Changes In Bleeding

Question 1

What is amenorrhoea? How is it classified?

Answer 1

Primary = failure to start menses by age of 16yrs in the presence of secondary sexual characteristics or in the absence of them by age 13: (TIC TACK)

1. Turner syndrome - XO, web neck/lymhpoedema/widely spaced nipples
2. Imperforate hymen - cyclical pain + bulging/bluish membrane on examination
3. Constitutional delay e.g. late bloomer (has secondary sex characteristics)
4. Testicular feminisation - XY but not internal female organs
5. Anatomical - mullerian Agenesis (secondary sexual characteristics + variable absence of female sex organs)
6. Congenital adrenal hyperplasia
7. Kallmann syndrome - failure to secrete GnRH

Secondary = menstruation previously occurring but stopped for 6+months: (SHAPE)

1. (Pregnancy, contraception, menopause, lactational amenorrhoea)
2. Sheehan’s syndrome - panhypopituitarism post bleed due to avascular necrosis of pituitary
3. Hypothalamic amenorrhoea (GnRH suppression due to e.g. stress, excessive exercise, eating disorder-lanugo hairs)
4. Ashermans - iatrogenic intrauterine adhesions
5. Premature ovarian failure - autoimmune, chemo/radiotherapy
6. Endocrine: polycystic ovarian syndrome, hypo+hyperthyroidism, Cushing’s, hyperprolactinaemia (e.g. prolactinomas), hypopituitarism

Oligomenorrhoea - menses >35 days apart

Question 2

How do you investigate amenorrhoea?

Answer 2

Exclude pregnancy - urinary or serum hCG

Bloods:
LH + FSH - Low = hypothalamic cause; Raised = ovarian cause (e.g. premature ovarian failure, menopause)
Prolactin - high levels inhibit periods (prolactinoma, antipsychs, breastfeeding etc)
Oestradiol - low in ovarian failure
Androgen levels - may be raised in PCOS
TFTs - may be high or low

Scans:
USS abdo - PCOS
MRI head - prolactinoma

Genetics/karyotyping

Question 3

What is a normal menstrual cycle? How long do you bleed for? How much do you bleed?

Answer 3

28 days - 21-35days
C. 5 (2-8 days) days bleeding

60-80mls

Question 4

What is menorrhagia/heavy bleeding?

Answer 4

Greater than normal blood loss at regular points in the cycle

A subjective view from the perspective of the woman

Interfering with QoL

Question 5

What are the causes of heavy menstrual bleeding?

Answer 5

Fibroids

Polyps

Adenomyosis

Coagulopathy

(Sometimes endometriosis)

40% have no identifiable pathology cause:
Ovulatory dysfunction - regular cycle
Anovulatory dysfunction - irregular cycle

Question 6

What are polyps?

Answer 6

Common benign localised growth of endometrium

Fibrous tissue covered by columnar epithelium

Malignant changes are rare but often like to biopsy anyway

Question 7

What is andenomyosis?

Answer 7

Very painful

Adenomyosis = diffuse, adenomyoma = single location

Really difficult to treat - hysterectomy often the only definitive treatment

More common in multiparity, 40-50yrs, uterine surgery

Question 8

What is precocious puberty?

Answer 8

Before age 8 in girls and 9 in boys

Central:
Early maturation of HPG axis
CNS abnormality -trauma, tumour, hydrocephalus

Pseudopuberty:
CAH
Adrenal tumours
Mc-Cune Albright syndrome

Question 9

What is primary dysmenorrhoea? How is it different from secondary?

Answer 9

No underlying pathology

Usually appears 1-2yrs of menarche

Excessive endometrial prostaglandin synthesis may be partially responsible

Best managed with NSDAIDs e.g. mefanamic acid or ibuprofen - as they inhibit prostaglandin synthesis

COCP is second line

Secondary dysmenorrheoa = starting a long time after menarche and is due to underlying pathology e.g. endometriosis, PID, fibroids etc - which all have their own treatments