5 Flashcards
What does amenorrhoea mean?
-absence of menstruation
What is primary amenorrhoea?
- when pt. Has never had a period by 16 y.o
- common causes are congenital disorders, hormonal disorders, structural disorders (imperforate hymen)
Describe the most common cause of primary amenorrhoea
- Turners syndrome
- 45XO
- 1:2500 live female births
- ovary does not complete its normal development (dysgenesis)
- only stroma is present at birth= “streak” ovaries/gonads
- Lab values: low estradiol, high FSH and LH
- no estrogen = no pubertal changes because of lack of negative feedback
- management: HRT (hormone replacement therapy)
- signs: short stature, shield-shaped chest, elbow deformity, short fingernails, webbed neck, low hairline, constriction of aorta, infertility
Describe some anatomical causes that can lead to primary amenorrhea
- affects 20% of cases of primary amenorrhoea
- imperforate hymen
- problem with the outflow tract
- transverse vaginal septum (rare); failure of fusion between Müllerian duct and UGS
- mullerian agenesis (Mayer Rokitansky Kuster Hauser Syndrome MRKH syndrome); congenital absence of vagina with variable uterine development
- meaning even if you have a period, will experience a pouch of blood that will not exit, very painful (hematocolpos)
What is complete androgen insensitivity syndrome, and how does it cause primary amenorrhea?
- X linked recessive disorder
- resistant to testosterone due to a defect in the androgen receptor
- 46XY but normal FEMALE phenotype (external)
- testes may be palpable in the labia or inguinal area
- absence of the upper vagina, uterus and Fallopian tubes
- testes should be surgically excised after puberty to prevent cancer risks
- since testosterone isnt working, the spare testosterone gets converted to oestrogen
- so oestrogen causes development of female phenotype
How does hypothalamic and pituitary disease cause primary amenorrhoea?
- isolated GnRH deficiency
- “idiopathic hypogonadotrophic hypogonadism”
- autosomal dominant or x-linked autosomal recessive
- poor development of secondary sexual characteristics
- with anosmia (cant smell)= Kallman syndrome
- constitutional delay of puberty which is more common in boys
What is secondary amenorrhea?
- pt. Started having periods but then subsequently menstruaion has stopped
- no period for >6 months
- causes: pregnancy, menopause (older women), weight loss
What are some anatomical causes of secondary amenorrhea?
scarring
-cervical stenosis
-asherman syndrome (intrauterine adhesions)
-occurs after having repeated operations or infections
Ovarian disorders
-primary ovarian insufficiency (POI); “premature menopause”
-depletion of oocytes BEFORE 40 y/o
-no estrogen, no inhibin which leads to high FSH (loss of negative feedback)
-same thing as menopause but starts earlier
How does PCOS cause secondary amenorrhea?
Polycystic Ovarian Syndrome
- syndrome of hyper androgenism (clinical or biochemical) and chronic anovulation
- 20% of amenorrhea cases
- up to 50% are Oligomenorrhoea (irregular bleeding)
- pt. Will present with secondary amenorrhea/infertility, acne, hirsutism (excessive hair growth) and obesity
- related to a lack of pulsatile GnRH release
- many follicles develop but a dominant one is not picked to mature
- therefore abnormal pattern of oestrogen secretion occurs
- anovulation caused by inappropriate feedback signals from ovary to hypothalamus/pituitary
- abnormal oestrogen secretion puts pt’s at risk of endometrial malignancy
- results in elevated LH
- results in raised insulin resistance, leading to high risk of diabetes
- on u/s shows up as multiple small follicles/cysts on ovaries
- management: contraceptive, lifestyle advice
- results in menstrual irregularity, androgen excess, obesity
What is Oligomenorrhoea?
- menstruation that has reduced in frequency
- leads to a cycle length of greater than 35 days, resulting in 4-9 periods a year
How can endocrine diseases cause secondary amenorrhea?
Thyroid disease
- menstrual abnormalities common in both hyper and hypothyroidism
- severe hyperthyroidism classically associated with amenorrhea
- may be preceded by Oligomenorrhoea
- complex interplay between thyroid hormones and HPG axis
- affects the pulsatility of GnRH
Hyperprolactinemia
- too much prolactin will suppress GnRH
- due to pregnancy, breastfeeding, renal failure, tumours and also dopamine drugs
- can have a side effect of hypothyroidism
How can hypothalamic and pituitary diseases cause secondary amenorrhea?
Prolactinoma
- adenoma in the pituitary
- high PRL level (>800)
- CT head: enhancing pituitary macroadenoma
Pituitary necrosis
- aka Sheehan syndrome
- obstructive haemmorhage and profound bleeding
Functional hypothalamic amenorrhea
- weight loss and excessive exercise
- emotional stress and stress induced by illness
- ex: gymnasts/athletes, anorexia
- risk of bone loss due to hypooestrogenemia
-abnormal GnRH secretion will lead to absent LH surge which will lead to anovulation and result in low estradiol
Explain some physiological causes of amenorrhea?
Pregnancy
-always rule out pregnancy in any woman of reproductive age with amenorrhea
Menopause
- towards the end of a woman’s reproductive timespan, periods may become irregular, before stopping completely
- still possible to get pregnant in the transition, therefore still need to rule out pregnancy
What is menorrhagia?
- heavy menstrual bleeding
- either by objective volume (>80ml) or pt. Says periods are becoming heavier or she is passing clots
- could also be caused by structural problems such as benign/malignant growths in endometrium
- or clotting disorders
- look for anaemia in these patients
What is metorrhagia?
-irregular variation of menstrual cycle (>7–9 days)
What are the ranges for frequency (days) of the menstrual cycle
Infrequent: >38
Normal: 24-38
Frequent: <24
What is the range of regularity (variation) of menstrual cycles?
Regular: <7-9 days
Irregular: >7-9 days
What is the range of duration of flow (days) of the menstrual cycle?
Normal: <8
Prolonged: >8
What is the range of volume (objective) of the menstrual cycle?
Heavy: >80mL
Normal: 5-80mL
Light: <5mL
What are the two duration of symptoms for abnormal uterine bleeding?
Acute
-episode of heavy bleeding that is sufficient quantity to require immediate clinical intervention to stop further blood loss
Chronic
-bleeding of abnormal volume, duration, regularity or frequency that has been present for most of the previous 6 months
What are the underlying causes of abnormal uterine bleeding?
PALM-COEIN (FIGO) Structural -Polyps -Adenomyosis -Leiomyoma (fibroid) -Malignancy/hyperplasia
Non-structural
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial
- Iatrogenic
- Not yet classified (DUB)
What are the types of symptoms you can get from abnormal uterine bleeding?
- Heavy
- irregular
- infrequent
- frequent
- prolonged
- shortened
- postcoital
- intermenstrual
- LOOK AT DIAGRAMS
How can fibroids cause AUB?
- fibroid is a benign tumour of uterine smooth muscle (leiomyoma)
- estrogen dependent
- about 40% prevalence
- Complications:
- HMB (Heavy Menstrual Bleeding) and IMB (Irregular Menstrual Bleeding)
- Subfertility and recurrent pregnancy loss
- Bulk pressure effects
- Rare malignant change to leiomyosarcoma 1:350 (will rarely become malignant)
- sometimes asymptomatic and will not cause pain
- only causes pain if fibroid is degenerating or it’s in torsion but happens rarely
How does Dysfunctional Uterine Bleeding cause AUB?
-“Bleeding of endometrial origin”
-Diagnosis of exclusion: HMB not present because of pathology
-PALM-COEIN: the “N” is not yet classified
-common at extremes of reproductive life
-Subdivided:
Anovulatory
-Inadequate signal
-Impaired positive feedback (i.e. adolescence)
Ovulatory (Idiopathic)
-could be secondary to increased prostaglandins and reduced endothelins (vasoconstriction)
-could be genetic
What is dysmenorrhea?
- painful periods
- can be crampy and intermittently intense, or continuous dull ache
- 45-95% of women of reproductive age experience it
- presents usually 1-2 days before or with onset of menses
- usually improves within 12-72hrs
- felt in lower abd and suprapubic area but can also radiate to back and thighs
- can interfere with quality of life
- often leads to chronic pelvic pain, and can be as a result of obstructive structural causes
- primary: occurs since menarche (unlikely to have a cause)
- secondary: developed over time (most likely to have a cause)
How is endometriosis a cause of dysmenorrhea?
- when endometrial lining grows outside of uterus
- endometrial glands and stroma that occur outside the uterine cavity
- 5-10% prevalence
- risk factors: nulliparity (no birthgiving), early menarche, short cycles, heavy bleeding, low BMI
- estrogen-dependent, benign, inflammatory disease
- responds to cyclical hormonal changes
- irritates the peritoneum which leads to pain and can cause dysmenorrhea, dyspareunia, chronic pain, and infertility
What are the most common sites for endometriosis to occur?
- Ovaries (most common) where an endometrioma (chocolate cyst that consists of blood and debris) can occur
- bladder
- rectum
- peritoneal lining and pelvic side walls
What s an adenomyosis?
- endometrial tissue found deep within myometrium
- causes heavy bleeding
What is retrograde menstruation?
-Can get a back flow of blood in through the tubes
How can we manage dysmenorrhea?
NSAIDS Hormonal contraceptives -COCP -Intrauterine device GnRH analogues -to take down scar tissue Surgery -adhesiolysis -treatment to endometriosis -hysterectomy Heat, ginger, acupuncture, TENS
How can we form a differential diagnosis on how to identify menstrual disorders?
Hormonal
-look at the HPG axis first and identify any problems
Structural
-if not problems with HPG axis, then move onto any structural problems
-can be investigated by USS, MRI or more intensive imaging (ex. Hysteroscopy)
System review
-thyroid disorders can cause menorhagia or Oligomenorrhoea
What is the HPO axis?
- GnRH produced by the hypothalamus
- acts on anterior pituitary to release gonadotrophins (FSH and LH)
- Gonadotrophins act on ovary
- promoting follicular development
- production of ovarian hormones (steroid, inhibin)
- as cells of the follicle develop and change, they produce hormones that spread around body and act in endocrine fashion
- controlled by effects of gonadal hormones
- negative AND positive feedback control
What is menopause?
- end of menstruation
- Greek for “monthly stop”
- part of women’s ageing process
- permanent cessation of menstruation for 12 consecutive months
- happens when there are not more primary follicles left
- oestrogen levels and progesterone levels starts to decline
When is it considered no longer possible for a woman to conceive?
After 12 consecutive months of no menstruation
What is physiological menopause?
- the normal decline in ovarian function due to ageing begins in most women between ages 45-55 on average 50
- results in infrequent ovulation
- decreased menstrual function and eventually cessation of menstruation
- irregular periods
What is pathological menopause
-gradual or abrupt cessation of menstruation before 40 years occur idiopathically in about 5% of women in USA
What are the 4 phases of menopause?
- Pre-menopause (may be slight changes to FSH/LH levels but cycle will be relatively normal, no detectable changes)
- Peri-menopausal (transition menopause, detectable changes in cycle)
- Menopause
- Post menopause
What is pre-menopause?
- initial changes prior to menopause in menstrual cycle
- cycle often shorten, oestrogen is early or absent so fertility problems can occur
- typically from 40+ years
- oestrogen declines so no negative feedback on HPG axis
- therefore LH and FSH rise
- FSH rises more than LH because no inhibin
What is peri-menopause?
-“transition phase”
-physiological changes occurs associated with end of reproduction capacity
-follicular phase shortens
-ovulation early or absent
-mood swings and hot flushes
Greater infrequency of meenstruation
-terminating with completion of menopause
What is the menopause phase?
-complete cessation of menstrual period s for consecutive 12 months
What is post-menopause?
- time after pt. Experience s menopause
- quality of oocytes decline as you age
Explain the “burning out of ovaries”
- reproductive life: about 400 primordial follicles grow into mature follicles and ovulate
- at around 45 y/o only few primordial follicles remain
- as you age oestrogen levels decrease as follicles decrease
- this causes rise of FSH and LH which does not help the quality of the oocytes
Which hormone is measured to diagnose physiological menopause?
FSH because it rises significantly higher than LH
What are the symptoms of menopause?
- Seven dwarves of menopause:
- itchy: peritis
- twitchy: restlessness in limbs
- sweaty: increased perspiration
- sleepy: since sweating keeps them up
- bloated: low oestrogen levels cause smooth muscles tones to bloat
- moody: due to low oestrogen levels
- forgetful
- relate to oestrogen deficiency
What symptoms would you feel in the early stages of menopause?
- hot flushes: peripheral vasodilation as a physiological response
- sweating
- insomnia
- menstrual irregularity
- mood swings or depression
WHat symptoms occur during the intermediate stage of menopause?
- relate to further depleting levels of oestrogen
- vaginal atrophy: since it needs oestrogen
- dyspareunia: painful sexual intercourse
- skin atrophy
- urge-stress incontinence
- frequency of UTIs
- thinning of uterus and loss of vaginal rugae
- reduction of pubic hair
- sagging skin, breasts
Why must we investigate for an endometrial carcinoma in menopausal patients?
- no more progesterone produced by corpus luteum since no more ovulation
- so pt. Is subject to unopposed oestrogen
- must check for symptoms of bleeding in post-menopause
What are the symptoms in the late stages of menopause?
- osteoporosis
- atherosclerosis
- CHD
- CVS disease
- Alzheimer’s
What are the effects of of a hot flush on the vasomotor system?
- suddenly, transient sensation of warmth to intense heat over face, chest, neck and head
- followed sometimes by profuse perspiration
- symptoms: chills, nausea, anxiety, head or chest pressure, feelings of suffocation, inability to concentration
- duration: few seconds to several minutes
- frequency: rare to recurrent every few minutes more at night or during stress
- treatment: potentially HRT
What are the psychological changes of menopause?
- frequent headache
- irritability
- fatigue
- depression and insomnia
- may more likely be related to loss of sleep due to night sweat
- diminished interest in sex may be due to emotional upset or may be secondary to painful intercourse due to a dry vagina
How does menopause change the ovaries?
- ovaries become smaller (atrophic)
- oestrogen production declines
- after menopause the substantially increased gonadotrophin levels maintain ovarian androgen secretion despite substantial oestrogen demise
How does menopause change your general appearance?
Skin
-skin loses elasticity and becomes thin and fine
-due to loss of elastin and collagen from skin
Weight
-weight increase is more likely due to irregular food habit due to mood swing
-more deposition of fat around hips, waist and buttocks
Hair
-menopausal balding
-becomes dry and coarse after menopause
-may be hair loss due to decreasing level of oestrogen
Voice
-voice becomes deeper due to thickening of vocal cords
How does menopause affect the digestive and urinary systems?
- motor activity of the entire digestive tract is diminished after menopause
- intestine tend to be sluggish resulting in constipation
- as oestrogen levels decline after menopause, the tissue lining the urethra and bladder become drier, thinner and less elastic
- changes in bladder
- loss of pelvic tone
- urinary inconteinence
- can lead to UTI
- Treatment: HRT with oestrogen such as vaginal cream which will help increase the muscle tone
How does menopause change the uterus?
- becomes small and fibrotic due to atrophy of the muscles after the menopause’s
- regression of endometrium
- shrinkage of myometrium
- cervix becomes smaller and appears to flush with vagina
- in older women, the cervix may be impossible to identify separately from vagina
- thinning of cervix
- vaginal rugae lost
How does menopause change the vulva?
-fat in the labia majora and the mons pubis decreases and pubic hair become spare
How does menopause change the breasts?
- in thin built women, breasts become flat and shrivelled
- in heavy built women they remain flabby and pendulous (saggy)
How does menopause affect the bone?
- reducing oestrogen levels will increase osteoclast activity since oestrogen suppresses osteoclasts
- more bone is absorbed, resulting in increased calcium loss
- lost in the first five years after onset of menopause
- leaves bone weak and liable to fracture in the smallest stress
- can result in osteoporosis which can result in NOF fractures
- bone mass reduces by 2.5% per year for several years
- can also reduce height due to reduced bone mass
How does menopause change the CVS system?
- mostly in elderly women
- low levels of oestrogen and progesterone cause changes in lipid profile in postmenopausal women
- changes metabolism of body
- increased cholesterol in blood can lead to hyperlipidaemia
- increased circulating lipid levels
- gradual rise in the risk of heart disease and stroke after menopause
- BP increases
- body weight increases
- body fat distribution more central
- carb tolerance decreases
- insulin resistance increases
- insulin sensitivity decreases
What are some non-hormonal treatments for menopause?
- General lifestyle advice that can help with vasomotor symptoms
- wear light layers to alleviate hot flashes and night sweats
- dietary advice to reduce weight gain and CVS risk
- avoid caffeine, alcohol and spicy foods
- reduce dietary fat intake and regular exercise
What are some hormonal treatments for menopause?
- replacing oestrogen locally (eg. Vaginal cream) or patches, or orally
- HRT
- manage symptoms related to low oestrogen levels
- can be used during any phase of menopause
- can improve well-being
- can limit osteoporosis
- NOT advised for cardioprotection
