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3a obs and gynae > Menstrual problems and fertility > Flashcards

Menstrual problems and fertility Flashcards

menstrual problems, menopause, fertility, PCOS (61 cards)

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1
Q

Define primary amenorrhoea

A

when menstruation has failed to start by the age of 16 y/o

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2
Q

Define secondary amenorrhoea

A

when previous normal menses ceases for >6 months

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3
Q

List some of the causes of primary amenorrhoea

A

constitutional delay

psychological - anorexia, athleticism

hypothalamic failure - Kallmanns syndrome (deficiency of GnRH), tumours

gonadal failure - PCOS, Turners syndrome (webbed neck, short stature, missing digits), gonadal dysgenesis

endocrine - congenital adrenal hyperplasia, hypo/hyperthyroidism

other - imperforate hymen, transverse vaginal septum (get cyclical abdominal pain)

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4
Q

List some of the causes of secondary amenorrhoea

A

non pathological - menopause, pregnancy, post COCP, drugs, lactation

psychological - anorexia, athleticism

endocrine - adrenal tumours, Cushings

pituitary- pituitary tumours, sheehans syndrome (PPH causing pituitary necrosis)

ovarian- premature ovarian failure, ashermans syndrome (intrauterine adhesions), PCOS

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5
Q

What necessary investigations would you do for amenorrhoea?

A
  1. pregnancy test
  2. FHS and LH
  3. Testosterone
  4. prolactin
  5. TFT
  6. karyotype
  7. transvaginal ultrasound
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6
Q

Define dysmenorrhoea

A

painful cramping in the lower abdomen usually before or at the start of menstruation

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7
Q

What is the difference between primary and secondary dysmenorrhoea

A

primary dysmenorrhoea = the pain has no obvious organic cause or underlying pathology

secondary dysmenorrhoea = the pain occurs due to underlying pathology

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8
Q

What is the cause for primary dysmenorrhoea?

A

decrease in progesterone allowing prostaglandin release which causes myometrium to contract resulting in pain and ischaemia

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9
Q

What are the possible causes for secondary dysmenorrhoea?

A

endometriosis **
adenomyosis **
fibroids**
pelvic adhesions**

PID
malignancy
ashermans syndrome

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10
Q

How is dysmenorrhoea managed?

A

analgesia and symptomatic control

1st line = mefenamic acid (NSAID) - inhibit prostaglandin production
COCP
paracetamol

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11
Q

Define menorrhagia

A

excessive menstrual blood loss that interferes with the womens quality of life (>80ml +/- >7 days bleeding)

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12
Q

What are the possible causes of menorrhagia?

A

no underlying cause = dysfunctional uterine bleeding
uterine fibroids *
polyps *
endometriosis*
coagulation factors e.g. von willebrands disease, anticoagulants
hypothyroidism

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13
Q

How is menorrhagia managed?

A
  1. antifibrinolytics e.g. transexamic acid - reduce blood loss by 50%
  2. NSAIDs e.g. mefenamic acid
  3. COCP
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14
Q

Define dysfunctional uterine bleeding

A

diagnosis of exclusion, defined at abnormal uterine bleeding in the absence of pregnancy, genital tract pathology or systemic disease

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15
Q

What is a polycystic ovary?

A

a characteristic transvaginal ultrasound appearance of multiple (>12) small (2-8mm) follicles in an enlarged (>10ml) ovary

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16
Q

What is the criteria for polycystic ovary syndrome?

A

2/3 of the following criteria:

  1. polycystic ovary on ultrasound
  2. hirsutism: clinical +/- biochemical
  3. irregular periods/ infrequent ovulation
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17
Q

What are the causes of PCOS?

A

genetic
insulin resistance
obesity - especially central obesity
hyperandrogegism

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18
Q

What is the pathology behind PCOS?

A
  1. insulin resistance and raised insulin levels
  2. leads to overproduction of ovarian androgens
  3. reduces steroid hormone binding globulin production in liver which increases free androgen levels
  4. increased androgens disrupt folliculogenesis
  5. leads to small multiple ovarian follicles and irregular ovulation as hirsutism
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19
Q

How does PCOS present?

A 
hirsutism 
acne
obesity 
amenorrhoea/ oligomenorrhoea
sub fertility 
deepening voice
balding
reduced breast size
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20
Q

Which investigations are necessary for PCOS?

A

transvaginal ultrasound - detect PCO
raised insulin levels
raised LH levels

+testosterone, low SHBG, prolactin

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21
Q

How is PCOS managed?

A
  1. lifestyle - weight loss
  2. to treat hirsutism - COCP and spironolactone
  3. to treat insulin resistance - metformin
  4. for infertility - clomifine, IVF
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22
Q

What are the complications of PCOS?

A 
Type 1 diabetes
gestational diabetes 
endometrial cancer 
infertility 
CVD
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23
Q

what is the menopause?

A

cessation of menstruation - diagnosed after 12 months of amenorrhoea or after onset of symptoms
average age of 51 years

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24
Q

What is classed as premature menopause?

A

menopause under 40 y/o

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25
What is perimenopause?
the time leading up to menopause | characterised by irregular periods and symptoms
26
What are premenopausal symptoms?
central effects of decreased oestrogen levels: - vasomotor symptoms e.g. hot flushes, sweats - MSK symptoms e.g. joint pain - Low mood and sexual difficulties e.g. irritable, lack of concentration, lack of libido, fatigue local effects of decreased oestrogen: - urogenital symptoms e.g. vaginal dryness, dyspareunia, recurrent UTIs, urinary frequency, post menopausal bleeding
27
What are the impacts of menopause?
1. osteoporosis - DXA scan if RF for osteoporosis 2. cardiovascular disease 3. dementia
28
How is menopause managed?
1. holistic approach 2. lifestyle advice - stop smoking, reduce alcohol, exercise, diet changes 3. inform about medical options e.g. hormonal (HRT, vaginal oestrogen), non hormonal (clonidine), CBT
29
What are the 2 types of oral HRT?
1. sequential HRT : oestrogen given for every day of the month, but progesterone only given in the last 14 days of the month - at risk of endometrial cancer 2. continuous combined HRT: oestrogen and progesterone given every day of the month - reduces risk of endometrial Ca
30
Who should be prescribed transdermal HRT?
``` gastric upset e.g. crohns increase risk of VTE older women hypertensions patients choice ```
31
What are the benefits of HRT?
relief of menopause symptoms bone mineral density protection colorectal cancer prevention
32
What are the risks of HRT?
breast cancer - if taking progesterone and oestrogen venous thrombo embolism cardiovascular disease stroke endometrial cancer - if only oestrogen HRT ovarian cancer
33
What are some of the causes for male infertility?
idiopathic oligospermia and asthenozoospermia alcohol smoking drugs e.g. anabolic steroids, sulfrasalazine obesity syndromes: Klinefelters syndrome, kallmans syndrome hypogonadism varicocele, mumps orchitis, epididymitis
34
How is semen analysed?
sample produced by masturbation and must be analysed within 1-2 hours sample is studied for: 1. count 2. motility 3. morphology if abnormal sample, need to repeat after 12 weeks
35
What is a normal semen analysis?
volume: >1.5 million count: >15 million/ml motility: >32%
36
Define azoospermia
no sperm present
37
Define oligospermia
<15 million/ml
38
Define asthenospermia
absent or low motility
39
If the sperm count is abnormal, what investigations are necessary?
testosterone, FHS, LH, prolactin clinical examination - testicular size karyotype - test for klinefelters, CF screen repeat in 12 weeks
40
What conservative advice is given for men with an abnormal semen analysis?
``` weight loss smoking cessation diet (folic acid, zinc, vit E) reduce alcohol intake wear loose clothing ```
41
Define subfertile
if conception has not occurred after a year of regular unprotected intercourse
42
What are the possible causes for female infertility?
unexplained ovulatory factors - PCOS, premature ovarian failure, hypogonadism, adrenal tumours, hyperprolactinaemia, gonadal dysgenesis tubal factors - infection (e.g. chlamydia, gonorrhoea, PID), surgery (adhesions), endometriosis uterine/ peritoneal other risk factors- alcohol, obesity, smoking, increasing age
43
What initial advice is given to women struggling to conceive?
80% couples conceive within first year preconception advice refer to fertility doctor in a year (early referral if <35 y/o and known problem)
44
What is included in preconception advice?
``` stop smoking weight loss: BMI 19-30 stop drinking alcohol start taking folic acid 0.4mg intercourse 2-3 times a week ```
45
How is ovulation function assessed?
day 21 mid luteal progesterone levels** | day 2-5 progesterone
46
How is tubular dysfunction assessed in fertility?
1st line = hysterosalpingogram (screen for tubal occlusion) 2nd = hysterosalpingo-contrast ultrasound sonography (safer as no radioactive contrast) 3rd = laparoscopy and methylene blue dye (visualise Fallopian tubes)
47
How is someone helped with fertility if they have PCOS?
1. normalise weight 2. clomifene (antioestrogen) 3. metformin 4. laparoscopic ovarian diathermy
48
What is clomifene?
= anti oestrogen blocks oestrogen receptors in hypothalamus and pituitary which causes release of LH and FHS which helps follicular maturation
49
How is the ovarian reserve tested?
1. FSH levels (>8.9 = low) 2. antral follicle count (<4= low) 3. anti mullerian hormone (<5.4= low)
50
What is the management plan for someone with tubular problems and sub fertile?
tubal surgery via laparoscopy tubal catheterisation IVF
51
List the options involved in assisted conception
ovulation induction intrauterine insemination IVF donor insemination/ egg/ embryo
52
What are the risks of iVF?
``` multiple pregnancy ectopic pregnancy miscarriage fetal abnormality ovarian hyperstimulation syndrome ```
53
Describe the IVF treatment cycle?
3 CYCLES OF IVF ON NHS IF <40 Y/O 1. ovarian stimulation and monitory - 2 weeks 2. egg collection 3. insemination 4. fertilisation check - day 1 5. embryo culture - 2-5 days 6. embryo transfer 7. luteal support 8. pregnancy test
54
What should women be screened for if presenting with sub fertility?
1. chlamydia screening 2. cervical cancer testing 3. TFTs (TSH) 4. prolactin 5. rubella status 6. viral status (HepB, HepC, HIV)
55
when should menopause be investigated?
<40 y/o or >45 y/o with atypical symptoms
56
What investigations are done for the menopause or premature ovarian failure?
1. FSH increase gives estimate of ovarian reserve increase FSH = decrease oocytes measure between day 2-5 2. anti mullerian hormone decreasing produced in granulosa cells of natural/ pre natural follicles gives direct measurement of ovarian reserve stable throughout cycle 3. oestrogen decreases
57
should you still use contraception if someone is going through the menopause?
if 12 months after the last period in women > 50 years | OR 24 months after the last period in women < 50 years
58
what are contraindications to HRT?
Current or past breast cancer Any oestrogen-sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia
59
which non HRT options are offered for management of menopause?
Vasomotor symptoms fluoxetine, citalopram or venlafaxine Vaginal dryness vaginal lubricant or moisturiser Psychological symptoms self-help groups, cognitive behaviour therapy or antidepressants Urogenital symptoms if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
60
How is premature ovarian failure diagnosed?
FSH >25 IU/L (2 samples with 4 weeks apart) + >4 months of amenorrhoea
61
define premature ovarian failure
menopause before the age of 40

3a obs and gynae (5 decks)

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