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Flashcards in Menstrual Cycle and problems Deck (39):

What is the difference between primary and secondary amenorrhoea? (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.


Name 3 causes of primary amenorrhoea? (3)

-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.


Name 3 causes of secondary amenorrhoea. (3)

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


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

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


Ursula presents with primary amenorrhoea, age 17.
Name 2 blood tests and an imaging investigation. (3)

Blood: LH, FSH, oestradiol, prolactin, karyotype
Pelvic USS


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

When and how does CAH present? (2)

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.


What is androgen insensitivity syndrome? (2)

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.


What is Asherman's syndrome? (1)

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.


Define dysfunctional uterine bleeding. (2)

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.


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

Tranexamic acid, mefenamic acid, norethisterone, COC, IUS
Surgery: hysterectomy or endometrial ablation if family complete.


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

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


Name 3 causes of dysmenorrhoea. (3)



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

Mefenamic acid is a NSAID
Tranexamic acid is an anti-fibrinolytic.


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

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


Define endometriosis. (3)

Presence of endometrial tissue outside of the uterus.


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

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


Define menorrhagia. (1)

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.


Name 2 causes of menorrhagia. (2)

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


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

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


How do NSAIDs help with menorrhagia? (1)

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


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

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


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

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


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

Cervical smear
Transvaginal USS
Biopsy (Pipelle or hysteroscopy)


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

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)


Define post-coital bleeding. (1)

Bleeding after intercourse that is not menstrual loss.


Name 2 causes of PCB. (2)

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


What is the pathophysiology behind primary dysmenorrhoea? (1)

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

Therefore treat with NSAIDs


Name 3 causes of secondary dysmenorrhoea. (3)

PID, fibroids, endometriosis, adenomyosis, ovarian tumour.


Define precocious puberty. (2)

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


Define menopause. (1)

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


Define the perimenopause. (1)

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


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

What is the age of premature menopause? (1)

51 years old

<40 years old


Name 3 causes of premature menopause. (3)

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


How is premature menopause managed? (1)

HRT until age 50.
If fertility desired, will require oocyte donation.


Define PMB. (2)

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


Give 3 symptoms of the menopause. (3)

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.


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

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.


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

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

Progesterone to protect endometrium


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

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.