Menstrual Disorders, Menopause and Secondary Amenorrhea

Question 1

what is the normal amount of menstrual loss over the duration of menstruation?

Answer 1

less than 80ml over 7 days

Question 2

what are the four aspects of menstruation which can lead to a menstrual disorder?

Answer 2

• abnormal frequency
• abnormal duration
• irregularity
• abnormal volume

Question 3

what does amenorrhea mean?

Answer 3

absent periods

Question 4

what does dysmenorrhea mean?

Answer 4

painful periods

Question 5

what does menorrhagia mean?

Answer 5

Heavy periods

Question 6

what volume of menstrual loss is classified as menorrhagia?

Answer 6

> 80ml in 7 days

Question 7

name a few causes of heavy periods related to abnormalities in the uterus/ovaries

Answer 7

• polyps
• endometriosis
• malignancy
• fibroids
• infection (PID/STI)
• polycystic ovaries

Question 8

name a few causes of heavy periods related to systemic problems

Answer 8

• bleeding disorders
• liver or renal disease
• hypothyroidism

Question 9

name a few iatrogenic causes of heavy periods

Answer 9

• anticoagulation drugs

- copper IUD

Question 10

what is another term for fibroids?

Answer 10

leiomyoma

Question 11

what is the treatment for fibroids?

Answer 11

• symptom management (COCP or coil for HMB)
• resection
• hysterectomy

Question 12

how does endometriosis present?

Answer 12

heavy menstrual bleeding
severe pelvic pain
anaemia/fatigue
dyspaerunia (pain during sex)
nausea
intermenstrual bleeding
painful urination/bowel movement
lower back pain

Question 13

how can endometriosis be diagnosed?

Answer 13

pelvic examination
transvaginal ultrasound
diagnostic laparoscopy

Question 14

what is an important complication of endometriosis in women of reproductive age?

Answer 14

infertility

Question 15

what is the medical management of endometriosis?

Answer 15

• pain relief
• COCP
• intrauterine device
• progesterone-only methods
• gonadotropin releasing hormone agonists

Question 16

what is the surgical management of endometriosis?

Answer 16

• ablation
• excision (if endometrioma)
• hysterectomy

Question 17

what is adenomyosis?

Answer 17

it’s embedding of the endometrium into the myometrium

Question 18

what is endometriosis?

Answer 18

it’s presence of endometrial tissue in abnormal areas outwith the uterus

Question 19

what is the management of adenomyosis?

Answer 19

hysterectomy

Question 20

what is the management of endometrial polyps?

Answer 20

resection (polypectomy)

Question 21

when is an endometrial biopsy taken for heavy period bleeding?

Answer 21

if patient older than 44 and not responded to medical treatment

Question 22

what investigations can be done to diagnose a cause for heavy mentrual bleeding?

Answer 22

• history and examination
• bloods - thyroid function and clotting profile
• liver and kidney tests
• pelvic ultrasound scan
• laparoscopy if endometriosis suspected
• hysteroscopy for polyps

Question 23

what are the hormonal treatment options for heavy menstrual bleeding?

Answer 23

• combined oral contraceptive pill
• progesterone-only pill
• progestogen injection
• Mirena IUS

Question 24

what are the surgical treatment options for heavy menstrual bleeding?

Answer 24

• ablation
• resection
• hysterectomy

Question 25

what management for heavy menstrual bleeding is given to women trying to conceive?

Answer 25

mefenamic acid | tranexamic acid

Question 26

define subtotal vs total hysterectomy

Answer 26

subtotal: cervix not removed total: cervix removed too

Question 27

what is salpingo-oophorectomy?

Answer 27

removal of fallopian tubes and ovaries

Question 28

what is an immediate result of an oophorectomy?

Answer 28

menopause

Question 29

name a few causes of amenorrhea

Answer 29

- stress - malnutrition - intense exercise - obesity - primary ovarian insuffiency - polycystic ovarian syndrome - abnormal prolactin levels - hormonal treatment - hyperthyroidism - obstruction

Question 30

what causes polycystic ovaries syndrome?

Answer 30

excess of androgens

Question 31

how is polycystic ovaries syndrome managed?

Answer 31

- management of symptoms | - advice on lifestyle (eg BMI, diet)

Question 32

two of which three criteria are necessary to diagnose polycystic ovarian syndrome?

Answer 32

- polycystic ovaries (ultrasound) - infrequent periods (no ovulation) - hyperandrogenism (clinical and biochemical)

Question 33

which acronym can be used to identify causes of heavy menstrual bleeding?

Answer 33

PALM COEIN

Question 34

what happens to the levels of oestrogen and FSH in menopause?

Answer 34

oestrogen levels drop | FSH levels rise

Question 35

what lab test is carried out to confirm menopause?

Answer 35

FSH levels

Question 36

what is the first line treatment of symptoms caused by menopause?

Answer 36

hormone replacement therapy

Question 37

what are the systemic options for hormone replacement therapy, and what do they depend on?

Answer 37

depends on whether woman still has uterus: - uterus = oestrogen + progesterone - no uterus = oestrogen only

Question 38

what are the local options for hormone replacement therapy?

Answer 38

vaginal oestrogen

Question 39

when is HRT contraindicated?

Answer 39

- if woman has hormone-dependent cancer - if woman has liver disease - if woman has unexplained bleeding - if woman has Hx of VTE/thrombophilia/breast ca

Question 40

if a woman is perimenopausal, what does that mean and what HRT option is offered to her?

Answer 40

perimenopausal = still some ovarian function | she will be offered cyclical combined HRT instead of continuous combined HRT

Question 41

name a complication of menopause which can affect bones

Answer 41

osteoporosis

Question 42

name a few symptoms experienced during menopause

Answer 42

``` hot flushes dyspareunia vaginal dryness night sweats bloating mood swings low libido muscle/joint pain ```

Question 43

name a few alternative treatments for menopausal symptoms if HRT is contraindicated

Answer 43

- selective estrogen receptor modulators (SERM) - SSRI/SNRI - natural remedies - non-hormonal vaginal lubricants

Question 44

what tool is used to assess for the risk of osteoporosis in menopausal women?

Answer 44

FRAX score

Question 45

if a woman presents with premature menopause without previous hysterectomy, what HRT treatment will she be offered and what age will she be advised to take it until?

Answer 45

woman still has a uterus = combined HRT | HRT until age 50

Question 46

name a few risks involved in taking HRT

Answer 46

- increased risk of breast/ovarian ca | - increased risk of VTE/CVA

Question 47

name a few benefits involved in taking HRT

Answer 47

- reduces hot flushes - reduces night sweats - relieves vaginal dryness - reduces risk of osteoporosis

Question 48

what is the main purpose of giving oestrogen as a hormone replacement therapy?

Answer 48

symptom relief

Question 49

what is primary amenorrhea?

Answer 49

never having had a period before

Question 50

name a few causes of secondary amenorrhea

Answer 50

- pregnancy - contraception (IUS, depo-provera) - PCOS - stress/BMI/strenuous exercise/malnutrition - premature menopause - increased prolactin - primary ovarian insufficiency - thyroid disease

Question 51

name a few investigations done to identify the cause of amenorrhea

Answer 51

- abdominal/bimanual examination - BMI - TSH, estrogen, testosterone, FSH/LH, prolactin - urine dipstick - pelvic ultrasound

Question 52

two of which three criteria are needed to make a diagnosis of PCOS?

Answer 52

- polycystic ovaries on ultrasound - anovulation - hyperandrogenism (clinical and biochemical)

Question 53

how is PCOS managed?

Answer 53

- lifestyle advice (eg BMI) - antiandrogen drugs (combined contraception, spironolactone) - endometrium protection (combined hormonal contraception) - clomifene/metformin

Question 54

which diabetic medication has been shown to help with ovulation in women with PCOS?

Answer 54

metformin

Question 55

what are women with PCOS at risk of if they have very infrequent periods?

Answer 55

endometrial hyperplasia