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
