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Obs & Gynae > Puberty and Menstrual Cycle > Flashcards

Puberty and Menstrual Cycle Flashcards

1
Q

What age does menarche occur?

A

13

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2
Q

What hormonal changes occur prior to puberty?

A

Gonadotrophin releasing hormone (GnRH) produced by hypothalamus
Stimulates FSH + LH (from pituitary)
Stimulates oestrogen from ovary

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3
Q

Where is GnRH produced?

A

Hypothalamus

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4
Q

Where are LH and FSH produced?

A

Anterior pituitary gland

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5
Q

What does the anterior pituitary gland produce?

A 
GH
Prolactin
LH and FSH (gonadotropes)
ACTH
TSH
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6
Q

What does the posterior pituitary produce?

A

Oxytocin

Vasopressin (ADH)

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7
Q

What are the three types of oestogen?

A

Estrone - menopause (ovary and adipose)
Estradiol - reproductive years (ovary/fat/liver/adrenal/breast/neural)
Estriol - pregnancy (placenta)

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8
Q

What occurs during days 1-4 of the menstrual cycle?

A

Menstruation
Endometrium is shed
Hormonal support withdrawn

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9
Q

What occurs during days 5-13 of the menstrual cycle?

A

Proliferation
Pulses of GnRH stimulate LH + FSH which induce follicular growth
Follicles produce oestradiol and inhibin
These suppress FSH secretion so only one follicle and oocyte mature

Oestrogen also causes endometrium to reform

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10
Q

When does ovulation occur?

A

Day 13

After sharp rise in LH

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11
Q

What occurs during ovulation?

A

Oestradiol rises, positive feedback on hypothalamus and pituitary -> increased LH -> ovulation

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12
Q

What occurs during days 14-28 of the menstrual cycle?

A

Luteal/secretory phase
Follicle from which egg was released becomes the corpus luteum
Produces low levels of oestradiol and more progesterone (peak at day 21)
Progestone causes secretory changes in endometrium
Corpus luteum fails if egg isn’t fertilised -> progesterone and oestrogen levels fall

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13
Q 
What is normal menarche?
Menarche?
Menopause?
Menstruation days?
Blood loss?
Cycle length?
A

Menarche 45 years

Menstruation

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14
Q

What is menorrhagia?

A

Heavy menstrual bleeding in otherwise normal menstrual cycle

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15
Q

What is dysmenorrhoea?

A

Painful periods

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16
Q

What is premenstrual syndrome?

A

Psychological and physical symptoms which are worse in the luteal phase

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17
Q

What pathologies cause menorrhagia?

A

Uterine fibroids
Polyps
Pelvic inflammatory disease
Ovarian, endometrial and cervical malignancies

Thyroid disease
Haemostatic disorders
Anticoagulant therapy

18
Q

What investigations are done for menorrhagia?

A

Bloods - Hb, TSH, coagulation

Imaging
- transvaginal USS (polyp, fibroid, mass)

Other

  • endometrial biopsy
  • hysteroscopy
19
Q

How is menorrhagia medically managed?

A

IUS - progesterone only

Antifibrinolytics (tranexamic acid) - taken during menstruation
NSAIDs - inhibit prostaglandin synthesis
COCP - less effective if pelvic pathology present

Progestogens - high dose oral or IM
GnRH analogues

20
Q

How is menorrhagia surgically managed?

A

Hysteroscopic

  • resection of polyps
  • endometrial ablation (reduces fertility)

More radical

  • myomectomy - removal of fibroids from endometrium
  • hysterectomy
  • uterine artery embolism
21
Q

What are indications for an endometrial biopsy?

A 
Endometrial thickness >10mm premenopausal, >4mm postmenopausal
Age >40yrs
Menorrhagia with IMB
Polyp on USS
Before IUS if irregular cycle
Prior to endometrial ablation
22
Q

What causes irregular bleeding?

A

Anovulatory cycles are common just after menarche and pre-menopause

Fibroids
Uterine and cervical polyps
Adenomyosis (endometriosis in uterine muscle wall)
Ovarian cysts
PID
23
Q

What investigations are done for irregular bleeding?

A

Exclude STI (chlamydia) and pregnancy

Bloods - Hb

Other

  • ?cervical smear
  • endometrial ablation (thickened endometrium, polyp, >40yrs)

Imaging
- USS for >35yrs

24
Q

How is irregular bleeding medically managed?

A

IUS or COCP
Cyclical progestogens
HRT in perimenopause

25
Q

How is irregular bleeding surgically managed?

A

Ablative techniques less likely to work well

26
Q

What are the types of amenorrhoea?

A

Primary - menstruation hasn’t occurred by age 16

Secondary - ceases for 6 months

Oligomenorrhoea - occurs every 35 days to 6 months

27
Q

What are causes of amenorrhoea?

A

Physiological

  • during pregnancy
  • after menopause
  • during lactation

Pathological

  • hypothalamus
  • pituitary
  • thyroid/adrenals
  • ovary, uterus, outflow tract
  • drugs (antipsychotics raise prolactin)
28
Q

What are hypothalamic causes of amenorrhoea?

A

Hypothylamic hypogonadism due to psychological factors, low weight or excessive energy

Reduces GnRH, FSH, LH and oestradiol

Reduced bone density
Oestrogen replacement (plus progesterone for endometrial protection)
29
Q

What are pituitary causes of amenorrhoea?

A

Hyperprolactinaemia caused by hyperplasia or benign adenomas

Tx: bromocriptine, cabergoline

Pituitary tumours
Sheehan’s sydrome (severe PPH -> pituitary necrosis, hypopituitary)

30
Q

What are adrenal/thyroid causes of amenorrhoea?

A

Hypothyroidism - raised prolactin
Hyperthyroidism
CAH

31
Q

What are ovarian causes of amenorrhoea?

A

Polycystic ovarian syndrome ( commonly causes oligomenorrhoea)
Premature menopause
Turner’s syndrome
Gonadal dysgenesis

32
Q

What are outflow tract causes of amenorrhoea?

A

Imperforate hymen or transverse vaginal septum obstruct menstrual flow (builds up in vagina or uterus and may be palpatable)
Rokitansky’s syndrome - absence of vagina

Cervical stenosis -> haematometra

33
Q

What are causes of post-coital bleeding?

A 
Ectropions
Benign polups
Invasive cervical cancer
Cervicitis
Vaginitis
34
Q

How is PCB managed?

A

Inspection of cervix and smear
Cryotherapy
Colposcopy to exclude malignant cause

35
Q

What causes dysmenorrhoea?

A

High prostaglandins in endometrium
Contraction and uterine ischaemia

Primary - coincides with start of menstruation

Secondary - pain precedes and is relieved by menstruation
Deep dyspareunia common
Fibroids
Adenomyosis
Endometriosis
PID
Ovarian tumous
36
Q

How is primary dysmenorrhoea managed?

A

NSAIDS or COCP

37
Q

What is precocious puberty?

A

Menstruation

38
Q

What causes precocious puberty and how is it managed?

A

No known cause - GnRH agonists inhibit sex hormone secretion

Increased GnRH secretion (meningitis, encephalitis, CNS tumours, hydrocephaly, hypothyroidism) may prevent normal pre-pubertal inhibition of hypothalamic GnRH release

Ovarian/adrenal causes - hormone producing tumours

39
Q

What causes increased androgens in females?

A

CAH

  • defective cortisol production
  • excess ACTH causes increased androgens
  • ambiguous genitalia
  • glucocorticoid deficiency
  • Addisonian crisis

Tx: cortisol and mineralocorticoid

40
Q

What causes reduced androgens in males?

A

Androgen insensitivity syndrome

  • androgens then converted to oestrogens so appear to be female
  • absent uterus, rudimentary testes
41
Q

How is PMS managed?

A

SSRIs given in second half of cycle
Continuous oral contraceptives
Evening primrose oil

Obs & Gynae (20 decks)

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