5.1 menstrual disorders Flashcards
what is primary amenorrhoea?
‘Primary’ amenorrhoea refers to when menstruation has not yet started by the age of
16 years in the presence of normal secondary sexual characteristics, or 14 years in the absence of other evidence of puberty.
Causes could be congenital, problems with the HPA axis or anatomical abnormalities
what is secondary amenorrhoea?
‘Secondary’ amenorrhoea refers to absent periods for at least 6 months in a woman who has previously had regular periods, or 12 months if she has had oligomenorrhoea (bleeds less frequently than 6 weekly).
Causes are usually due to a problem with the HPA axis
what are some physiological causes of amenorrhoea?
childhood
pregnancy
luring lactation
after the menopause
what is the overlap between primary and secondary amenorrhoea?
The overlap in presentation of primary and secondary is because “secondary” causes may present as primary if they happen early enough in life
what is the most common cause of primary amenorrhoea with normal secondary sexual characteristics?
gentiourinary malformations such as inperforate hymen, a vagnial septum, absent vagina or absent uterus
what is a imperforate hymen?
congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during fetal development. It is most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the uterus.
if the mullerian duct and urogenital sinus do not join correctly in development, how will this affect menstration?
incomplete joining would leave a gap between the uterus and vagina, and the correct outflow tract would not be created. clood flow would accumulate in the peritoneal cavity.
what might cause primary amenorrhoea without second sexual characteristics developing?
constitutional delay of puberty idiopathic hypogonadotrophic hypogonadism Kallmann syndrome complete androgen insensitivity syndrome Turners syndrome
what is turners syndrome?
A genetic disorder where there is loss of one of the sex chromosomes of the 23rd pair. the karyotype is therefore 45XO. Ovary does not complete its normal development and instead under goes dysgenesis.
what hormonal abnormalities are present in a person with turners syndrome?
low oestrogen
high FSH and LH due to no negative feedback from oestrogen
what is complete androgen insensitivity syndrome?
X-linked recessive disorder
Resistant to testosterone due to a defect in the androgen receptor. excess testosterone then converted to oestrogen. 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. The testes should be surgically excised after puberty
what is isolated GnRH deficiency?
A disease of the hypothalamus which is characterized by absent or incomplete sexual maturation by the age of 18, in conjunction with low levels of circulating gonadotropins and testosterone and no other abnormalities of the hypothalamo–pituitary axis.
what is Kallman syndrome?
condition characterized by delayed or absent puberty and an impaired sense of smell.
what are anatomical causes for secondary amenorrhoea?
Scarring
• Cervical stenosis
• Asherman syndrome (intrauterine adhesions)
Ovarian disorders
• Primary ovarian insufficiency (POI) – “Premature menopause”
what is Asherman syndrome?
absence of menses because of endometrial scarring or cervical stenosis resulting from injury or disease.
what is primary ovarian insufficiency?
premature menopause - depletion of oocytes before age of 40. No oestrogen, no inhibin and high FSH due to loss of feedback.
what are some of the non-anatomical causes of secondary amenorrhea?
PCOS Thyroid disease Hyperprolactinaemia Prolactinoma Pituitary necrosis Functional hypothalamic amenorrhoea
describe the clinical findings of a patient with PCOS
- amenorrhoea or oligomenorrhea
- elevated LH
- raised insulin resistance resulting in diabetes
- polycystic ovaries on ultrasound
- excess androgens resulting in hirsuitism and acne
what are the psychosocial issues associated with PCOS?
body image
self esteem
depression
anxiety
what is the treatment for PCOS?
COCP
lifestyle advice
describe how thyroid disease influences menses?
Menstrual abnormalities common in both hyper and hypothyroidism. Severe hyperthyroidism classically
associated with amenorrhea
what are some of the causes of hyperprolactinaemia?
pituitary tumours
hypothyroidism
medicines given for depression, psychosis and hypertension
how is a prolactinoma diagnosed?
High blood prolactin levels (greater than 800)
CT head showing an enhancing pituitary macroadenoma
what is Sheehan syndrome?
hypopituitarism developing postpartum as a result of pituitary necrosis; caused by ischemia due to a hypotensive episode during delivery.
what are some of the causes of functional hypothalamic amenorrhea?
weight loss and excessive exercise
emotional stress and stress induced by illness
what is abnormal uterine bleeding?
- Duration greater than eight days
- Flow greater than 80 mL/cycle or subjective impression of heavier-than-normal flow
- Occur more frequently than every 24 days or less frequently than every 38 days - Intermenstrual bleeding or postcoital spotting
- Absence of menses
what is meant by metrorrhagia?
irregular menses, lasting linger than 7-9 days.
what is the difference between acute and chronic abnormal uterine bleeding?
Acute: episode of heavy bleeding that is of 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 Structural - Polyps - Adenomyosis - Leiomyoma (fibroid) - Malignancy/hyperplasia Non-structural - Coagulopathy - Ovulatory dysfunction (includes thyroid) - Endometrial - Iatrogenic - Not yet classified
what are leiomyoma?
benign tumours of uterine smooth muscle. Oestrogen dependent and therefore often worsen in pregnancy and shrink in menopause
what are some of the complications of leiomyomas?
HMB (menorrhagia) and IMB
subfertility and recurrent pregnancy loss
bulk pressure effects
what is dysfunctional uterine bleeding?
bleeding of endometrial origin that is abnormal. most common cause of menorrhagia. A diagnosis based on exclusion.
what causes dysfunctional uterine bleeding?
altered endometrial prostaglandin metabolism seems to play an important role in the aetiology of DUB. Prostaglandin inhibitors decrease menstrual blood loss in DUB
Anovulatory
- Inadequate signal
- Impaired positive feedback (ie. adolescence)
Ovulatory
– “Idiopathic”
- secondary to increased prostaglandins and reduced endothelins (vasoconstrictors) - ?genetic
what is dysmenorrhea?
Painful menstruation: crampy and intermittently intense; or continuous dull ache Presentation = 1-2 days before or with onset of menses. Improved 12-72. Lower abdomen and suprapubic area
• Primary – since menarche
• Secondary – developed over time
what are the common symtoms of endometriosis?
causes dysmenorrhea, dyspareunia, chronic pain and infertility
what is endometriosis?
Endometrial glands and stroma that occur outside the uterine cavity. Oestrogen-dependent, benign, inflammatory disease. Responds to cyclical hormonal changes
what are the risk factors of endometriosis?
nulliparity, early
menarche, short cycles, heavybleeding, low BMI
what are the most common sites of endometriosis?
- Ovaries
- Endometrioma = chocolate cyst
- Bladder
- Rectum
- Peritoneal lining and pelvic side walls
what is adenomyosis?
endometrial tissue found deep within the myometrium
where is blood likely to accumulate in endometriosis?
pouch of douglas / rectouterine pouch
how is dysmenorrhea managed?
NSAIDS
hormonal contraceptives (COCP, intrauterine device )
GnRH analogues
Surgery - adhesiolysis, treatment to endometriosis, hysterectomy
