Menstrual Cycle and problems

Question 1

What is the difference between primary and secondary amenorrhoea? (1)

Answer 1

Primary (5%): failure to establish menstruation by age of 16 years (or by 14 years if no development of secondary sexual characteristics)

Secondary (95%): Absence of menstruation for >6 consecutive months in a woman who has previously established regular menses.

Question 2

Name 3 causes of primary amenorrhoea? (3)

Answer 2

• If normal secondary characteristics: constitutional delay, androgen insensitivity syndrome, anatomical defects (eg imperforate hymen)
• If absent secondary sexual characteristics: Kallman’s syndrome, anorexia, excessive exercise, gonadal dysgenesis (eg 45X), congenital infections, pituitary tumours, head injury
• Intersex conditions: congenital adrenal hyperplasia, 5a reductase deficiency, true hermaphrodites.

Question 3

Name 3 causes of secondary amenorrhoea. (3)

Answer 3

• Pregnancy
• Ovary: PCOS, premature ovarian failure
• Pituitary: hypopituitarism, trauma, tumour (eg prolactinoma), cranial irradiation, Sheehan’s syndrome
• Hypothalamus: Hypogonadotrophic gonadism
• Other: Endocrine (thyroid, Cushing’s)

Question 4

Name 3 blood tests you would do to investigate a patient presenting with secondary amenorrhoea. (3)
Name 2 imaging you would request. (2)

Answer 4

LH, FSH, oestrodiol, prolactin, testosterone, TFT, ?dexamethasone suppression test, beta-hcg
USS pelvis, MRI pituitary fossa, bone mineral density scan (if oestrogen deficient)

Question 5

Ursula presents with primary amenorrhoea, age 17.

Name 2 blood tests and an imaging investigation. (3)

Answer 5

Blood: LH, FSH, oestradiol, prolactin, karyotype

Pelvic USS

Question 6

How does congenital adrenal hyperplasia cause primary amenorrhoea? (2)

When and how does CAH present? (2)

Answer 6

Autosomal recessive condition that causes deficient production of cortisol.
Pituitary produces excess ACTH due to lack of negative feedback, so excessive androgens are produced.

Presents at birth with ambiguous genitalia or Addisonian crisis.
Presents at puberty with primary amenorrhoea and enlarged clitoris.

Question 7

What is androgen insensitivity syndrome? (2)

Answer 7

Genetically male child has cell receptor insensitivity to androgens, they are then converted peripherally to oestrogens.
They are therefore phenotypically female and present with primary amenorrhoea. Examination will reveal no uterus and rudimentary testes that require removal.

Question 8

What is Asherman’s syndrome? (1)

Answer 8

Presence of intrauterine adhesions that may partially or completely occlude the uterine cavity.
can occur following surgery or excessive curettage for evacuation of retain products of conception.

Question 9

Define dysfunctional uterine bleeding. (2)

Answer 9

Abnormal uterine bleeding in the absence of organic pathology.
it is a diagnosis of exclusion.
Tends to occur at the extremes of reproductive age or in obesity; 90% occurs with anovulatory cycles.

Question 10

What is the management of dysfunctional uterine bleeding? (2)

Answer 10

Tranexamic acid, mefenamic acid, norethisterone, COC, IUS

Surgery: hysterectomy or endometrial ablation if family complete.

Question 11

What is the difference between primary and secondary dysmenorrhoea? (1)

Answer 11

Primary: Painful menstruation in the absence of pathology
Secondary: Painful menstruation with identifiable pathology.

Question 12

Name 3 causes of dysmenorrhoea. (3)

Answer 12

Fibroids
Endometriosis
Adenomyosis
PID
Menorrhagia

Question 13

What type of drugs are mefenamic acid and tranexamic acid? (2)

Answer 13

Mefenamic acid is a NSAID

Tranexamic acid is an anti-fibrinolytic.

Question 14

Dyspareunia can be separated into superficial and deep dyspareunia.
Give 2 causes of each. (4)

Answer 14

Superficial: infections, atrophy, vaginismus, lichensclerosis, lichen planes, scarring
Deep: PID, endometriosis, fixed uterine retroversion, pelvic congestion syndrome, pelvic adhesion, ovarian cyst.

Question 15

Define endometriosis. (3)

Answer 15

Presence of endometrial tissue outside of the uterus.

Question 16

What is the average age of menarche in the UK? (1)

Answer 16

13

Budding age 8, pubic hair, age 11-13.

Question 17

Define menorrhagia. (1)

Answer 17

Excessive bleeding in an otherwise normal cycle; either severe enough to h=impact the physical, mental or social wellbeing or blood loss >80ml per cycle.

Question 18

Name 2 causes of menorrhagia. (2)

Answer 18

Usually no obvious cause.
Fibroids, endometrial or cervical polyps, PID, ovarian/cervical or endometrial cancer, adenomyosis, coagulopathy e.g. vW disease

Question 19

What is the medical management of menorrhagia in a women who has completed her family? (3)

Answer 19

First: insertion of IUS
Second: Tranexamic acid (anti-fibrinolytic), NSAID
Third: Oral/IM progesterone, GnRH agonist

Question 20

How do NSAIDs help with menorrhagia? (1)

Answer 20

Menorrhagia is due to high levels of prostaglandins, so inhibition of prostaglandins can help reduce blood loss.

Question 21

What surgical options are available for a women with menorrhagia who has completed her family? (3)

Answer 21

• Polypectomy if appropriate
• Myomectomy if appropriate
• Endometrial ablation (if older, uterus <10w size, pure menorrhagia. Reduces fertility but does not sterilise)
• Hysterectomy
• Uterine artery embolisation (if due to fibroids. Effect on fertility not known)

Question 22

Name 3 causes of inter-menstrual bleeding (IMB). (3)

Answer 22

Non-malignant: fibroids, polyps, adenomyosis, ovarian cysts, PID
Malignant: endometrial cancer, cervical cancer, ovarian cancer

Question 23

Hallie comes to see you with a 3 month history of inter-menstrual bleeding.
Name 3 investigations you would do. (3)

Answer 23

FBC
Cervical smear
Transvaginal USS
Biopsy (Pipelle or hysteroscopy)

Question 24

Name 3 indications for undertaking biopsy of endometrium. (3)

Answer 24

Age >40
USS: endometrial thickness.. >4mm if post menopausal or >10mm if pre-menopausal
If USS suggestive of polyp
History of menorrhagia and IMB
Prior to endometrial ablation (unable to biopsy after)

Question 25

Define post-coital bleeding. (1)

Answer 25

Bleeding after intercourse that is not menstrual loss.

Question 26

Name 2 causes of PCB. (2)

Answer 26

Cervical ectropion, cervical polyp, cervical cancer, atrophic vaginitis (uncommon)

Question 27

What is the pathophysiology behind primary dysmenorrhoea? (1)

Answer 27

High levels of prostaglandins in the endometrium,increasing uterine contraction and myometrial ischaemia.

Therefore treat with NSAIDs

Question 28

Name 3 causes of secondary dysmenorrhoea. (3)

Answer 28

PID, fibroids, endometriosis, adenomyosis, ovarian tumour.

Question 29

Define precocious puberty. (2)

Answer 29

Menarche under 10 years old OR development of secondary sexual characteristics before 8 years old.

Question 30

Define menopause. (1)

Answer 30

Permanent cessation of menstruation from loss of ovarian follicular activity.
Natural menopause is 12 months after last period.

Question 31

Define the perimenopause. (1)

Answer 31

From the first signs of menopause e.g. vasomotor symptoms to 12 months after last menstruation.

Question 32

What is the median age of menopause in the UK? (1)

What is the age of premature menopause? (1)

Answer 32

51 years old

<40 years old

Question 33

Name 3 causes of premature menopause. (3)

Answer 33

Idiopathic
Medical: eg autoimmune, ovarian dysgenesis, chemotherapy, infections
Surgical: bilateral oophorectomy

Question 34

How is premature menopause managed? (1)

Answer 34

HRT until age 50.

If fertility desired, will require oocyte donation.

Question 35

Define PMB. (2)

Answer 35

Post menopausal bleeding is vaginal bleeding more than 12 months after last period.

Question 36

Give 3 symptoms of the menopause. (3)

Answer 36

Early: hot flushes, night sweats, insomnia, depression

Later: skin/breast atrophy, hair loss, atrophic vaginitis, prolapse, urinary symptoms (frequency, nocturia), osteoporosis, increased risk of cardiovascular disease.

Question 37

Joleen is 53 and has been experiencing hot flushes and low mood.
What investigations would you do? (3)

Answer 37

Serum FSH level: level varies throughout cycle, but increased levels suggest ovarian failure
Serum anti-mullerian hormone: direct measure of ovarian reserve, levels are stable throughout cycle. Low levels, highly suggestive of ovarian failure.

TFT’s for thyrotoxicosis
Catecholamines for phaechromocytoma.

Question 38

Who should have oestrogen and progesterone HRT and who should have oestrogen only HRT? (2)
Why? (1)

Answer 38

Oestrogen only: women who have had a hysterectomy
Oestrogen + progesterone: women with intact uterus.

Progesterone to protect endometrium

Question 39

Give 2 advantages of HRT and 2 disadvantages. (4)

Answer 39

Adv: protects against osteoporosis, reduces urinary symptoms and is the treatment of choice for premature menopause
Disadv: menstruation, oestrogenic and progestogenic side effects, increased risk of VTE and breast cancer.