Abnormal Periods Flashcards
Define PRIMARY AMENORRHEA.
Primary amenorrhea is failure to achieve mensuration by 15 years of age. Concerns should be raised if secondary sex characteristics are not achieved by 13 years of age.
Outline some causes for PRIMARY AMENORRHEA.
IF NORMAL PUBERTY
✔️ outflow obstruction (e.g. imperforate hymen, transverse vaginal septum, obstructed cervix)
✔️ Mullerian anomalies (e.g. agenesis of the ovaries, uterus, fallopian tubes)
IF DELAYED PUBERTY
✔️ hypothalamic causes (e.g. anorexia nervosa, trauma, tumour)
✔️ pituitary causes (e.g. prolactinoma, trauma, tumour)
✔️ ovarian causes (e.g. Turner’s syndrome, acquired damage through chemotherapy, radiotherapy etc)
Identify appropriate investigations for PRIMARY AMENORRHEA.
✔️ estradiol, LH and FSH levels ✔️ androgen levels (testosterone) ✔️ cortisol levels ✔️ chromosomal analysis ✔️ transvaginal USS
Define SECONDARY AMENORRHEA.
Secondary amenorrhea is defined as absence of period for > 3 months in a woman with previously regular cycles or > 6 months in a woman with irregular cycles.
Outline some common causes for SECONDARY AMENORRHEA.
HYPOTHALAMIC CAUSES ✔️ anorexia nervosa / low energy intake ✔️ high stress levels ✔️ high exercise levels ✔️ low body weight (particularly low body fat %age)
PITUITARY CAUSES ✔️ prolactinoma (hyperprolactinemia) ✔️ Sheehan's Syndrome ✔️ trauma ✔️ tumour
OVARIAN CAUSES
✔️ primary ovarian insufficiency
✔️ PCOS
STRUCTURAL CAUSES
✔️ fibrosis / adhesions
✔️ Asherman’s Syndrome
SYSTEMIC CAUSES ✔️ pregnancy (most common) ✔️ hyperthyroidism ✔️ Addison's Disease ✔️ chronic kidney disease
Identify some appropriate investigations for SECONDARY AMENORRHEA.
✔️ estradiol, LH, FSH ✔️ androgens ✔️ serum cortisol levels ✔️ prolactin levels ✔️ thyroid function tests ✔️ progestin challenge ✔️ transvaginal USS
What is the PROGESTIN CHALLENGE? What does a positive result mean?
The progestin challenge is used to investigate secondary amenorrhea. It is used to determine whether or not oestrogen is present in circulation.
10mg of progestin is given over 7 to 10 days. This is then ceased.
A positive test is if the woman experiences a withdrawal bleed within the following two weeks.
If the test is POSITIVE, it means that oestrogen is present but ovulation is not occurring.
Ddx include: ✔️ PCOS ✔️ primary ovarian insufficiency ✔️ stress, excessive exercise, weight loss, anorexia nervosa ✔️ outflow obstruction
Define DYSMENORRHEA. What is the difference between primary and secondary dysmenorrhea?
Dysmenorrhea is a term used to describe painful periods; usually associated with the use of analgesics and may interfere with daily life.
Primary dysmenorrhea is idiopathic. It is most common in teenager girls and young women in their early 20’s.
Secondary dysmenorrhea occurs in the context of another disease / condition. It is more common in women in their late 20’s to early 30’s.
Identify risk factors for PRIMARY DYSMENORRHEA.
✔️ early age of menarche ✔️ family history of dysmenorrhea ✔️ smoking ✔️ nulliparity ✔️ obesity
Identify some risk factors for SECONDARY DYSMENORRHEA.
✔️ endometriosis ✔️ adenomyosis ✔️ leiomyoma ✔️ chronic PID ✔️ ovarian or endometrial cysts
What symptoms might a woman with abnormal uterine bleeding present with?
✔️ heavy periods (menorrhagia) ✔️ painful periods (dysmenorrhea) ✔️ intermenstural bleeding ✔️ irregular periods ✔️ post coital bleeding ✔️ deep dyspareunia (painful sex) ✔️ dyschezia
What are differentials for ABNORMAL UTERINE BLEEDING?
STRUCTURAL CAUSES ✔️ polyps (endometrial / cervical) ✔️ adenomyosis ✔️ leiomyoma (uterine fibroids) ✔️ malignancy (endometrial / cervical)
FUNCTIONAL CAUSES ✔️ coagulopathies ✔️ ovarian dysfunction ✔️ endometrial ✔️ endocrine ✔️ iatrogenic ✔️ not otherwise specified
ADENOMYOSIS ✔️ risk factors ✔️ clinical presentation ✔️ appropriate investigations ✔️ appropriate management
RISK FACTORS
✔️ woman > 40 years
CLINICAL PRESENTATION ✔️ cyclical menorrhagia + dysmenorrhea ✔️ bloating ✔️ feeling of pressure in the bladder / rectum ✔️ urinary incontinence symptoms
INVESTIGATIONS ✔️ urine dipstick + MCS ✔️ FBC + Inflammatory markers ✔️ UECs ✔️ eLFTs ✔️ coags ✔️ TFTs ✔️ prolactin level ✔️ transvaginal USS ✔️ hysteroscopy +/- biopsy
MANAGEMENT
✔️ myomectomy
✔️ hysterectomy
UTERINE FIBROIDS ✔️ risk factors ✔️ clinical presentation ✔️ appropriate investigations ✔️ appropriate management
RISK FACTORS
✔️ woman aged 30 to 50 years
✔️ maternal / family history of fibroids
CLINICAL PRESENTATION F - frequency of urination I - iron deficiency anaemia B - bloating R - reproductive issues O -obstipation and rectal pressure I - infertility D - dysmenorrhea and menorrhagia S - symptomless / asymptomatic
APPROPRIATE INVESTIGATIONS ✔️ urine dipstick + MCS ✔️ urine pregnancy test ✔️ FBC + Inflammatory markers ✔️ UECs ✔️ eLFTs ✔️ coags ✔️ TFTs ✔️ prolactin level ✔️ transvaginal USS ✔️ MRI (to differentiate between fibroids and adenomyosis) ✔️ hysteroscopy +/- biopsy
MANAGEMENT ✔️ NSAIDs for pain relief ✔️ anti-fibrinolytic (e.g. tranexamic acid) for bleeding ✔️ iron supplementation for IDA ✔️ GnRH analogue / agonist ✔️ COCP ✔️ Mirena IUD ✔️ myomectomy ✔️ hysterectomy ✔️ uterine artery embolisation
Define ENDOMETRIOSIS. Briefly outline the pathogenesis of the disease.
Endometriosis is the presence of endometrial tissue outside of the uterine cavity (e.g. fallopian tubes, ovaries, abdomen).
The condition affects between 5 to 10% of women of reproductive age and has a broad spectrum of presentation.
Exact pathogenesis is unknown. The formation of endometrial tissue outside of the uterine cavity is attributed to one of three mechanisms:
- retrograde menses
- lymphatic drainage
- metaplastic change
Symptoms are due to proliferation of ectopic endometrial tissue with normal fluctuations in hormones associated with ovulation and menses. Presence of endometrial tissue promotes inflammation in that area (cytokines, prostaglandins, leukocytes etc). The inflammatory response not only stimulates pain, but also fibrosis and chronic change within the pelvis.
