Obstetrics and Gynaecology > Menstruation > Flashcards

Menstruation Flashcards

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1
Q

What is dysmenorrhoea?

A

Excessive pain during menstrual period

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2
Q

How does dysmenorrhoea commonly present?

A

Lower abdominal or pelvic pain

Radiate to pelvis and thighs

+ malaise, nausea, vomiting, dizziness, diarrhoea

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3
Q

What investigations would you request for dysmenorrhoea?

A

High vaginal and endocervical swabs - infection?
Transvaginal USS - if masses on examination
Speculum exam
Cervical smear - if nearly due
Pelvic USS

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4
Q

Compare the pain in primary vs secondary dysmenorrhoea

A

primary: Pain at onset of menses. Often within first 2 years of menarche
secondary: Pain precede start of menses by days. Occur years after menarche

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5
Q

What can cause secondary dysmenorrhoea?

How is it managed in primary care?

A 
Endometriosis
Adenomyosis
PID
Adhesions
Fibroids
Non-gynae such as IBD and IBS

Refer all to gynae for investigation

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6
Q

What is primary dysmenorrhoea?

A

Pain in absence of any underlying pelvic disorder -

Diagnosis of exclusion

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7
Q

What causes primary dysmenorrhoea?

A

Excess release of prostaglandins from endometrial cells:

  • Spiral artery vasospasm
  • Increase myocetrial contractions
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8
Q

What are the risk factors for primary dysmenorrhoea?

A

Early menarche
Heavy periods
Smoking
Nullparity

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9
Q

How is primary dysmenorrhoea managed?

A

Stop smoking, TENS, heat

  1. NSAIDs (inhibit prostaglandin production)
    - mefenamic acid and naproxen
  2. Hormones: Monophasic use of COCP, IUS
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10
Q

How is primary amenorrhoea defined?

A

Menses not occurred by:
14 - absence of any secondary sexual characteristics
16 - other secondary sexual characteristics developing normally

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11
Q

How is secondary amenorrhoea defined?

A

Menstruation occurred before but has stopped for 6 successive months

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12
Q

What is oligomenorrhoea?

A

Irregular periods with intervals between cycles of >35 days or <9 periods in a year

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13
Q

What is a good way of categorising differentials of amenorrhoea?

A 
Hypothalamic - low GnRH
Pituitary
Ovarian
Genital tract
Other
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14
Q

What are some causes for reduced GnRH i.e. hypothalamic amenorrhoea?

A

Secondary:

  • Eating disorders
  • Severe chronic conditions - thyroid

Primary:
- Kallmann syndrome (poor smell and hearing)

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15
Q

What pituitary issues can lead to amenorrhoea?

A

All secondary:

  • Prolactinomas - prolactin suppress GnRH
  • Other pituitary tumours - mass effect
  • Sheehan’s syndrome - blood loss in childbirth
  • Prolonged contraceptive use - down regulate pituitary
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16
Q

What ovarian issues can cause amenorrhoea?

A

Secondary:

  • PCOS
  • Premature ovarian failure

Primary:
- Turner’s syndrome

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17
Q

How is premature ovarian failure characterised?

A

Amenorrhoea + raised gonadotrophins (FSH and LH) before 40

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18
Q

What conditions affecting the genital tract can cause amenorrhoea?

A

Secondary: Ashermann’s syndrome - intrauterine adhesions following uterine surgery

Primary: Mechanical obstruction - imperforate hymen

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19
Q

What are the other causes of amenorrhoea?

A

Secondary:
- Pregnancy

Primary:

  • Congenital adrenal hyperplasia
  • Constitutional delay
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20
Q

What are the primary causes of amenorrhoea?

A 
Congenital adrenal hyperplasia
Constitutional delay
Mechanical obstruction
Turners syndrome
Kallmann syndrome
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21
Q

What questions do you need to ask in a history about amenorrhoea?

A 
Full menstrual history
Poss. of pregnancy
Galactorrhoea
Vasomotor symptoms 
Acne, hirsutism, balding
Exercise and eating habits
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22
Q

What investigations would you request for a women with amenorrhoea?

A 
FSH and LH
Total Testosterone
BMI
Pregnancy test
Prolactin
Thyroid function
Pelvic USS
Sex hormone binding globulin
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23
Q

What would a raised FSH and LH in the context of amenorrhoea indicate?

A

Ovarian failure

Turner’s

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24
Q

What would a normal to low FSH and LH in the context of amenorrhoea indicate?

A

Constitutional delay

Hypothalamic cause

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25
What may a raised total testosterone in amenorrhoea indicate?
Congenital adrenal hyperplasia PCOS
26
What would an a)low and b)raised sex hormone binding globulin in amenorrhoea indicate?
Low - contraceptive pill Raised - obesity
27
How can amenorrhoea be managed?
COCP or POP - regulate periods Hormone replacement with vitamin D and calcium if ovarian failure Weight management Metformin - PCOS
28
Define menorrhagia
Excessive menstrual loss that interferes with the women's daily living
29
What is the average blood loss in a menstrual cycle?
30-40ml
30
What can cause menorrhagia?
Anovulatory cycles Structural issues - fibroid, polyp, adenomyosis Systemic conditions - hypothyroidism, clotting disorder Copper coil PID Malignancy
31
How would you assess a woman with menorrhagia?
FBC - anaemia TV USS - palpable mass, dysmenorrhoea, intermenstrual bleeding, treatment failure +/- Abdominal exam - masses +/- Pelvic exam +/- Speculum exam
32
What is dysfunctional uterine bleeding?
Menorrhagia which can't be attributed to specific cause 50% of cases
33
How is menorrhagia managed?
Do not need contraception? Mefenamic acid or TXA Need contraception? 1. Mirena IUS 2. COCP 3. long acting progesterone e.g. depo-provera
34
What are the surgical management options for menorrhagia?
Endometrial ablation | Hysterectomy
35
What is menopause?
Permanent cessation of menstruation
36
What is the average age of menopause?
51 yo
37
When is menopause diagnosed?
12 months of amenorrhoea
38
How long do menopausal symptoms normally last?
7 years
39
What is climacteric/perimenopause?
Period prior to menopause where women experience symptoms such as ovarian function start to fail From age 45
40
What hormonal changes occur in menopause?
!!Reduction in follicle!! number - also less inhibin Decrease in available binding sites !!Reduced sensitivity!! of ovary to circulating LH and FSH !!Reduced oestrogen secretion!! Negative feedback reduced Circulating LH and !!FSH increase!!
41
How is menopause diagnosed?
Clinical diagnosis - hormone levels not normally necessary Raised FSH not diagnostic but indicate reduced ovarian response Investigate differentials
42
How long do women need to use contraception around menopause?
<50 yeas old = 2 years after last period | >50 years old = 1 year after last period
43
What are some psychological symptoms associated with menopause?
``` Dizzy Interrupted sleep Anxiety Poor memory/concentration Depressive mood Irritable Reduced libido ```
44
What happens to menstruation in menopause?
Abnormal cycle length - could be shorter or longer Oestrogen breakthrough bleeding
45
What changes are seen in the vagina in menopause?
Dryness | Painful intercourse
46
What urinary symptoms may be present in menopause?
Incontinence Urgency Atrophy - share embryological origin with vagina so affected by low oestrogen
47
What musculoskeletal problems may women suffer from in menopause?
Joint soreness Joint stiffness Back pain
48
What skin changes are seen in menopause?
``` Hot flush - spread from face down to neck and chest Dry Itching Thinning Tingling ```
49
How do breasts change in menopause?
Enlargement | Pain
50
What are some systemic symptoms of menopause?
Weight gain | Night sweats
51
Why can you get breakthrough bleeding in menopause?
Progesterone req. to support endometrium If no ovulation then endometrial lining break down
52
What diseases are associated with menopause?
Vascular - ischaemic heart disease, stroke, peripheral artery disease Osteoporosis Alzheimers
53
Why is menopause associated with IHD, stroke and peripheral artery disease?
Oestrogen lower LDL and raise HDL Redistribution of body fat to abdomen
54
How is menopause managed?
Lifestyle modification | HRT
55
What lifestyle changes can be made to help reduce menopause symptoms?
Stop smoking Reduce alcohol and caffeine intake Regular exercise and weight loss Calcium supplements
56
How are vasomotor symptoms of menopause managed?
fluoxetine | or citalopram or clonidine
57
How are psychological symptoms of menopause managed?
HRT and CBT
58
How is a low sexual desire in menopause managed?
HRT | Testosterone supplementation
59
How is vaginal dryness in menopause managed?
Lubrication | Estriol (vaginal oestrogen)
60
Who is HRT used in?
Menopausal women where benefits will outweigh risks
61
What are the types of HRT?
Oestrogen and progesterone or oestrogen alone Cyclical (progesterone for last 14 days) or continuous Oral or transdermal
62
What must women with a uterus who request only oestrogen replacement therapy also have?
Mirena coil to provide progesterone
63
What are the side effects of HRT?
Erratic bleeding for first 3 months Progesterone - fluid retention, weight gain, mood swings, pelvic pain Oestrogen - breast tenderness, leg cramps, bloating
64
What are the risks of HRT?
VTE - much higher risk if combined and oral. Reduced risk with transdermal patch Breast cancer - much higher risk if combined and continual not cyclical Stroke Endometrial cancer - oestrogen only Ovarian cancer IHD
65
How is HRT stopped?
Gradually reduced or stopped immediately If stopped immediately, may get short term symptom recurrence
66
What are the cautions and contraindications for HRT?
Breast cancer Oestrogen sensitive cancers Undiagnosed vaginal bleeding Untreated endometrial hyperplasia
67
What are the benefits of HRT?
Improved symptoms - esp. vasomotor, mood and urogenital Reduced risk of CVD and osteoporosis Reduced risk of colorectal cancer
68
In perimenopausal women would you use cyclical or continuous HRT preparations? Why?
Use cyclical as they get a predictable withdrawal bleed whereas in continuous they get unpredictable bleeds
Obstetrics and Gynaecology
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