8. Menstrual disorders Flashcards
Define amenorrhoea
absence of menstruation
what are physiological periods of amenorrhoea?
ildhood, during pregnancy, during lactation and after the menopause.
WHat is primary amenorrhoea?
Absence of menstruation by age 16 in the presence of normal secondary sexual characteristics, or 14 years in the absence of other evidence of puberty.
What is secondary amenorrhoea?
absent periods for at least 6 months in a woman who has previously had regular periods
What are 4 causes of primary amenorrhoea and which is most common?
- Turner’s syndrome
- Anatomical causes (most common)
- Complete Androgen Insensitivity Syndrome
- Hypothalamic and pituitary disease
What are 3 different anatomical causes of primary amenorrhoea?
- Imperforate hymen
- transverse vaginal septum
- absent vagina or uterus
What is the hymen?
Thin piece of mucosal tissue that surrounds or partially covers the external vaginal opening
What is imperforate hymen?
•An imperforate hymen is a 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.
How does a transverse vaginal septum form?
Due to improper fusion of the mullerian ducts and the urogential sinus
when is an underlying hormonal or chromosomal cause suspected in primary amenorrhea?
If there are no secondary sexual characteristics with primary amenorrhoea
What is Turner Syndrome and how often does it occur?
45XO, missing X chromosome. 1:2500 live female births
Why does primary amenorrhoea occur in Turner’s syndrome?
Ovary does not complete its normal development (ovarian dysgenesis)
No oestrogen = no pubertal changes
How do the ovaries appear on examination?
“streak” ovaries/gonads
What would be the typical lab values of a patient with turner’s syndrome?
- Low estradiol
* High FSH and LH
What other symptoms of Turner’s syndrome are seen as a result of ovarian dysgenesis?
No secondary pubertal changes:
- short stature
- poor breast development
- no pubic hair
Other than amenorrhoea, what will patients with anatomical causes also present with and why?
Cyclical pain due to blood pooling in the uterus or upper vagina every month
What is Complete Androgen Insensitivity Syndrome?
• X-linked recessive disorder
• Resistant to testosterone due to a defect in
the androgen receptor
What would be an individuals genotype and phenotype in CAIS?
46XY but normal female phenotype (female externally)
- insensitive to testosterone so oestrogen causes female characteristics
Why would a person with CAIS have primary amenorrhoea?
Absence of upper vagina, uterus and fallopian tubes. The gonads would be testes, which may be palpable in the labia or inguinal area (surgically removed post puberty)
What hypothalamic/pituitary disorder can cause primary amenorrhoea?
Isolated GnRH deficiency (“Idiopathic hypogonadotrophic hypogonadism”)
• Autosomal dominant or x-linked autosomal
recessive
What does GnRH deficiency also result in?
Poor development of secondary sexual characteristics
What is isolated GnRH deficiency with anosmia called?
Kallman syndrome
What is the diagnosis of GnRH deficiency for primary amenorrhoea?
Constitutional delay of puberty - all aspects of puberty delayed
What are 4 possible causes of secondary amenorrhoea?
- Anatomical causes
- PCOS
- Endocrine
- Hypothalamic and pituitary
What are 2 anatomical causes of secondary amenorrhoea?
Scarring and ovarian disorders
What type of scarring can cause secondary amenorrhoea?
- Cervical stenosis
* Asherman syndrome (intrauterine adhesions)
What are Asherman syndrome and what can cause it?
Intrauterine adhesions (scarring) due to repeated surgeries or instrumentation of the uterus or even repeated infections
What ovarian disorder can cause secondary amenorrhoea?
Primary ovarian insufficiency (POI) - “Premature menopause”
What is primary ovarian insufficiency, what hormone levels would you expect?
Depletion of oocytes before age 40,
• No oestrogen, no inhibin = High FSH (loss of negative
feedback)
What is PCOS and what percent does it contribute to amenorrhoea and oligomenorrhoea?
Polycystic ovarian syndrome
- 20% of amenorrhoea
- 50% of oligomenorrhoea
What the is triad associated with PCOS?
Menstrual irregularity, Androgen excess, obesity
What results from androgen excess in PCOS?
Hirsutism (male pattern hair growth in women), acne
Which hormone is elevated in PCOS?
Elevated LH, causes imbalance of other hormones as well leading to problems with ovulation.
what is PCOS? what causes it?
It is a syndrome of hyperandrogenism and chronic
anovulation in which other causes have been ruled out.
Clinically, the patients present with secondary amenorrhea /infertility, hirsutism and obesity.
The syndrome is related to a lack of pulsatile GnRH release. Many follicles begin to develop but a dominant follicle is not selected to mature. These follicles
respond to pituitary hormones by producing an abnormal pattern of oestrogen secretion. Chronic anovulation is thought to occur because of inappropriate feedback signals from the ovary to the hypothalamus/pituitary.
How does PCOS affect insulin?
Raised insulin and insulin resistance leading to diabetes
What is seen in ultrasound of PCOS?
Multiple small follicles (4-9mm)
What is the main treatment for PCOS?
COCP (Combined oral contraceptive pill), lifestyle advice
What 2 endocrine problems can cause secondary amenorrhoea?
Thyroid disease and hyperprolactinaemia
How does thyroid disease cause amenorrhoea?
Exact reason unknown, Complex interplay between thyroid hormones and HPG axis. Thought to disrupt pulsatility of GnRH
What type of thyroid disease (hypo/hyper) cause menstrual abnormalities?
Both, Severe hyperthyroidism classically associated with amenorrhea (May be proceeded by oligomenorrhea)
How does prolactinaemia cause amenorrhoea?
High prolactin levels interfere with the normal production of other hormones, such as oestrogen and progesterone. This can change or stop ovulation and
also lead to irregular or missed periods.
What could cause pathological prolactinaemia?
–Pituitary tumors (prolactinomas)
–Hypothyroidism (underactive thyroid)
–Medicines given for depression, psychosis, and high blood pressure
What can casue physiological prolactinaemia?
Pregnancy, breastfeeding
How does hypothyroidism cause prolactinaemia?
Increase of TRH, TRH stimulates production of prolactin
What hypothalamic and pituitary conditions can cause secondary amenorrhoea?
- prolactinoma
- pituitary necrosis (sheehan syndrome)
- functional hypothalamic amenorrhoea
What is sheehan syndrome and what causes it?
Pituitary necrosis due to excess blood loss (hemorrhage) or extremely low blood pressure during or after labour
When does functional hypothalamic amenorrhoea occur?
- Weight loss and excessive exercise
* Emotional stress and stress induced by illness
Why is there risk of bone loss in functional hypothalamic amenorrhoea?
Due to hypooestrogenaemia
What parameters are important in abnormal uterine bleeding (AUB)?
Frequency (days), Regularity (variation), Duration of flow (days), Volume (objective and subjective)
What is the normal frequency of menstruation?
24-38 days
What is the range (variation) for a regular menstruation?
<7-9 days
What is the normal duration of menstruation?
<8 days
What is the normal volume of menstruation?
5-80 ml
What is the term for infrequent periods?
Oligomenorrhoea
What is the term for irregular periods?
Metrorrhagia
What is the term for heavy period?
Menorrhagia
What is an acute AUB?
episode of heavy bleeding that is of sufficient quantity to require immediate clinical intervention to stop further blood loss
What is a chronic AUB?
bleeding of abnormal volume, duration, regularity, or frequency that has been present for most of the previous 6 months
What are the different structural causes of AUB?
PALM: • Polyps • Adenomyosis • Leiomyoma (fibroid) • Malignancy/hyperplasia
What are the different non-structural causes of AUB?
COEIN: • Coagulopathy • Ovulatory dysfunction (includes thyroid) • Endometrial • Iatrogenic • Not yet classified (DUB)
what are the type of symptoms for AUB?
- Heavy
- Irregular
- Infrequent
- Frequent
- Prolonged
- Shortened
- Postcoital
- Intermenstrual
What are fibroids and what are they dependent on?
Benign tumour of uterine smooth muscle, oestrogen dependent
What does the oestrogen dependency of fibroid cause/
They get worse during pregnancy due to increase oestrogen levels and shrink after menopause
What is the prevalence of fibroids?
40%, more common in women with family history, haven’t had children, african decent
What are some complication of fibroids?
- HMB and IMB
- Subfertility and recurrent pregnancy loss
- Bulk pressure effects
How can fibroids cause subfertility?
If they grow into and impinge upon the uterine cavity
Do fibroids normally cause pain, when might they cause pain/
No, except:
- if it begins to degenerate
- if it is connected to uterus by a stalk and torsion occurs, leading to necrosis of the fibroid
What is the diagnosis of exclusion of AUB?
Dysfunctional Uterine Bleeding (DUB) - the most common cause of menorrhagia and is the term used
when there are no apparent local or systemic causes for menorrhagia
What are the 2 subdivision of DUB?
Anovulatory and ovulatory
When is DUB most common?
Early reproductive years and perimenopause
Define dysmenorrhea
painful menstruation: crampy and intermittently intense; or continuous dull ache
What is the typical presentation of dysmenorrhoea (when are where)?
- 1-2 days before or with onset of menses
- Improved 12-72h
- Lower abdomen and suprapubic area
What is primary and secondary dysmenorrhoea?
- Primary - since menarche
* Secondary - developed over time
Give one example of a cause of dysmenorrhoea.
Endometriosis
What is endometriosis?
Endometrial glands and stroma that occur outside the uterine cavity
What is the prevalence of endometriosis and what are the risk factors?
5-10% prevalence
• Risk factors: nulliparity, early menarche, short cycles, heavy bleeding, low BMI
What is endometriosis dependent on?
Oestrogen dependent, shred and proliferates cyclically along with uterus lining
Why does endometriosis cause adhesion?
Sheds along with uterine lining, blood in body cavities leading to inflammation, causes scarring and adhesions
What symptoms can endometriosis cause?
dysmenorrhea, dyspareunia, chronic pain, and infertility. Can also be asymptomatic.
What are the most common sites for endometriosis to occur?
- Ovaries (Endometrioma = chocolate cyst)
- Bladder
- Rectum
- Peritoneal lining and pelvic side walls
What is endometrioma?
Endometriosis within ovaries (chocolate cyst)
What is adenomyosis?
uterine thickening that occurs when endometrial tissue moves into the muscular walls of the uterus (rather than just lining the uterus).
What is the main theory for pathophysiology of endometriosis?
Retrograde menstruation into fallopian tubes and into peritoneal cavity, blood implants where it shouldn’t
What are different treatment available for dysmenorrhoea?
- NSAIDs
- Hormonal contraceptives (COCP, Intrauterine device)
- GnRH analogues
- Surgery (Adhesiolysis, Treatment to endometriosis, Hysterectomy)
- Heat, ginger, acupuncture, TENS
