Dysmenorrhea Flashcards
DDX of secondary amenorrhea
With hyperandrogegism
- PCOS
- antonomus hyperandrogegism (androgen secretion independent of HPO axis) can be ovarian tour, hyperthecosis, adrenal androgen-secreting tumour.
- late onset or mild cognital adrenal hyperplasia
Without hyperandrogegism
- increase gonadotrophin(↑ FSH) and decrease gonodism (↓E). 3 types Idiopathic, autoimmune (T1DM, Addison’s or thyroid), Iatrogenic (radiation or cyclophosphamide)
- Hyperprolactinemia
- Endocrinopathies - most common ↑or↓ thyroid
- Hypogonadotrophic hypogonadism
- Functional hypothalamic - most common - amenorrhea often related to stress, excessive exercise +/or anorexia
Causes of hypogonadotrophic hypogonadism
Pituitary compression or destruction Pituitary adenoma, craniopharoma? Lymphocytic hypophysitis, infiltration Head injury Sheehan's syndrome
Types of amenorrhea
Primary amenorrhea
Secondary amenorrhoea
Oligomenorrhea
Define primary amenorrhea
No menses by age 13 in the absence of 2° sexual characteristics or no menses by age 15 with 2° sexual characteristics or no menses 2 yrs after thelarche
Define secondary amenorrhea
No menses for >6 m or 3 cycle after documented menarche.
Define oligomenorrhea
episodic vaginal bleeding occurring at internals >35 days
DDX of primary amenorrhea and 2° sexual development
Normal breast and pelvic development - Hypothyroidism - hyperprolactinemia - PCOS - Hypothalamic dysfunction Normal breast and abnormal uterine development - Androgen insensitivity - Anatomic abnormality eg mullerian genesis, uterovaginal septum, Imperforate hymen.
DDX of primary amenorrhea and without 2° sexual development
↑FSH (hypergonadotrophic/ ↓gonadism
- Gonada dysgenesis - abnormal sex chromosome eg Turner’s, Noral sex chromosome
↓FSH (↓gonadtrophic, ↓gonadis)
- constitutional delay - most common. Can be due to Congenital abnormality such as isolated GnRH deficiency, pituitary failure e.g. Kallman syndrome, Head injury, pituitary adenoma. Can also be acquired such as endocrine disorders e.g. T1DM, Pituitary tumour, systemic disorder e.g. IBD, JRA, Chronic infection
What work up for a patient with amenorrhoea
BhcG
Hormonal work up - TSH, Prolactin, FSH, LH, Androgens, Estradiol
Progesterone challenge to assess E status
if withdrawal bleed = adequate E. If no withdrawal bleed = inadequate E or excessive androgens or progesterone
Karyotype if premature ovarian failure or absent puberty
USS to confirm normal anatomy and ID PCOS.
Mx of primary amenorrhea caused by androgen insensitivity syndrome
Gonadal resection after puberty,
Psychological counselling
creation of neo vagina
Mx of primary amenorrhea caused by Anatomical abnormalities e.g. imperforate yen, cervical agenesis, transverse vaginal septum
Surgical management
Mx of primary amenorrhea caused by mullein dysgenesis
Psychological counselling
creation of neovagina with dilation
diagnosis study to confirm normal urinary system and spine.
Mx of secondary amenorrhea caused by uterine defect e.g. Asherman’s syndrome
Evolution with hypersalpingography or sonohysterography.
Hysteroscopy excision of synechiae
Mx of secondary amenorrhea caused by HP acts dysfunction
ID modifiable underlying cause
COCP to ↓ risk osteoporosis, maintain normal vaginal and breast development (not proven)
Mx of secondary amenorrhea caused by premature ovarian failure
Screen for DM, ↓thyroid, ↓PTH, ↓corticolism.
Hormonal therapy with E and P to reduce risk of osteoporosis - OCP
Mx of secondary amenorrhea caused by hyperprolactinemia
MRI/CT if neg Bromocriptine, cabergolin if fertility wanted += surgery
Mx of secondary amenorrhea caused by PCOS
Cycle control
Infertility
Hirsutism.
Prolactinoma Symptoms
Galactorrhea
visual changes
headache
Ix for 1° amenorrhea with secondary sex characteristics
Karyotypes
XX = imperforate hymen, transverse vagina spectrum, cervical agenesis, mullein ageneses
XY = androgen insensitivity syndrome
Ix for 1° amenorrhea without secondary sex characteristics
FSH/LH
If high = hypergonadotrophic gondola agenesie/dysgenesis
If low = hypogonadotrophic with constitutional delay or HP axis abnormalities.
Ix for 2° amenorrhoea
Start with B-hcG
Ix for 2° amenorrhoea with -ve B-hcG
Prolactin first
- Normal = Progestin challenge.
- Abnormal >100 then CT head. test TSH for hypothyroidism
What to do after progestin challenge
Withdrawal bleed - test FSH/LH
if high = premature ovarian failure or PCOS due to increase androgen
If normal or low = HPA axis dysfunction need MRI. Measure progesterone. may be caused by wt los, increase exercise and systemic disease.
No withdrawal bleeding = uterine defect, washerman’s syndrome or HPA axis dysfunction.
Define abnormal uterine bleeding
Change in frequency, duration or amount of menstrual flow
What are the different types of abnormal uterine bleeding
amenorrhea - absence of periods
Hypomenorrhea - decrease amount of blood
Oligomenorrhea - cycle intervals >35 days
polymenorrhea - cycle intervals 7 days or excessive amount >80cc/cycle
Metrorrhagia - irregular intervals particularly between period
Menometrorrhagia - excessive blood at period and in-between
Post menopausal - any bleeding after >1yr after menopause. Must rule out endometrial cancer.
Compare anovulatory and ovulatory forms of abnormal uterine bleeding
Anovulatory is more common, unpredictable endometrial bleeding of various flow and duration where ovulatory is of typical cyclic but heavy or prolonged.
Causes of anovulatory causes of abnormal uterine bleeding
PCOS thread dysfunction elevated prolactin E producing tumors Stress Wt loss exercise liver and kidney function structural disease Drug AE
Causes of ovulatory abnormal uterine bleeding
anatomic eg polyps, fibroid, adenomyosis, neoplasm, Foreign body
Homeostatic defect
infection
trauma
local disturbances in prostaglandin eg ↑endomyometrial vasodilatory prostaglandin, ↓vasoconstrictive PG.
Pathogenesis of anovulatory abnormal uterine bleeding
oestrogen dependent breakthrough bleeding. Increase E chronically with not enough P -> ↑ proliferation -> ↑ ET that out grows blood supply = focal necrosis = partial shedding = irregular prolonged/heavy bleeding.
DDX of abnormal uterine bleeding by age
Pre menarchal - trauma, sexual abuse
Pre menopausal - ovulary, anovulatory, pregnancy related
Post - menopausal - genital tract disease - atrophy, neoplasms, or systemic disease or Drugs e.g. HRT, anticoagulants
work up for abnormal uterine bleeding
Vital +/- orthostatic vitals
FBC, serum ferritin
BhcG
TSH, free T4
Coagulation profile esp in adolescent to rule out vWD
Prolactin if amenorrheic
RSH, LH
Serum androgens esp testeren
Day 21 progesterone to confirm ovulation
pap smear
Pelvis USS - polyps, fibroids, easier ET (Post menopause)
TVUSS - polyps and fibroids
Endometrial biopsy if >40 yr to exclude endometrial Ca
D+ C to diagnosis not to tx
Tx of abnormal uterine bleeding
resus if needed
Tx underlying disorders- if all causes are ruled out = DUB
Medical DUB
Stop constant bleeding = continuous progestogen: medroxy-P4 acetate 30mg daily
Non-hormonal = NSAIDs or tranexamic acid
Hormonal = COCP, Mirena, or cyclical progestogens day 5 - 25
If abnormal endometrium - pipette, repeat USS in early follicular stage or Hysteroscopy
Clomiphene - if fertility is desired
Fibroids - refer
Surgical - Endometrial ablation, hysterectomy or myomectomy.
Define Dysmenorrhea
Painful menstruation
Types of Dysmenorrhoea
Primary - Idiopathic - begin 6m-2yr after menarche Secondary - Endometriosis - Adenomyosis -Uterine polyps - Uterine anomalies eg non-communicaating uterine hormones - Leiomyoma - Intrauterine synechiae - Ovarian cysts - Cervical stenosis - Imperforate Hymene, Transverse vaginal septum - PID - IUD - Copper - Foreign body.
Symptoms of Primary Dysmenorrhea
Low midline abdo pain radiates to back or thighs
Varies from dull dragging to a severe cramping pain
Maximun pain at beginning of period
May commence up to 12hrs before menses
Usually last 24hr-2-3days.
+/- Nausea and vomiting
Headache, syncope or flushing
Signs of Primary dysmenorrhea
No abnormal findings
Tx of Primary dysmenorrhea
Rule out underlying pathology and dyspareunia, abnormal bleeding or infertility.
Full explain and reassurence
Promote healthy lifestyle eg reg exercise and stop smoking and reduce alcohol
Define premenstrual syndrome
Physiological and emotional distrubances 1-2 wk prior to mensus
Cause of premenstrual syndrome
Multifactoral, Genetic, Hormone effect and NT = Serotonin dysfunction
Symptoms and diagnostic criteria
1 - At least 1 affective+1somatic symptom in 5 d before menses for 3 cycles.
- Affective = depression, angry, outbursts, irritability, anxiety, confusion, social withdrawal
- Somatic = Breast tenderness, abdo bloating, headache, swelling or peripheral
2 - Symptoms relieved 4d post onset of menses,
3 - symptoms present in absence of drugs or alcohol
4 - reproducible in 2 cycle
5 - ID dysfunction in social or economic performance
Tx of premenstrual syndrome
Goal is symptom relief
Psycholical support
Diet/supplements - avoid Sodium, caffeine + alcohol, Ca, Mg, VE, VBG
Med - NSAIDs if pain/discomfort
- SSRI - either for the 14 days of luteal phase or continuous
- Spironolactone - in luteal phase to reduce fluid retention
- COCP
- Danazol - androgen -ve to block the POAxis.
Mind/body approach - exercise, CBT, Relaxation, if therapy
Herbal remedies - evening primrose oil, black cohosh, St John Wart
Surgery - BSO if severe.
