The menstrual cycle and its disorders

Question 1

Puberty TAM

Answer 1

Thelarche (9-11) = breasts

Adrenarche (11-12) = pubic hair

Menarche (13+) = menstruation (may be irregular at first but becomes regular as oestrogen rises)

Most growth finishes at 16 years

Question 2

Day 1-4 menstruation

Answer 2

endometrium shed

hormonal support withdrawn

myometrial contract (can be painful)

Question 3

Day 5-13 proliferative phase

Answer 3

GnRH from hypothalamus to pituitary

pituitary release LH+FSH for follicular growth

Follices produce oestradiol and inhibin -> negative feedback so only 1 follice and 1 oocute mature

oestrodiol increases -> positive feedback -> LH levels rise -> ovulation 36 hours after LH surge

oestradiol -> endometrium re-forms and becomes proliferative (thickens as stromal cells proliferate and glands elongate)

Question 4

Days 14-28 luteal/secretory phase

Answer 4

Follices become CL

CL produces oestrodiol but MORE progesterone (peaks at day 21)

progesterone -> secretory changed in endometrium (stromal cells enlarge and glands swell and blood supply increases)

CL starts to fail if egg not fertilised -> P+O levels fall -> menstruation

Question 5

Definition of AUB

Answer 5

any variation from normal menstrual cycle, and includes changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss

HMB most common complaint of AUB

Question 6

Abnormal uterine bleeding and definitions of terms (FIGO)

Answer 6

Question 7

Normal menstruation ranges

Answer 7

Question 8

PALM COEIN for AUB

Answer 8

Question 9

HMB definition: clinical and objective

Answer 9

clinical = excessivew menstrual blood loss that interferes with woman’s physical, emotional, social and material quality of life, and which can occur alone or in a combination with other symptoms

objective = blood loss >80mL in an otherwise normal menstrual cycle. Max amount woman can los per cycle without becoming iron deficient

Question 10

HMB Aetiology

Answer 10

mainly fibroids (30%) and polyps (30%)

Question 11

HMB Hx and O/E

Answer 11

Hx:

• contraception
• amount and timing
• anaemia (fatigue, weight loss, dizziness, dyspnoea, CP)
• FHx
• thyroid (hypothyroidism)
• anticoagulation

O/E:

• anaemia signs
• irregular enlargement of uterus = fibroids
• tenderness with/without enlargement = adenomyosis

Question 12

HMB Ix

Answer 12

Hb

Coag

TFT

TVUSS (+saline)

Endometrial biopsy (pipelle/hysteroscopy)

• HMB and over 40 y/o
• bleeding NRT
• RF for cancer (young women) -> PCOS, nulliparity, HNPCC, obesity, diabetes
• Acute admission
• If USS suggest polyp or focal endometrial thickening

Question 13

HMB Mx

Answer 13

1. IUS
2. Tranexamic acid/mefanamic acid OR -> COCP
3. progestogens
4. GnRH analogues
5. Hysteroscopic (polyp removal, endometrial ablation,TRCE an old way)/hysterectomy

Question 14

Irregular and intermenstrual bleeding DDx

Answer 14

same as HMB

increased cancer risk for older women

Question 15

irregular and intermenstrual bleeding Ix

Answer 15

Hb

Exclude malignancy

Cervical smear

USS

• over 35 y/o
• if NRT under 35 y/o

Endometrial buipsy

• similar indications for HMB

Question 16

Irregular and intermenstrual bleeding Mx

Answer 16

Drugs

• for anovulatory/apathological
• 1 = IUS/COCP
• 2 = Progestogens

Surgery

• polyp for gistology
• similar to HMB

Question 17

amenorrhoea/oligomenorrhoea: 1o and 2o and oligo

Answer 17

1o amen = no menstruation before 14 y/0

2o amen = menstruation stops more than 3 months

oligo = menstruation every 35 days - 6 months

Question 18

physiological causes of amen/oligo

Answer 18

1o = constituional delay, drugs

2o = pregnancy, lactation, menopause, drugs

Question 19

pathological causes of amen/oligo

Answer 19

Hypothalamus

• hypothalamic hypogonadism (low BMI, exercise, Sheehan’s syndrome) MX: COCP
• anorexia nervosa

Pituitary

• hyperprolactinameia MX: cabergoline, bromocriptine

Adrenal/thyroid

• hypothyrodisim (incereased prolactin)
• CAH

Ovary

• PCOS
• Turners (45 XO)
• Asherman’s syndrome

Outflow tract

• Imperforate hymen
• Transverse vaginal septum
• Rokitansky’s syndrome

Question 20

Postcoital bleeding aetiology

Answer 20

cervical ectropions

benign polyps

invasive cervical cancer

cervicitis/vaginitis

Question 21

postcoital bleeding mx

Answer 21

inspect and smear

polyp histology

colposcopy = look at cervix

Question 22

Dysmennorhoea physiology

Answer 22

due to contraction and uterine ischaemia

high PG levels

Question 23

Dysmenorrhoea primary vs secondary

Answer 23

Primary

• no organic cause
• very common
• pain on menstruation
• Mx: NSAIDS, COCP, reassure

Secondary

• pelvic US + laparascopy
• fibroids, adenomyosis, PID
• pain relieved on menstruation

Question 24

Precocious puberty features

Answer 24

<8 y/o menstruating, reduction in secondary sexual characteristics

low height

Question 25

precocious puberty aetiology

Answer 25

80% apathological central (increased GnRH) = meningitis, ewncephalitis, CNS tumours, hydrocephalus, hypothyroid ovarian/adrenal (increased oestrogen) = hormone producing tumours * McCune-Albright syndrome = bone and ovarian cysts, cafe au lait spots, precocious pubert. Mx: cyproterone acetare (antiandrogenic progestogen)

Question 26

Ambiguous development and intersex (female and male aetiology)

Answer 26

increased androgen in female (CAH) * high ACTH, high androgens * low GC, Addisonian crisis * Ambiguous genitals * Enlarged clitoris + amenorrhoea * Mx: cortisol and MR replacement decreased androgen in male (Androgen Insensitivity Syndrome) * androgen converted to oestrogen (appears female) * amenorrhoea, uterus absent, rudimentary testes present * Mx: testes removed (can be malignant), oestrogen replacement started

Question 27

PMS definition

Answer 27

Psych/behavioural/physica; sx rregularly in luteal phase, resolved by end of menstruation

Question 28

PMS Hx and O/E

Answer 28

cyclical behavioural and psych * tension, irritable, aggression, depression, loss of control physical * bloated, minor GI upset, breast pain O/E * psych eval (depression and neurosis) * menstrual diaries for at at least 2 cycles

Question 29

PMS Mx

Answer 29

Drugs: * SSRIs (second half of cycle) * continuous oral contraceptives (100 ug HRT patch) * GnRH agonist and add-back orestrogen therapy * bilateral oophectomy Other: * evening primrose oil (breast tenderness) * pyridoxine (vit B6) 50 mg BD (mild PMS, can cause neuropathy ine excessive doses) * Vitex agnus-castus extract (can help) * CBT

Question 30

Menstrual cycle disorders at a glance

Answer 30