5 - Menstrual Disorders Flashcards
What is primary amenorrhea?
Failure of menstrual periods to start by 15 in a female with normal growth and secondary sexual characteristics
OR
Failure of periods to start by 13 years of age in girls with no secondary sexual characteristics
What are some differentials for primary amenorrhea?
- Constitutional Delay in puberty
- Turner syndrome (45 XO)
- Kallmann syndrome
- AIS
- Anorexia
- Excessive exercise
- Extreme physical or psychological stress
- Structural abnormalities e.g imperforate hymen
- Pregnancy
How do you split causes of primary amenorrhea into a surgical sieve?
- Hypogonadotrophic hypogonadism
- Hypergonadotrophic hypogonadism
- Structural Abnormalities
What is congenital adrenal hyperplasia?
Deficiency of the 21-hydroxylase enzyme, autosomal recessive
This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth
- Tall for their age
- Facial hair
- Absent periods (primary amenorrhoea)
- Deep voice
- Early puberty
What investigations can you do for primary amenorrhea?
- Detailed history: of their general health, development, family history, diet and lifestyle.
- Examination: height, weight, stage of pubertal development and features of any underlying conditions.
Initial investigations
- FBC and ferritin for anaemia
- U&E for CKD
- Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal blood tests
- FSH and LH low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
- TFTs
- Insulin-like growth factor I is used as a screening test for GH deficiency
- Prolactin is raised in hyperprolactinaemia
- Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia
Genetic testing
Imaging
- Xray of the wrist to assess bone age for constitutional delay
- Pelvic US
- MRI brain to look at pituitary and olfactory bulbs in possible Kallman syndrome
How is primary amenorrhea managed?
Constitutional delay** **in growth and development: reassurance and observation
Stress or low body weight: reduction in stress, CBT, healthy weight gain.
Hypogonadotrophic hypogonadism (e.g Kallman): treatment with pulsatile GnRH can be used to induce ovulation and menstruation. If no pregnancy wanted just use COCP for sex hormone replacement
Ovarian cause of amenorrhoea: COCP may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency
What is secondary amenorrhea?
Cessation of menstruation for 3–6 months in women with previously normal and regular menses
or for 6–12 months in women with previous oligomenorrhoea.
What are some causes of secondary amenorrhea?
- Pregnancy and breastfeeding
- Menopause
- Asherman’s Syndrome (blockage to outflow)
- Polycystic Ovary Syndrome (PCOS)
- Drug-induced amenorrhoea (e.g. oral contraceptive)
- Physical stress, excess exercise and weight loss
- Sheehan syndrome
- Hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
Why do menses stop with stress?
Reduces the production of GnRH in response to significant physiological or psychological stress
Hypogonadotropic hypogonadism to prevent pregnancy in situations where the body may not be fit for it, for example:
- Excessive exercise (e.g. athletes)
- Low body weight and eating disorders
- Chronic disease
- Psychological stress
How does Hyperprolactinaemia cause secondary amenorrhea?
Prolactin has negative feedback on GnRH
Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production.
What investigations are done for secondary amenorrhea?
- Detailed history and examination
- Hormonal blood tests
- Ultrasound of the pelvis to diagnose PCOS
Hormone Tests
- b-hCG
- FSH and LH (if high FSH suggests primary ovarian failure, if high LH then suggests PCOS)
- Prolactin
- TFTs
- Testosterone (PCOS)
How are people with secondary amenorrhea managed?
Treat underlying cause
Replacement hormones to improve symptoms
If continues for a year risk of osteoporosis as low oestrogen so need adequate vitamin D and calcium intake and HRT or COCP
If a woman has secondary amenorrhea and a raised prolactin, what is the next investigation to do?
MRI brain to look for prolactinoma
What is the definition of menorrhagia?
Heavy menstrual bleeding over 80ml
Often reported on symptoms of having to change pad every 1-2 hours, bleeding lasting longer than 7 days, passing large clots
What are some causes of menorraghia?
Split into local and systemic causes
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- PID
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- PCOS
- Hypothyroidism
What questions do you need to ask in the history with menorraghia?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and PCB
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
What investigations are done for menorraghia?
- Pelvic Exam with Speculum and Bimanual: assess for fibroids, do not do if young
- FBC: look for iron deficiency anaemia
- Hysteroscopy or Pelvic US: If suspected submucosal fibroids, polyps or endometrial pathology send for hysteroscopy. If larger fibroids, adenomyosis or decline hysteroscopy send for pelvic transvaginal US
- Additional Tests: STI screen, coagulation screen, Ferritin, TFTs. Only do these if clinically indicated e.g other signs of these
How is menorraghia in women treated with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis?
1st Line: LNG-IUS
Non-Hormonal: Tranexamic acid (no pain) or Mefenamic Acid (pain as well as HMB)
Hormonal: COCP or Cyclical oral progestogens
Make sure to remove copper coils if any present. If above do not work then refer to secondary care
If medical management has failed for menorrhagia, what other options are available to treat this?
Second-generation endometrial ablation: Novosure
Hysterectomy
Hysteroscopic Removal of any fibroids
What is some management for HMB due to fibroids larger than 3cm?
Non-hormonal: Tranexamic acid or NSAIDs
Hormonal: LNG-IUS, combined hormonal contraception, cyclical oral progestogens, ulipristal acetate
Uterine artery embolisation
Surgical: Myomectomy or hysterectomy
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What is the serious side effect of ulipristal acetate?
Liver failure
What medication should be given before surgical procedures for fibroids if they are distorting the uterine cavity?
GnRH analogues
What are some causes of irregular menstruation?
Indicated anovulation or irregular ovulation
- Early periods or Perimenopause
- PCOS
- Physiological stress
- Drugs: POP, antidepressants, antipsychotics
- Hormonal imbalances: thyroid abnormalities, Cushing’s, high prolactin
What are some investigations done for irregular menstruation?
- Pelvic examination, including speculum examination +/- cervical smear if overdue
- Pregnancy test
- Pelvic ultrasound
How is irregular menstruation managed?
If investigations rule out pathology, management options include:
- COCP to regulate bleeding
- Mirena IUS to reduce overall bleeding
- Norethisterone: taken on cycle days 5-26 to prevent bleeding
- Progestogens e.g. medroxyprogesterone acetate: will induce amenorrhoea but cannot be used long term
What is oligomenorrhoea and some causes of this?
Infrequent menstrual periods (fewer than six to eight periods per year). Regularly going over 35 days for a period
- Hormonal contraception
- PCOS
- Anorexia
- Excessive exercise
- Antipsychotics and anti-epileptics
- Primary ovarian insufficiency
- Hyperthyroidism
What are some causes of dysmenorrhea?
Painful periods that are debilitating and impacting life. Can be primary or secondary
- Primary dysmenorrhoea (no underlying pathology)
- Endometriosis or adenomyosis
- Fibroids
- PID
- Copper coil
- Cervical or ovarian cancer
How is dysmenorrhea investigated?
- STI screen
- Examination for abdominal tenderness/mass, bimanual examination assessing for cervical tenderness
- Pelvic ultrasound if investigations suggest pathology (e.g. fibroids, endometriosis)
How is dysmenorrhea managed?
- Hot water bottle
- TENS
- NSAIDs (e.g. Ibuprofen, Mefenamic acid
- COCP/COCP
- Progesterone intrauterine device
If does not improve after 3-6 months of this then refer to gynaecology
How can you tell the difference between primary and secondary dysmenorrhea?
Primary
- Usually starts 6–12 months after the menarche, once cycles are regular.
- The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
- Usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynaecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain.
- Pelvic exam normal
Secondary
Starts after several years of painless periods.
- The pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
- Other gynaecological symptoms (such as dyspareunia) are often present.
- Pelvic examination may be abnormal, but the absence of abnormal findings does not exclude secondary dysmenorrhoea.
What are some causes of post-coital bleeding?
RED FLAG! Need to consider speculum
- Cervical cancer
- Ectropion
- STIs
- Trauma
- Atrophic vaginitis
- Polyps
- Endometrial cancer
- Vaginal cancer
What examinations and investigations should be done for post-coital bleeding?
- Abdominal Exam
- PV Exam: Speculum and Bimanual. See if any friability of tissues and any cervical motion tenderness
- Pregnancy Test
- STI screen
- Smear if overdue
- Refer for TVUS if postmenopausal
- Consider colposcopy or hysteroscopy
What are some causes of intermenstrual bleeding?
RED FLAG NEED TO CONSIDER CERVICAL CANCER
- Hormonal contraception
- Cervical ectropion, polyps or cancer
- STIs
- Endometrial polyps or cancer
- Vaginal pathology, including cancers
- Pregnancy
- Ovulation can cause spotting in some women
- Medications, such as SSRIs and anticoagulants
What investigations are done for intermenstrual bleeding?
- Abdominal Exam
- PV Exam: Speculum and Bimanual. See if any friability of tissues and any cervical motion tenderness
- Pregnancy Test
- STI screen
- Smear if overdue
- Refer for TVUS if postmenopausal
- Consider colposcopy or hysteroscopy
What are some differential diagnoses for vaginal discharge?
- Bacterial vaginosis
- Candidiasis (thrush)
- Chlamydia
- Gonorrhoea
- Trichomonas vaginalis
- Foreign body
- Cervical ectropion
- Polyps
- Malignancy
- Pregnancy
- Ovulation (cyclical)
- Hormonal contraception
What are some causes of post menopausal bleeding?
- Endometrial cancer
- Vaginal Atrophy
- Cyclical HRT or breakthrough continuous HRT
- Bleeding disorders
How is post-menopausal bleeding investigated?
2 week wait referral to gynaecology
- Abdo exam
- PV exam (Speculum and Bimanual)
- TVUS
- Hysteroscopy
- Endometrial biopsy
How do you take a menstrual history?
- Age of menarche
- Date of LMP
- Duration
- Frequency
- Blood loss and clots
- Dysmenorrhea
- Impact on life
How do GnRH analogues help endometriosis?
They are given SC/IM injection and then slowly released and the hypothalamus because desensitised to GnRH
Initial worsening of symptoms
What is Tibolone?
‘Bleed free HRT’
Can only be given if no periods in 12 months. Mix of oestrogen, progesterone and testosterone
Good if endometriosis and fibroids as does not stimulate these conditions
What are some differentials for an adnexal mass?
What are some psychological causes of chronic pelvic pain?
- IBS
- Depression
- Previous sexual, emotional or physical abuse causing PTSD
What is the mechanism of action of Mefenamic Acid and Tranexamic Acid?
Mefenamic: COX inhibitor stopping prostaglandin synthesis, stops pain
Tranexamic: Anti-fibrinolytic. For HMB
