Menstrual Problems

Question 1

What is puberty?

Answer 1

The development of adult sexual characteristics

Question 2

Describe the sequence of puberty in a female.

Answer 2

1. Breast buds
2. Growth of pubic hair
3. Growth of axillary hair
4. Menarche

Question 3

When does the growth spurt phase happen in puberty?

Answer 3

It is the first change in puberty and is usually completed 2 years after menarche when the epiphyses fuse

Question 4

Describe how the hormones are produced in the menstrual cycle.

Answer 4

Pulsatilla production of GnRH by the hypothalamus
Stimulates the pituitary to produce FSH and LH
These stimulate the ovary to produce oestrogen and progesterone
These feedback on the hypothalamus and the pituitary

Question 5

Describe the steps in the menstrual cycle.

Answer 5

First 4 days - FSH high - stimulates primary follicle development in the ovary
Production oestrogen by the follicle - stimulates glandular proliferative endometrium development and cervical mucus receptive to sperm (clear and stringy
14 days before onset of menstruation - oestrogen high enough to stimulate an LH surge
This stimulates ovulation
The primary follicle then becomes the corpus luteum and produces progesterone
This causes the endometrial lining to be receptive to implantation (glands become convoluted - secretory phase)
The cervical mucus thickens and becomes hostile to sperm
If unfertilised - the corpus luteum breaks down and hormone levels fall
The spiral arteries in the uterine endothelial lining constrict and the lining sloughs - menstruation

Question 6

When are menstrual cycles more likely to be irregular?

Answer 6

Straight after menarche

Right before menopause

Question 7

How can you differentiate cervical mucus that is receptive to sperm to cervical mucus that isn’t on a slide?

Answer 7

If allowed to dry on a slide, cervical mucus that is receptive produces a ferning pattern due to its high salt content
Cervical mucus that isn’t receptive doesn’t produce a ferning pattern

Question 8

What is menstruation?

Answer 8

The loss of blood and and uterine epithelial slough.

Lasts 2-7 days and is usually heaviest at the beginning

Question 9

How much blood is usually lost during menstruation?

Answer 9

20-80ml

Question 10

What is menopause?

Answer 10

When the ovaries fail to develop follicles.
Without hormonal feedback from the ovary gonadotrophin levels rise.
Periods cease
Usually around 50 years of age

Question 11

How can menstruation be prolonged?

Answer 11

Try norethisterone 5mg/8h from 3 days before the period is due until bleeding is acceptable
Can also take 2 packets of COCP consecutively without a break

Question 12

What is primary amenorrhoea?

Answer 12

Failure to start menstruating

Needs investigation if 16 and not had periods/14 and no signs of puberty

Question 13

What must a woman have for normal menstruation to occur?

Answer 13

Be structurally normal

Have a functioning HPO axis

Question 14

What is secondary amenorrhoea?

Answer 14

This is when periods stop for over 6 months with reasons other than pregnancy.
HPO axis dysfunction is the most common cause, endometrial and ovarian causes are rarer.

Question 15

What are the possible causes of ovarian insufficiency/failure?

Answer 15

Secondary to chemotherapy, radiotherapy or surgery.

Genetic disorders particularly those affecting the X chromosome like Turner’s syndrome

Question 16

What is oligomenorrhoea?

Answer 16

Infrequent periods.

Common at the extremes of reproductive life when regular ovulation does not occur.

Question 17

What is a cause of oligomenorrhoea?

Answer 17

PCOS

Question 18

What is menorrhagia?

Answer 18

Excessive menstrual blood loss

Question 19

What is dysmenorrhea?

Answer 19

Painful periods +/- NV

Can be primary or secondary

Question 20

What is primary dysmenorrhea?

Answer 20

Pain without organ pathology

Often starting with anovulatory cycles after menarche

Question 21

Describe the pain in primary dysmenorrhea.

Answer 21

Crappy with ache in the back/groin
Worse during the first day or two
Excess prostaglandins cause painful uterine contractions producing ischaemic pain.

Question 22

What is the treatment for primary dysmenorrhea?

Answer 22

NSAIDs (inhibit prostaglandins - reduce contractions and hence pain) e.g. mefenaic acid
Paracetamol
Pain with ovulatory cycles - ovulation suppression with the combined pill

Question 23

What is secondary dysmenorrhea? What are the causes?

Answer 23

Associated with pathology
Adenomyosis, endometriosis, PID, fibroids
Therefore, occurs later in reproductive life

Question 24

Describe the pain in secondary dysmenorrhea.

Answer 24

More constant through the period

May be associated with deep dyspareunia

Question 25

What is the treatment for secondary dysmenorrhea?

Answer 25

Treat the cause | Hormonal contraception may help (avoid IUDs as these make it worse except mirena)

Question 26

What are the causes of intermenstrual bleeding?

Answer 26

``` Midcylce fall in oestrogen production Cervical polyps Ectropion Carcinoma Cervictis/vaginitis Hormonal contraception (spotting) IUCD Chlamydia Pregnancy-related ```

Question 27

What are the causes for post-coital bleeding?

Answer 27

Cervical trauma Polyps Cervical, endometrial and vaginal carcinoma Cervicitis/vaginitis

Question 28

What is the management for postcoital bleeding?

Answer 28

Screen or chlamydia and treat if positive Refer all with persistent bleeding Risk of cervical carcinoma is increased in those with post-coital bleeding

Question 29

What is postmenopausal bleeding?

Answer 29

Bleeding occurring over a year after the last period | Considered to be due to endometrial carcinoma until proven otherwise.

Question 30

What are the other causes of postmenopausal bleeding? (Apart from endometrial carcinoma)

Answer 30

Vaginitis (often atrophic) Foreign bodies e.g. pessaries Carcinoma of the cervix/vulva Endometrial/cervical polyps Oestrogen withdrawal (HRT/ovarian tumour) May be confused with urethral or rectal bleeding

Question 31

What is the investigation/management for primary amenorrhoea?

Answer 31

In most patients puberty is just late (often familial) so reassurance is all that is needed In some the cause is structural or genetic - check that the internal and external genitalia are normal Causes can be the same as secondary amenorrhoea so do the tests you would do for that Examine and do karyotyping to look for Turner’s syndrome/androgen insensitivity syndrome Aim of treatment is for the patient to look normal, function sexually and if possible, enable reproductive wishes

Question 32

What are the causes of secondary amenorrhoea?

Answer 32

HPO axis (34%) - Stress (emotions, exams) - Increased exercise (common in competitive athletes) - Weight loss Hyperprolactinaemia Hypo/hyperthyroidism Severe systemic disease e.g. renal failure Pituitary tumours and necrosis (Sheehan’s syndrome) - rare Ovarian causes - PCOS - ovarian insufficiency/failure (premature menopause) Uterine causes - pregnancy-related - Asherman’s syndrome - post-pill amenorrhoea

Question 33

Describe the aetiology and pathophysiology of primary dysmenorrhea.

Answer 33

Corpus luteum regresses when not fertilised Decline in oestrogen and progesterone production Decline in progesterone causes endometrial cells to release prostaglandin 2 main actions of prostaglandin - spiral artery vasospasm - ischaemic necrosis and shedding of superficial layer of endometrium - increased myometrium contractions 1o dysmenorrhea thought to occur due to excessive release of prostaglandins (PGF2alpha and PGE2)

Question 34

What are the risk factors for 1o amenorrhoea?

Answer 34

``` Early menarche Long menstruated phase Heavy periods Smoking Nulliparity ```

Question 35

What are the clinical features of 1o dysmenorhoea?

Answer 35

Lower abdo/pelvic pain Can radiate to lower back/nterior thigh Crampypain Lasts 48-72 hours around the menstrual period Typically worse at the onset of menses Can be associated with malaise, NV, diarrhoea, dizziness Unremarkable examination though uterine tenderness may be present

Question 36

What are the differentials for 1o dysmenorrhea?

Answer 36

It is a diagnosis of exclusion so need to exclude the main causes of 2o dysmenorrhea: - endometriosis - adenomyosis - PID - adhesions Other - IBD, IBS

Question 37

What investigations need to be done for 1o dysmenorrhea?

Answer 37

Investigations to rule out other pathology High vaginal and endocervical swabs to rule out STI Transvaginal USS if pelvic mass palpated

Question 38

What is the management for 1o dysmenorrhea?

Answer 38

Stop smoking Local application of heat (hot water bottle, heat patch) TENS First line (analgaesia): - NSAIDs (ibuprofen, naproxen, mefanamic acid) - inhibit the production of prostaglandins - Paracetamol Second line (3-6 month hormonal contraception trial) - monophasic COCP - IUS e.g. mirena

Question 39

What is dysfunctional uterine bleeding/abnormal uterine bleeding?

Answer 39

Accounts for 40-60% of heavy menstrual bleeding cases where it cannot be attributed to any uterine, endocrine, haematological or infective pathology after investigation. It is a diagnosis of exclusion.

Question 40

What are the causes of heavy menstrual bleeding?

Answer 40

PALM (structural causes) - polyp - adenomyosis - leiomyoma (fibroid) - malignancy and hyperplasia COEIN (non-structural) - coagulopathy - ovulatory dysfunction - endometrial - iatrogenic - not yet classified

Question 41

What are the risk factors for heavy menstrual bleeding?

Answer 41

Menarche and approaching menopause Obesity Previous C section risk factor for adenomyosis)

Question 42

What are the clinical features of heavy menstrual bleeding?

Answer 42

``` Excessive bleeding impacting on QoL Fatigue SOB Pallor Palpable uterine/pelvic mass - fibroids? - is uterus smooth or irregular Tender uterus/cervical excitation (adenomyosis/endometriosis) Inflamed cervix/polyp/tumour Vaginal tumour ```

Question 43

What are the differentials for heavy menstrual bleeding?

Answer 43

``` Pregnancy - normal/miscarriage/ectopic Endometrial or cervical polyps (IMB/PCB) - not associated with dysmenorrhea Adenomyosis Fibroids Malignancy/endometrial hyperplasia Coagulopathy Ovarian dysfunction - PCOS, hypothyroidism Iatrogenic — contraceptive hormones, IUD Endometriosis ```

Question 44

What are the blood tests that need to be done for heavy menstrual bleeding?

Answer 44

FBC (anaemia) TFTS (hypothyroidism) Other hormone testing (if other relevant features) - PCOS Coagulation screen + test fro vW - if suspicion of clotting disorder

Question 45

What imaging is required for HMB?

Answer 45

US pelvis - if uterine/pelvic mass is palpable or if pharmacological treatment has failed Cervical smear High vaginal and endocervical swabs Pipelle endometrial biopsy (persistent IMB, >45, failure of medications) Hysteroscopy and endometrial biopsy if USS finds pathology/is inconclusive

Question 46

What is the pharmacological management of HMB?

Answer 46

LNG-IUS (contraceptive, licensed for 5 years, thins endometrium, shrinks fibroids) Tranexamic acid/mefanamic acid/COCP Progesterone only - norethisterone, depo, implant

Question 47

What is the surgical management of HMB? -m for women ho don’t want to conceive

Answer 47

Endometrial ablation | Hysterectomy