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Gynaecology > Menstrual Problems > Flashcards

Menstrual Problems Flashcards

1
Q

What is puberty?

A

The development of adult sexual characteristics

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2
Q

Describe the sequence of puberty in a female.

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

When does the growth spurt phase happen in puberty?

A

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

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4
Q

Describe how the hormones are produced in the menstrual cycle.

A

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

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5
Q

Describe the steps in the menstrual cycle.

A

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

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6
Q

When are menstrual cycles more likely to be irregular?

A

Straight after menarche

Right before menopause

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7
Q

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

A

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

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8
Q

What is menstruation?

A

The loss of blood and and uterine epithelial slough.

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

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9
Q

How much blood is usually lost during menstruation?

A

20-80ml

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10
Q

What is menopause?

A

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

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11
Q

How can menstruation be prolonged?

A

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

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12
Q

What is primary amenorrhoea?

A

Failure to start menstruating

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

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13
Q

What must a woman have for normal menstruation to occur?

A

Be structurally normal

Have a functioning HPO axis

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14
Q

What is secondary amenorrhoea?

A

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.

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15
Q

What are the possible causes of ovarian insufficiency/failure?

A

Secondary to chemotherapy, radiotherapy or surgery.

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

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16
Q

What is oligomenorrhoea?

A

Infrequent periods.

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

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17
Q

What is a cause of oligomenorrhoea?

A

PCOS

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18
Q

What is menorrhagia?

A

Excessive menstrual blood loss

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19
Q

What is dysmenorrhea?

A

Painful periods +/- NV

Can be primary or secondary

20
Q

What is primary dysmenorrhea?

A

Pain without organ pathology

Often starting with anovulatory cycles after menarche

21
Q

Describe the pain in primary dysmenorrhea.

A

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

22
Q

What is the treatment for primary dysmenorrhea?

A

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

23
Q

What is secondary dysmenorrhea? What are the causes?

A

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

24
Q

Describe the pain in secondary dysmenorrhea.

A

More constant through the period

May be associated with deep dyspareunia

25
Q

What is the treatment for secondary dysmenorrhea?

A

Treat the cause

Hormonal contraception may help (avoid IUDs as these make it worse except mirena)

26
Q

What are the causes of intermenstrual bleeding?

A 
Midcylce fall in oestrogen production
Cervical polyps
Ectropion
Carcinoma 
Cervictis/vaginitis
Hormonal contraception (spotting)
IUCD
Chlamydia
Pregnancy-related
27
Q

What are the causes for post-coital bleeding?

A

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

28
Q

What is the management for postcoital bleeding?

A

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

29
Q

What is postmenopausal bleeding?

A

Bleeding occurring over a year after the last period

Considered to be due to endometrial carcinoma until proven otherwise.

30
Q

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

A

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

31
Q

What is the investigation/management for primary amenorrhoea?

A

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

32
Q

What are the causes of secondary amenorrhoea?

A

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

33
Q

Describe the aetiology and pathophysiology of primary dysmenorrhea.

A

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)

34
Q

What are the risk factors for 1o amenorrhoea?

A 
Early menarche
Long menstruated phase
Heavy periods
Smoking
Nulliparity
35
Q

What are the clinical features of 1o dysmenorhoea?

A

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

36
Q

What are the differentials for 1o dysmenorrhea?

A

It is a diagnosis of exclusion so need to exclude the main causes of 2o dysmenorrhea:

  • endometriosis
  • adenomyosis
  • PID
  • adhesions

Other - IBD, IBS

37
Q

What investigations need to be done for 1o dysmenorrhea?

A

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

38
Q

What is the management for 1o dysmenorrhea?

A

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

39
Q

What is dysfunctional uterine bleeding/abnormal uterine bleeding?

A

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.

40
Q

What are the causes of heavy menstrual bleeding?

A

PALM (structural causes)

  • polyp
  • adenomyosis
  • leiomyoma (fibroid)
  • malignancy and hyperplasia

COEIN (non-structural)

  • coagulopathy
  • ovulatory dysfunction
  • endometrial
  • iatrogenic
  • not yet classified
41
Q

What are the risk factors for heavy menstrual bleeding?

A

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

42
Q

What are the clinical features of heavy menstrual bleeding?

A 
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
43
Q

What are the differentials for heavy menstrual bleeding?

A 
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
44
Q

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

A

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

45
Q

What imaging is required for HMB?

A

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

46
Q

What is the pharmacological management of HMB?

A

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

47
Q

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

A

Endometrial ablation

Hysterectomy

Gynaecology (12 decks)

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