Amenorrhoea Flashcards
What is primary amenorrhoea?
No periods:
- <16 if secondary sexual characteristics present
- <14 if no secondary sexual characteristics
What is secondary amenorrhoea?
Menstruation previously occurred but stopped >6 months
What are the causes of primary amenorrhoea when secondary sexual characteristics are present? (5)
- Constitutional Delay
- Genitourinary malformation
- Androgen resistance syndrome (XY karyotype)
- Hyperprolactinaemia
- Pregnancy
What are the causes of primary amenorrhoea when secondary sexual characteristics are absent? (3)
- Ovarian failure
- Hypothalmic failure
- HPA axis failure
What are the causes of ovarian failure? (4)
- Chemo
- Radiation
- Chromosomal gonadal abnormality (turners)
- Developmental abnormality (Mullerian agenesis)
What are the causes of hypothalmic failure?
- Chronic illness
- Excessive exercise
- Stress
- Significantly underweight
What are the causes of HPA axis failure?
- Tumours /irradiation/ infection/ head injury inv. hypothalmus or pituitary
- Kallmanns syndrome
- Prader willi syndrome
What are the features of Kallmanns syndrome?
Delayed or absent puberty + impaired sense of smell
What causes Kallmanns syndrome?
Hypogonadatropic hypogonadism - impairment of hypothalamus to release GnRH
Which hormone is lacking in Kallmanns syndrome?
GnRH
What are the causes of secondary amenorrhoea when there are no signs of androgen excess?
- Pregnancy/lactation/menopause
- Premature ovarian failure
- Progesterone contraception
- Weight loss
- Pituitary disease/hyperprolactinaemia
- Thyroid disease
- Iatrogenic (medications, surgery, irradiation, chemo)
What are features of androgen excess? (3)
Hair growth
Acne
Development of male characteristics
What are the causes of secondary amenorrhoea when there are signs of androgen excess?
- PCOS
- Cushing’s
- Adrenal/ovarian carcinoma
- Late onset congenital adrenal hyperplasia
What would an FSH > 20 suggest in a pt with amenorrhoea?
Premature menopause
What would a low FSH and LH suggest in a pt with amenorrhoea?
Hypothalamic-pituitary cause of amenorrhoea
What would an increased prolactin suggest?
Stress
Hypothyroidism
Prolactinoma
Drugs
What drugs (and indications) cause an increased prolactin? (3)
Phenothiazines (antipsychotic)
Domperidone (antiemetic)
Metoclopramide (nausea/vomiting)
What would a testosterone >5 suggest? (2)
Androgen secreting tumour
Late onset congenital adrenal hyperplasia
What are the Rotterdam criteria?
2/3 to diagnose PCOS:
Polycystic ovaries on US
Oligo-ovulation or anovulation
Clinical/biochemical Signs of hyperandrogenism
What causes darkened skin (acanthosis nigricans) in PCOS?
Hyperinsulinaemia
What is the management of PCOS? (5)
- Weight loss (increases insulin sensitivity)
- Metformin (increases insulin sensitivity)
- Clomifene citrate (induce ovulation to conceive)
- Ovarian drilling if not responding to Clomifene
- COCP (control bleeding)
What are the long term consequences of PCOS? (4)
- Gestational diabetes
- T2DM
- Cardiovascular disease
- Endometrial cancer
What are the causes of menorrhagia?
- Dysfunctional uterine bleeding (diagnosis of exclusion)
- Copper coil
- Fibroids
- Endometriosis
- Adenomyosis
- Pelvic infection
- Polyps
- Endometrial carcinoma
Other: - Hypothyroidism
- Caogulation disorder
What would an enlarged uterus on examination suggest?
Fibroids or adenomyosis
What should you do if there is inter-menstrual bleeding or post-coital bleeding
Check smear history
In a 48 year old patient with menorrhagia who has failed medical therapy, what investigations are needed?
Transvaginal US
Endometrial biopsy
Outpatient hysteroscopy
What is the 1st line treatment of menorrhagia?
Mirena IUS
What are the management options for menorrhagia?
Drugs - Mirena - Tranexamic acid - Mefenamic acid - COCP - Progestogens IM Surgery - Endometrial ablation - Uterine artery embolisation - Myometomy - Hysterectomy
What is the average age of menopause in the UK?
52
What symptoms do women going through the menopause experience?
Menstrual irregualrity
Vasomotor disturbance (sweats, palpitations, flushes)
Atrophy of genitalia, breasts and skin
Osteoporosis
What type of HRT should be given to women without a uterus?
Oestrogen only
What type of HRT should be given to women with a uterus who have had a period in the last 12 months?
Oestrogen and cyclical progesterone
What type of HRT should be given to women with a uterus who have not had a period in the last 12 months?
Continuous combined HRT
What are contraindications to HRT?
Oestrogen dependent cancer Past PE Undiagnosed PV bleeding High LFTs Pregnancy Breast feeding Phlebitis
What are fibroids?
Benign smooth tumours of the uterus
What percentage of women of reproductive age have fibroids?
20-40%
Wha are the risk factors for fibroids?
Increasing age
Afro-carribean
FH of fibroids
What other diseases are associated with fibroids?
Skin and uterine leiomyomata
Renal cell cancer
How and why does pregnancy affect fibroids?
Enlarge in pregnancy as they are oestrogen dependent
also COCP
When do fibroids atrophy?
After menopause
How can fibroids present?
Asymptomatic Menorrhagia Fertility problems Pain Mass
How do fibroids affect periods?
Menorrhagia
Not IMB/PMB
Why do fibroids cause fertility problems?
Submucosal fibroids interfere with implatation
When do fibroids cause pain?
Torsion of a pedunculated fibroid
Or thrombosis of the blood supply (red degeneration)
What symptoms may come up in a systems review in a patient with fibroids?
Large fibroids may cause:
- increased urinary frequency (bladder)
- Oedematous legs/varicous veins (veins)
What are the medical treatment options for fibroids?
GnRH analogues
- goserelin SC monthly for 3-6 months prior to surgery to shrink fibroids
Ullipristal acetate
- Selective progesterone receptor modulator
- Taken daily for 3-6 months to shrink fibroids and induce amenorrhoea prior to surgery
What are the surgical treatment options for fibroids?
Myomectomy - hysteroscopic - laparoscopic - open Uterine artery embolisation Hysterectomy
What is red degeneration of fibroids?
Thrombosis of capsular vessels, followed by venous engorgement and inflammation
Causes abdo pain and localised peritoneal tenderness
How do you treat red degeneration of fibroids?
Bed rest and analgesia
Should resolve over 4-7 days
Plan C-section if large masses of fibroids are noted
