Menstrual physiology and problems

Question 1

Define menorrhagia

Answer 1

Excessive bleeding that interferes with a womans life. Objectively, >80ml loss.

Question 2

Commonest cause of menorrhagia?

Answer 2

Idiopathic. Subtle abnormalities in endometrial haemostasis or uterine prostaglandin levels.

Question 3

What are the major pathological causes of menorrhagia?

Answer 3

Fibroids (30%) and polyps (10%)

Question 4

What are the rare causes of Menorrhagia?

Answer 4

Thyroid disease, Haemostatic disorder (von Willebrands), Anticoagulants, Coagulopathy.

Question 5

Clinical presentation of Menorrhagia?

Answer 5

Flooding, clots.

Question 6

What are the examination findings in fibroids?

Answer 6

Irregularly enlarged uterus.

Question 7

What are the examination findings in adenomyosis?

Answer 7

Tenderness without enlargement.

Question 8

What investigations would you perform in Menorrhagia?

Answer 8

Anaemia - Hb.

Systemic causes - TFTs, coagulation.

TVUSS.

Biopsy / hysteroscopy if USS indicated.

Question 9

What are the indications for an endometrial biopsy?

Answer 9

Endometrial thickness >10mm premenopausal, >4mm postmenopausal.

Polyp.

>40y.

+ Intermenstrual bleeding.

Acute admission due to menorrhagia.

Ablative surgery to be performed.

IUS to be used to control bleeding.

Not responding to Tx.

Question 10

What are the two methods of obtaining an endometrial biopsy?

Answer 10

Pipelle. Hysteroscopy.

Question 11

What is the first line treatment for menorrhagia?

Answer 11

IUS. Reduces menstrual flow by >90% with few side effects. But can’t conceive!

Note - copper IUD may increase loss.

Question 12

What is the second line treatment for menorrhagia?

Answer 12

Antifibrinolytics (tranexamic acid) to be taken during menstruation. 50% decrease in loss. No need for prescription. Good if trying to conceive.

NSAIDs (mefanamic acid) inhibit prostaglandin synthesis. 30% decrease in loss. Also good for dysmenorrhoea.

COCP. But less effective if pelvic pathology present.

Question 13

What are the third line treatments for menorrhagia?

Answer 13

Progestogens wil cause amenorrhoea, but withdrawal restarts bleeding.

GnRH agonists cause amenorrhoea. Duration limited to 6m without HRT. S/E osteoporosis and CVD.

Question 14

What are the surgical treatments for Menorrhagia?

Answer 14

Hysteroscopic removal of polyps.

Endometrial ablation lightens periods, retains fertility.

Transcervical resection of fibroids (mucosal fibroids of up to 3cm).

Question 15

What are the radical treatments for Menorrhagia?

Answer 15

Myomectomy - removal of fibroids from myometrium. Used when fertility required.

Hysterectomy - last resort!

Uterine artery embolisation - retains uterus and avoids surgery. ?fertility effects.

Question 16

What are the causes of irregular / intermenstrual bleeding?

Answer 16

Anovulatory cycles. Common just after menarche and before menopause.

Pelvic pathology: fibroids, polyps, adenomyosis, ovarian cysts, chronic infection.

Question 17

What investigations would you perform in irregular / intermenstrual bleeding?

Answer 17

Anaemia - Hb.

Exclude malignancy.

USS if >35y or <35y and treatment failed.

Endometrial biopsy.

Question 18

What is the treatment for anatomically normal irregular bleeds?

Answer 18

IUS.

COCP.

Progestogens.

HRT in perimenopause.

Also - Antifibrinolytics and NSAIDs.

Question 19

What is the treatment for anatomically abnormal irregular bleeding?

Answer 19

Surgery! Note that ablative techniques are less useful as they rarely get rid of all endometrium, so some bleeding continues.

Question 20

What is the definition of Amenorrhoea? What is primary vs secondary?

Answer 20

Absence of menstruation.

Primary = no period by 16y.

Secondary = previously normal menstruation stops for >6m.

Question 21

What is oligomenorrhoea?

Answer 21

Infrequent menstruation occuring every 35d-6m.

Question 22

What are the physiological causes of amenorrhoea?

Answer 22

Secondary: Pregnancy, Menopause, Lactation.

Primary: Constitutional delay

Question 23

What are the common pathological causes of amenorrhoea?

Answer 23

Most common are secondary causes:

Premature menopause.

PCOS.

Hyperprolactinaemia.

Question 24

What are the hypothalamic causes of amenorrhoea?

Answer 24

Hypotholamic hypogonadism. This can be due to:

• Low weight
• Anorexia nervosa
• Excessive exercise

This causes low GnRH, hence low FSH, LH and oestradiol.

Prolonged hypo-oestrogenism requires monitoring and treatment with oestrogen (bone protection) and progesterone (endometrium protection) using COCP.

Question 25

What are the pituitary causes of amenorrhoea?

Answer 25

_Hyperprolactinaemia_. Usually caused by pituitary adenomas or hyperplasia. _Sheehan's syndrome_. Rare. Severe PPH causes pituitary necrosis and hypopituitarism.

Question 26

What is the treatment for hyperprolactinaemia?

Answer 26

_Bromocriptine_, or _Cabergoline_, or Rarely surgery.

Question 27

What are the adrenal and thyroid causes of amenorrhoea?

Answer 27

_Hyper / hypothyroidism_. Hypo causes raised prolactin levels and anaemia. _Congenital adrenal hyperplasia / virilising tumours._

Question 28

What are the ovarian causes of amenorrhoea?

Answer 28

_PCOS_. Can cause primary or secondary. _Premature menopause_. _Turner's syndrome_. _Gonadal dysgenesis_.

Question 29

What are the anatomical causes of amenorrhoea?

Answer 29

_Imperforate hymen_. _Transverse vaginal septum_. _Cervical stenosis_. _Asherman's syndrome_.

Question 30

What are the common causes of post-coital bleeding?

Answer 30

_Cervical carcinoma_. _Cervical ectropion_. _Cervical polyps_. _Cervicitis / vaginitis_.

Question 31

What is the management of postcoital bleeding?

Answer 31

Inspect cervix and take smear. Polyp -\> avulse and send for histology. Normal smear - ectroption can be frozen. Abnormal smear - colposcopy.

Question 32

What causes dysmenorrhoea?

Answer 32

High prostaglandin levels cause contraction and uterine ischaemia.

Question 33

What is primary dysmenorrhoea? How do you manage it?

Answer 33

Dysmenorrhoea with no organic cause. Coincides with start of menstruation. Common - 50% of women. Management - NSAIDs or ovulation suppression (COCP).

Question 34

What is secondary dysmenorrhoea? What are the common causes?

Answer 34

Pain due to pelvic pathology. Pain precedes and is relieved by menstruation. Caused by: fibroids, adenomyosis, endometriosis, PID, ovarian tumours.

Question 35

What is the definition of precocious puberty?

Answer 35

Menstruation occuring before age 10, or secondary sexual characteristics by age 8. It causes shortened final height due to early epiphyseal fusion.

Question 36

What are the causes of precocious puberty?

Answer 36

_Idiopathic in 80%_. _Central causes - increased GnRH_: meningitis, encephalitis, CNS tumours, hydrocephaly, hypothyroidism. _Ovarian / adrenal - increased oestrogen_: hormone producing tumours _McCune-Albright syndrome_: bone and ovarian cysts, cafe au lait spots and precocious puberty.

Question 37

What is the treatment for precocicous puberty?

Answer 37

Idiopathic: _GnRH agonists_. Tumours: _removal_. McCune-Albright: cyproterone acetate.

Question 38

What causes intersex conditions in genetic females?

Answer 38

Excess androgens. _Congenital adrenal hyperplasia_. Recessive inheritance. Defective cortisol production causing increased ACTH and excess androgens. Presents at birth with ambiguous genitalia. May get addisonian crises. Treat with cortisol and mineralocorticoid replacement. Rarely: androgen-secreting tumours or Cushing's syndrome.

Question 39

What causes intersex conditions in genetic males?

Answer 39

Insufficient androgens. _Androgen insensitivity syndrome_. Androgens don't bind so are converted peripherally to oestrogens. Person appears to be female, so presents with amenorrhoea and an absent uterus. Treat by removing rudementary testes and replacing oestrogen.

Question 40

What days does the menstruation phase occur on? What happens?

Answer 40

Days 1-4. Endometrium is shed as hormones withdraw. Myometrial contraction occurs, which can be painful.

Question 41

What days does the proliferative phase occur on? What happens?

Answer 41

Days 5-13. GnRH pulses cause LH and FSH secretion. LH and FSH cause antral follicles to mature. The follicle produces Oestradiol and inhibin. These cause negative feedback on FSH, positive feedback on LH and endometrial reformation and proliferation. The LH surge causes ovulation to occur.

Question 42

What days does the luteal / secretory phase occur on? What happens?

Answer 42

Days 14-28. Follicle becomes the corpus luteum and secretes oestradiol and progesterone. This causes the endometrium to swell and blood supply to increase. If the egg isn't fertilised, the corpus luteum starts to fail, so the cycle starts over again.