervical carcinoma Cervical ectropion Cervical polyps Cervicitis, vaginitis
50
Investigation of postcoital bleeding? x3
Smear from cervix Avulsion of polyp if present Colposcopy
51
Management of post-coital bleeding if due to ectropion
Can freeze it with cryotherapy
52
What is dysmenorrhoea associated with?
High prostaglandin levels in the endometrium | Due to contraction and uterine ischaemia
53
What is primary dysmenorrhoea
When there is no organic cause for dysmenorrhoea - usually coincides with start of menstruation NSAIDs and COC to treat
54
What is secondary dysmenorrhoea
When pain is due to pelvic pathology | Pain often preceeds and is relieved by the onset of menstruation
55
What else is common with secondary dysmenorrhoea x3
Deep dyspareunia Menorrhagia Irregular menstruation
56
Causes of secondary dysmenorrhoea? x5
``` Fibroids Adenomyosis Endometriosis PID Ovarian tumours ```
57
What is the definition of precocious puberty?
When menstruation occurs before age 10 or other secondary sexual characteristics before age 8
58
What is the consequence for height in precocious puberty?
Early growth spurt but final height reduced due to early fusion of the epiphyses
59
Treatment of precocious puberty
GnRH agonists - inhibit sex hormone secretion and cause regression of secondary sexual characteristics
60
How often is no cause found for precocious puberty?
In 80% of cases
61
Central causes of precocious puberty x5
Increased GnRH secretion - meningitis, encephalitis, CNS tumours, hydrocephaly and hypothyroidism - may all prevent normal pubertal inhibition of GnRH release from hypothalamus
62
Ovarian/adrenal causes of precocious puberty?
Increased oestrogen secretion - Hormone producing tumours of the ovary or adrenal glands (McCune-Albright syndrome)
63
What is McCune-albright syndrome?
Bone and ovarian cysts, cafe au lait spots and precocious puberty - Treat with antiandrogenic progestogen
64
Drug management of PMS x2
SSRIs in second half of cycle | Ablating the cycle with contraception
65
What is good for the breast tenderness of PMS
Evening primrose oil

Gynaecology (8 decks)

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