Abnormal Vaginal Bleeding Flashcards
Define primary amenorrhoea
- Lack of menstruation by age 16 in the presence of secondary sexual characteristics (or by age 14 in their absence)
If suspecting a physiological delay in onset of menstruation, what can you give to identify this / reassure the patient?
- Progesterone challenge
- Norethisterone for 5 days, and then a withdrawal bleed should occur
Define secondary amenorrhoea
Absence of menstruation for 6 months in the absence of pregnancy
What examination findings might ascertain a cause of amenorrhoea?
- Extremes of BMI
- Presence of secondary characteristics
- Stigmata of endocrinopathies (e.g. thyroid)
- Evidence of virilisation (deep voice, balding, clitoromegaly)
- Abdominal mass (genital tract obstruction)
- Pelvic exam - imperforate hymen, blind ending vaginal septum, absence of cervix and uterus
Name some physiological and iatrogenic causes of amenorrhoea
- Pregnancy
- Breastfeeding (high postpartum levels of prolactin suppress ovulation)
- Menopause
- Contraceptives
- Therapeutic progestogens (such as GnRH analogues)
Name some hypothalamic causes of amenorrhoea
- Stress
- Anorexia
- Excessive exercise
- Pseudocyesis (phantom pregnancy)
- SOL
- Surgery
- Radiotherapy
- Kallman’s syndrome (primary GnRH deficiency)
What anterior pituitary causes would cause amenorrhoea?
- Prolactinoma
- SOL
- Surgery
- Sheehan’s syndrome
What are some ovarian causes of amenorrhoea?
- PCOS
- POI (surgery, viral infection, cytotoxic drugs, radiotherapy)
- Ovarian dysgenesis (Turner’s syndrome 45XO)
- Menopause
What are some genital tract causes of amenorrhoea?
Genital tract outflow obstruction
- Imperforate hymen
- Transverse vaginal septum
- Cervical stenosis
- Asherman’s syndrome
What are some endocrinopathies that can cause amenorrhoea?
- Hyperprolactinaemia
- Cushing’s syndrome
- Hypo/hyperthyroidism
- CAH
Why does primary hypothyroidism cause amenorrhoea?
TSH stimulates prolactin secretion
What investigations can you do for someone with amenorrhoea?
- Pregnancy test
- FSH/LH
- Testosterone
- Prolactin level
- TFTs
- Pelvic ultrasound scan
- Karyotype (if uterus absent or Turner’s expected)
Treatment for amenorrhoea depends on what?
Desire for fertility
Those requiring ovulation usually respond well to an anti-estrogen such as clomifene
What is oligomenorrhoea?
Cycles lasting longer than 32 days (although some sources say 35 days, some say 42 days)
Name some causes of oligomenorrhoea
- PCOS most common
- Borderline low BMI
- Obesity
- Ovarian resistance leading to anovulation
- Milder degrees of hyperprolactinaemia and mild thyroid disease
Once ruled out pathology, and fertility is not desired yet, what is the treatment for oligomenorrhoea?
- CHC or cyclical progestogens
- Minimum of 3 periods a year is recommended to reduce the risk of endometrial hyperplasia due to unopposed estrogen (if not on hormones)
Define primary dysmenorrhoea
- Pain has no obvious cause
- Begins with onset of ovulatory cycles, within first 2 years of menarche
- Pain more severe on the day of menstruation or the day preceding it
- Prostaglandins are involved in the aetiology
If no physical cause is found for primary dysmenorrhoea, what can you give to diagnose?
- Ovulation suppression by tricycling COCP or GnRH analogues for 6-12 months
Name some causes of secondary dysmenorrhoea
- Endometriosis
- Adenomyosis
- PID
- Pelvic adhesions
- Fibroids
- Cervical stenosis
- Asherman’s syndrome
What medications can be given for secondary dysmenorrhoea?
- Mefenamic acid (or ibuprofen / naproxen)
- COCP
- DMPA
- LNG-IUS
What is the cause of HMB in 60% of cases?
Dysfunctional uterine bleeding
Name some benign uterine pathology that causes HMB
- Fibroids (>50% of those with HMB will have fibroids)
- Polyps
- Adenomyosis
- Pelvic infection
What investigations should be done for heavy menstrual bleeding?
- Pregnancy test
- FBC
- Ferritin, TFTs, clotting if clinically indicated
- STI screen
- If under 45, can consider treating first before further investigations
- If over 45, TV USS, pipelle biopsy, hysteroscopy and biopsy
Name some medical treatments for HMB
- LNG IUD (reduction in blood loss by 90%)
- Antifibrinolytics (TXA 1g TDS for 4 days)
- NSAIDs
- COCP
- Oral progestogens are of limited benefit
- DMPA
- GnRH analogues