78. Menstrual disturbance Flashcards
DDX dysmennorhoea
primary dysmenorrhoea
endometriosis
adenomyosis
fibroids
PID
IUD
DDX menorrhagia
benign
anovulatory cycles (extremes of reproductive age)
dysfunctional uterine bleeding
gynae
fibroids
adenomyosis
PID
iatrogenic
IUD
systemic
hypothyroidism
bleeding disorders eg von willebrans
DDX secondary amenorrhoea
pregnancy
hypothalamic amenorrhoea
pituitary pathoogy
sheehans syndrome
PCOS
premature ovarian insufficiency
menopause
ashermans
What gynaecological conditions can cause sub fertility
annovulation
- priamary amenorrhoea eg hypothalamic
- secondary eg pcos
tubal
- endometriosis
uterine
- fibroids
- polyps
History taking menstrual disturbance
Examination menstrual disturbance
Examination findings menstrual disturbance
What is primary dysmenorrhoea
Primary dysmenorrhoea occurs in young females in the absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain.
It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
primary dysmenorrhoea
management primary dysmenorrhoea
- NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
- combined oral contraceptive pill
how is the pain in secondary dysmenorrhoea different to priamry
In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
what is dysfunctional uterine bleeding
this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
what is primary amenorrhoea vs secondary?
primary -the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary - pt previously had periods, subsequently stopped, cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhea
what is oligomenorrhoea
irregular and inconsistent menstrual blood flow
PC: menorrhagia, prolonged menstruation (>7days), abdominal pain worse during menstruation, bloating or feeling full in the abdomen, urinary or bowel symptoms due to pelvic pressure, deep dyspareunia, reduced fertility
o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus
fibroids
PC: cyclical abdominal or pelvic pain, deep dysparenunia, dysmenorrhoea, infertility, cyclical bleeding from other sites eg haematuria, urinary symptoms, bowel symptoms
o/e: endometrial tissue visible in vagina, particularly in posterior fornix, fixed cervix on bimanual examination, tenderness in the vagina, cervix and adenexa
endometriosis
Usually presents in later reproductive years
PC: dysmenorrhoea, menorrhagia, dysparenunia, infertility
o/e: enlarged and tender uterus. More soft than a uterus containing fibroids
adenomyosis
PC: Cessation of menstruation for 3-6 months in women with previously normal and regular menses
- ?pregnancy
PC: secondary amenorrhoea
HoPC: excessive exercise, low body weight/eating disorders, chronic disease, psychological stress
hypothalamic amenorrhoea
PC: weight gain, hair loss, constipation, cold, amenorrhoea, struggled to breastfeed after birth
HoPC: recent post partum haemorrhage
sheehans syndrome
PC: oligomenorrhoea, secondary amenorrhoea, subfertility and infertility
HoPC: hirsutism, acne, obesity, acanthosis nigricans
PCOS
PC: oligomenorrhea, secondary amenorrhoea in patients <40, hot flushes, night sweats, vaginal dryness
premature ovrian insufficiency
PC: no periods for 12 months, hot flushes, night sweats, vaginal dryness, mood disturbance
menopause
PC: secondary amenorrhoea, lighter periods, dysmenorrhoea
HoPC: recent dilatation and courgette, uterine surgery or endometritis
ashermans syndrome
What are fibroids
Fibroids are benign smooth muscle tumours of the uterus.
Risk factors for fibroids
race, increasing age
Occur in around 20% of white women
Occur in 50% of black women
later reproductive years.
Typical history fibroids and examination
PC: menorrhagia, prolonged menstruation (>7days), abdominal pain worse during menstruation, bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, e.g. frequency, may occur with larger fibroids, subfertility, deep dyspareunia, reduced fertility
o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus
PC: may be asymptomatic, menorrhagia (may result in iron-deficiency anaemia)
bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, e.g. frequency, may occur with larger fibroids, subfertility
fibroids
investigation ?fibroids
Diagnosis
transvaginal ultrasound
hysteroscopy?
Management asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids if fibroids <3cm
- levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity - Non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid
- Hormonal: combined oral contraceptive pill or oral progestogen eg norethisterone
- injectable progestogen
- try any not tried or rf for surgical consideration
Management of menorrhagia secondary to fibroids if fibroids >3cm
- Refer to secondary care
- In meantime : non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid
Considered in secondary care:
1. levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
- Medical treatment to shrink/remove fibroids
- GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment - Surgical treatment to shrink/remove fibroids
- myomectomy if wanting to preserve fertility
- hysteroscopic endometrial ablation
- hysterectomy
- uterine artery embolization
Side effects of GnRH agonists
menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Examples of GnRH agonists
leuprorelin (brand name Lupron) and triptorelin (brand name Decapeptyl), goserelin (zoladex)
Mechanism of action GnRH agonists
Prolonged activation of GnRH receptors by GnRH leads to desensitization and consequently to suppressed gonadotrophin secretion. This is the primary mechanism of action of agonistic GnRH analogues.
Prognosis and complications of fibroids
- regress after menopause as estrogen driven
- red degeneration particularly in pregnancy
- subfertility
- iron deficiency anemia
what is endometriosis
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus.
what are chocolate cysts
Endometriomas in the ovaries are often called “chocolate cysts”.
what is an endometrioma
A lump of endometrial tissue outside the uterus is described as an endometrioma.
typical history endometriosis
PC: cyclical abdominal or pelvic pain, deep dyspareunia, dysmenorrhoea, infertility, cyclical bleeding from other sites eg haematuria, urinary symptoms, bowel symptoms
examnination endometriosis
o/e: endometrial tissue visible in vagina, particularly in posterior fornix, fixed cervix on bimanual examination, tenderness in the vagina, cervix and adnexa
plan ?endometriosis
Plan
Investigation
Laparoscopic surgery (gold standard)
USS may show chocolate cysts
Management
Non-hormonal:
Analgesia for pain (NSAIDs and paracetamol)
Hormonal:
Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists
Surgical:
Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy
Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.
gold standard investigation endometriosis
laparoscopy
what may uss show endometriosis
chocolate cysts
how does the pill help endometriosis
by reducing endometrial thickening, the pill may slow the development of endometriomas and reduce dysmenorrhoea
The normal rise and fall of hormones causes thickening and shedding, by taking the pill, the thickening is less and therefore the shedding is less painful (and can be less frequent as you can take pill packets back to back)
how could a GnRH agonist help endometriosis ?
endometriosis is estrogen driven, this is what causes the thickening, therefore by decreasing the
what is adenomyosis
Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
typical history adenomyosis
Usually presents in later reproductive years
PC: dysmenorrhoea, menorrhagia, dyspareunia, infertility
o/e: enlarged and tender uterus. More soft than a uterus containing fibroids
Plan invetsigating adenomyosis
Investigation
Initial
Transvaginal USS
MRI or transabdominal USS if transvaginal USS not suitable
GOLD STANDARD
Histological examination after hysterectomy
gold standard invetsigation adenomyosis
Histological examination after hysterectomy
Management of adenomyosis
Management
Non-hormonal:
Tranexamic acid (antifibrinolytic) where no associated pain
Mefenamic acid (NSAID) where associated pain
Hormonal:
COCP
Cyclical oral progestogens
Progesterone only eg POP, implant, depot
Secondary care:
GnRH analogues
Ablation
Uterine artery embolisation
Hysterectomy
what is pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix.
most common cause PID
Chlamydia trachomatis
causes of PID
Chlamydia trachomatis is the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
features of PID
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
plan ?PID
Invetsigation
- Pregnancy test to exclude an ectopic pregnancy
- Triple swab (NAAT for chlamydia and gonorrhoea, high vaginal charcoal swab for trichomonas, endocervical charcoal swab for gonorrhoea sensitivities)
- Pus cells on microscopy. The absence of pus cells is useful for excluding PID.
- Raised CRP/ESR
Management
1. Refer to GUM
2. Treat with low threshold as often swabs negative
3. 1g IM ceftriaxone (for gonorrhoea), doxycycline 100mg bd for 14 days (chlamydia and mycoplasma genitalium), metronidazole bd for 14 days (for anaerobes such as gardanella)
Complications of PID
perihepatitis (Fitz-Hugh Curtis Syndrome)- occurs in around 10% of cases
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
RUQ pain, with features of PID
perihepatitis (Fitz-Hugh Curtis Syndrome)
pharmacological management of PID
Ceftriaxone IM 1g (to cover gonorrhoea)
Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
what is the most common cause of inherited abnormal bleeding
von willebrand disease
inheritance von willebrand disease
usually autosomal dominant
what is von willebrand disease
Inherited deficiency, absence or malfunctioning von willebrand factor (involved with platelet adhesion) causing easy and prolonged bleeding
typical history von willebrand disease
PC: unusually easy, prolonged or heavy bleeding
Bleeding from gums when brushing teeth
Nose bleeds
Menorrhagia
Heavy bleeding during surgical operations
FHx: von willebrand disease
plan ?von willebrand disease
Plan
Investigation
Refer to specialist for bleeding assessment
Management
Von Willebrand disease does not require day to day treatment. Management is required either in response to major bleeding or trauma (to stop bleeding) or in preparation for operations (to prevent bleeding):
Desmopressin can be used to stimulates the release of VWF
VWF can be infused
Factor VIII is often infused along with plasma-derived VWF
Management of menorrhagia
Combination of:
Tranexamic acid
Mefanamic acid
Norethisterone
Combined oral contraceptive pill
Mirena coil
Hysterectomy may be required in severe cases.
most common cause of secondary amenorrhoea
pregnancy
what is hypothalamic amenorrhoea? typical history?
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way 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
what type of pituitary adenoma may cause amenorrhoea
- prolactinoma (high prolactin inhibits release of GnRH –> no release of LH and FSH) hypogonadotrophic hypogonadism
- compressive pituiatry adenoma –> low LH and FSH
plan ?pituitary adenoma causing secondary amenorrhoea
Plan
Investigation
a pituitary blood profile (including: GH, prolactin, ACTH, FH, LSH and TFTs)
formal visual field testing
MRI brain with contrast
Management
dopamine agonists (e.g. cabergoline, bromocriptine) which inhibit the release of prolactin from the pituitary gland
surgery is performed for patients who cannot tolerate or fail to respond to medical therapy.
“A 26-year-old woman comes to see her GP after complaining of weight gain, hair loss, constipation and feelings of being cold all the time. She is also amenorrhoeic and struggled to breastfeed after birth. She has no significant past medical history but during her daughter’s birth she suffered from a large amount of blood loss and subsequent hypovolaemic shock which required a 6 weeks hospital stay.”
sheehans
pathophysiology sheehans syndrome
Sheehan’s syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency. Therefore widespread hypopituitarism which includes low FH and LSH
how does hypothyroidism cause secondary amenorrhoea
Low thyroid hormones → high thyroid releasing hormone(TRH) → increased prolactin production → decreases the release of GnRH → decreases LH and FSH
how does hyperthyroidism cause secondary amenorrhoea
High thyroid hormone → increases sex hormone binding globulin (SHBG) → prevents ovulation
how are insulin and testosterone related?
Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism
how does insulin cause anovulation
Hyperinsulinemia affects granulosa cells in small follicles and theca cells. This condition induces early response to luteinizing hormones on granulosa cells of small follicles and causes premature differentiation of these cells, which eventually results in anovulation
typical history PCOS
PC: oligomenorrhea, secondary amenorrhoea, subfertility and infertility
HoPC: hirsutism, acne, obesity, acanthosis nigricans, ask about snoring and daytime somnolence (increased risk of OSA), depression
o/e: overweight/obesity, acanthosis nigricans
what is acanthosis nigricans
thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.
What is the rotterdam criteria?
Rotterdam criteria for diagnosis of PCOS (2 of:)
Amenorrhoea (no or infrequent periods)
Clinical or biochemical signs of hyperandrogenism (hirsutism, acne) (raised total or free testosterone)
Polycystic ovaries on USS (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
clinical signs of hyperandrogenism?
hirsutism
acne
definition of polycystic ovaries?
the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries
and/or increased ovarian volume > 10 cm³)
what biochemical markers are suggetsive, but not diagnostic of PCOS
Raised LH:FSH ratio
Raised prolactin or normal
SHBG may be normal or low
Investigations PCOS
TV USS “string of pearls” polycystic ovaries as defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
Testosterone
FH, LH, prolactin, TSH, SHBG
OGTT if eligible, Check for impaired glucose tolerance
QRISK
General management of PCOS
Weight loss, refer to dietician
Refer for specialist consideration of metformin
Management of amenorrhoea PCOS
Amenorrhoea - needs to be controlled in order to prevent endometrial hyperplasia and endometrial cancer
- Cyclical progestogen (such as medroxyprogesterone 10 mg daily for 14 days) to induce a withdrawal bleed) then,
- Refer for transvaginal USS to asses thickness of endometrium
- If normal choose from following treatments as prevention
- A cyclical progestogen, such as medroxyprogesterone 10 mg daily for 14 days every 1–3 months.
- COCP
- The levonorgestrel-releasing intrauterine system (LNG-IUS
why does amenorrhoea need to be controlled PCOS
in order to prevent endometrial hyperplasia and endometrial cancer
management acne pcos
+ Advise that weight loss may decrease hyperandrogenism
- COCP- use a lower risk one 1st line but Co-cyprindiol (Dianette) may be considered, but increased risk of VTE
- Normal acne treatment eg 1. a fixed combination of topical adapalene with topical benzoyl peroxide
management hirsutism pcos
+ Advise that weight loss may decrease hyperandrogenism
1. COCP but not Co-cyprindiol (Dianette) 1st line as increased risk of VTE
2. Topical eflornithine
management subfertility pcos
+ Weight loss
1. Specialists may use clomifene or metformin
how does clomifene work?
Clomifene works by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion therefore more FSH and more
define premature ovarian insufficiency
menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.
pathophysiology premature ovarian insufficieny
Hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism).
Causes:
Idiopathic
Iatrogenic eg chemo, radiotherapy, surgical oophorectomy
Autoimmune
Genetic
Infections such as mumps, tuberculosis or CMV
typical history premature ovarian insufficiency
PC: hot flushes, night sweats, vaginal dryness, mood swings, amenorrhoea, subfertility
plan ?premature ovarian insufficiency
Plan
Investigations
1. FSH raised >25IU twice, separated by more than 4 weeks (difficult to interpret if on hormonal contraception
Management
1. HRT until age 51 either traditional HRT or COCP
2. Ensure adequate vitamin D and calcium intake
what are women with premature menopause at higher risk of?
Cardiovascular disease
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
Pelvic organ prolapse
urinary incontinence
what is the menopause
Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation. On average, women experience the menopause around the age of 51 years, although this can vary significantly.
Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
what are some peri-menopausal symptoms
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
when would peri-menopausal symptoms usually resolve
Likely to resolve after 2-5 years without treatment
how long do women need contraception for?
Women need to use effective contraception for:
- Two years after the last menstrual period in women under 50
- One year after the last menstrual period in women over 50
Management of menopause?
- no treatment
- lifestyle managemet (exercise, weight loss, sleep hygeine, relaxation)
- non-HRT management: SSRIs, vaginal moisuriser, vaginal oestrogen, CBT
- HRT management
What s ashermans syndrome
Asherman’s syndrome is where symptomatic adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
typical history ashermans
PC: amenorrhoea, lighter periods, dysmenorrhoea, subfertility, miscarriage
gold standard invetsgationa dn treatment ashermans
hysteroscopy with dissecting adhesions
