Menstrual Problems

Question 1

Symptoms of PMS?

Answer 1

abdo bloating
breast tenderness (cyclical mastalgia)
headaches
oedema
mood changes

Question 2

when should PMS symptoms resolve?

Answer 2

within 4 days of onset of menses

Question 3

Possible treatments for PMS?

Answer 3

1. Effective- SSRIs, supression of ovulation, oophrectomy
2. May be effective- diet, exercie, psychological approaches, vit b6 (pyridoxine)
3. not effective- progesterone, evening primrose oil, vit E, st john’s wort

Question 4

Definition of menorrhagia?

Answer 4

Heavy periods
blood loss >80mls per month
(60% develop anaemia)

Question 5

causes of menorrhagia?

Answer 5

1. uterine pathology (common)
2. dysfunctional uterine bleeding- DUB (very common)
3. medical disorders/clotting (very rare)

Question 6

Benign uterine causes of menorrhagia?

Answer 6

1. uterine fibroids (leimyomas)- benign tumours of myometrium, well circumcised whorls of smooth muscle cells with collagen
2. endometrial polyps- localised growths of endometrium, contain fibrous tissue, covered by columnar epithelium
   3, adenomyosis
3. PID

Question 7

Malignant uterine cause of menorrhagia?

Answer 7

endometrial cancer

Question 8

What is DUB?

Answer 8

Diagnosis of exclusion
menorrhagia in the absence of recognisable pelvic pathology or complications of pregnancy/systemic disease
commonly occurs around menarche and menopause

Question 9

Investigations of Menorrhagia?

Answer 9

FBC, Coag Screen and TFT
USS
endometrial assessment (biopsy, hysterectomy in >40yrs)
cervical smear

Question 10

Treatment of polyps?

Answer 10

polypectomy under LA or GA

Question 11

Treatment of fibroids?

Answer 11

1. Medical- GnRH used to shrink

2. Surgical- hysteroscopic resection, hysterectoy, myomectomy, uteine artery embolisation

Question 12

Medical treatment of DUB?

Answer 12

1. Prostaglandin synthesis inhibitors
   (NSAIDs can reduce by upto 25%- reduction of endometrial prostaglandin conc)
2. Antifibronolytics eg. tranexamic acid- reduce upto 50%
3. COCP- reduce upto 50%
4. Systemic Progesterones (noriestherone 5mg from day 5 of cycle)- upto 80%
5. Levonorgesterol IUS- blood loss reduction upto 95%
6. GnRH analogues- brings menopause
7. Danazol

Question 13

How does danazol work?

Answer 13

synthetic androgen with anti-oestrogenic and anti-progesteronic activity
inhibits pituitary gonadotrophons and supresses endometrium

Question 14

Surgical treatment of DUB?

Answer 14

endometrial ablation

hysterectomy (removal of the uterus)- subtotal, total, TAH BSO

Question 15

Pros of TAH?

Answer 15

cervix is removed, no further smears or risk of cervical malignancies

Question 16

cons of TAH?

Answer 16

increased surgical morbidity

conservation of cervix may be associated with better sexual funtion

Question 17

Pros of Subtotal hysterectomy?

Answer 17

fewer complications than TAH (less bleeding, infection, bladder injury and ureteric damage)

Question 18

Cons of subtotal hysterectomy?

Answer 18

risk of cervical cancer remains same as before

Question 19

pros of vaginal hysterectomy?

Answer 19

may be lower incidence of bladder and bowel injury

no abdo wound

Question 20

cons of vaginal hysterectomy?

Answer 20

limited ovarian access
contraindicated if- large uterus, restricted uterine mobility, limited vaginal space, adnexal patholgy, cervix flush with vagina

Question 21

When does primary dysmenorrhoea usually start?

Answer 21

typically within first 2 years of menarche

Question 22

Treatment of primary dysmenorrhoea?

Answer 22

1. Prostaglandin synthesis inhibitors- NSAIDs
2. COCP- supresses ovulation
3. depot progesterones
4. Mirena

Question 23

what is secondary dysmenorrhoea?

Answer 23

Associated with underlying patholgy- treat the pathologu

Question 24

What is primary amenorrhoea(reduced/absent menstrual bleeding)?

Answer 24

menstruation has never occurred

most girls start menses before 15

Question 25

what is secondary amenorrhoea?

Answer 25

established menstruation ceases | no mentstruation for 6 months (or 3x previous cycle length) in the absence of pregnancy

Question 26

Commonest cause of primary amenorrhoea?

Answer 26

Imperforate hymen mestrual blood retained withing vagina (haematocolpos) causes cyclical lower abdo pain

Question 27

investigations and treatment for imperforate hymen?

Answer 27

inspect vulva- distended hymenal membrane may be seen + dark blood Treatment- incision under GA

Question 28

chromosomal causes of primary amenorrhoea?

Answer 28

XO- turners XY- testicular feminization 5-alpha-reductase deficiency XX/XY- true hermaphrodite

Question 29

hypothalamic causes of primary amennorrhoea?

Answer 29

``` physiological delay weight loss/ anorexia/ heavy exercise isolated GnRH deficiency congenital CNS defects intracranial tumours ```

Question 30

pituitary causes of primary amenorrhoea?

Answer 30

``` partial/total hypopituitarism hyperprolactinaemia pituitary adenoma empty sella syndrome trauma/surgery ```

Question 31

ovarian causes of primary amenorrhoea?

Answer 31

``` true agenesis premature ovarian failure radiation/chemo/autoimmune PCOS virillizing ovarian tumours ```

Question 32

Phsyiological causes of secondary amenorrhoea?

Answer 32

pregnancy lactation menopause

Question 33

hypothalamic causes of secondary amenorrhoea?

Answer 33

weight loss/anorexia heavy exercise stress

Question 34

pituitary causes of secondary amenorrhoea?

Answer 34

partial/total hypopituitatism hyperproteinlactinaemia trauma/surgery

Question 35

ovarian causes of secondary amenorrhoea?

Answer 35

``` PCOS resistant ovary syndrome premature ovarian failure radiation/ chemo/ surgery virilizing ovarian tumours ```

Question 36

Causes of hyperprolactinaemia?

Answer 36

``` Pituitary adenomas (microadenomas, macroadenomas) Secondary to other causes- primary hypothyroidism, Chronic renal failure, stalk compression, PCOS, drugs ```

Question 37

What drugs may cause hyperprolactinaemia?

Answer 37

phenothiazides, haloperidol, metoclopramide, cimetidine, methyldopa, antihistamines and morphine

Question 38

Management of amenorrhoea

Answer 38

1. exclude pregnancy 2. ask about menopausal sx 3. hx- wt changes, drugs, medical conditions 4. exam- ht, wt, visual fields, presence of hirtuism or virilisation 5. serum LH, FSH, prolactin, testosterone, thyroxine and TH 6. TV USS (looking for PCOS)

Question 39

Average age of menopause in UK?

Answer 39

50.8 yrs | supply of oocytes become exhausted

Question 40

Short term problems of oestrogen deficiency?

Answer 40

Vasomotor- headache, hot flush, night sweats, palpitations, insomnia Psychological- irritability, poor concentration, poor short-term memory, depression, lethargy, loss of libido, generalised aches

Question 41

Urogential problems of oestrogen deficiency?

Answer 41

``` urethral symptoms uterine prolapse stress/urge incontinence dysparenuria atrophic vaginitis ```

Question 42

Treatment of menopause?

Answer 42

Hormones- oral, transdermal patches, S/c implants, vaginal preparations

Question 43

side effects of HRT?

Answer 43

nausea and breast tenderness endometrial cancer (mirena can be used with unopposed oestrogen to protect against cancer) breast cancer thromboembolic disease

Question 44

contraindications of HRT?

Answer 44

``` pregnancy thromboembolic disease hx of recurrebt thromboembolism liver disease undiagnosed vaginal bleeding ```