Gynae: Hx & Differential Diagnosis Flashcards
Make sure you look at hx taking for:
- Menstrual disorders
- STIs
- Other gynae problems e.g. incontinence
- Obstetric histories
What 4 parameters are used to describe the menstrual cycle?
- Frequency (referring to length of menstrual cycle)
- Regularity (referring to variation in length of menstrual cycle)
- Duration of flow (how many days bleeding for)
- Volume
- Objective (quantity in mLs)
- Subjective (impact on woman’s physical, social, emotional and/or quality of life)
What is meant by primary amenorrhoea?
Primary amenorrhoea is the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics.
State some potential causes of primary amenorrhoea, categorise into:
- Hypogonadotropic hypogonadism
- Hypergonadotropic hypogonadism
- Structural disorders
- Other hormonal disorders
Hypogonadotropic hypogonadism (abnormal functioning of hypothalamus or pituitary leading to deficiency of GnRH and/or LH/FSH which leads to deficiency of oestrogen):
- Constitutional delay in growth & development
- Kallman syndrome
- Hypothyroidism
- Hyperprolactinaemia
- Chronic conditions e.g. CF, IBD
- Excessive exercise or dieting
- Growth hormone deficiency
- Damage to hypothalamus or pituitary e.g. previous radiotherapy or surgery
Hypergonadotropic hypogonadism (abnormal functioning of gonads in which gonads fail to respond to gonadotrophins):
- Turner’s syndrome
- Congenital absence of ovaries
- Previous damage to ovaries (e.g. cancers, infection)
Structural disorders
- Imperforate hymen
- Transverse vaginal septum
- Vaginal agenesis
- Absent uterus
- FGM
(Mayer-Rokitansky-Kuster-Hauser syndrome – characterised by agenesis of the Mullerian-duct system in varying degrees. This translates to congenital absence of the uterus and upper two thirds of the vagina and therefore a cause of primary amenorrhoea)
Other hormone disorders
- Complete androgen insensitivity (46XY but defect in androgen receptor)
- Congenital adrenal hyperplasia
***More in menstrual disorders FCs
What is meant by secondary amenorrhoea?
Secondary amenorrhoea is defined as the cessation of menstruation for 3–6 months in women with previously normal and regular menses (ZtoF says 3 months) or for 6–12 months in women with previous oligomenorrhoea.
State some potential causes of secondary amenorrhoea
- Pregnancy (most common)
- Menopause
- Physiological stress due to e.g. excessive exercise, low body weight, chronic disease, psychosocial factors
- PCOS
- Medications e.g. hormonal contraceptives
- Premature ovarian insufficiency
- Thyroid abnormalities (hyper or hypo)
- Excessive prolactin
- Cushing’ syndrome
What do we mean by abnormal uterine bleeding?
Broad term that describes irregularities in menstrual cycle; these can abnormalities in frequency, duration, regularity of cycle length and volume of menses.
What does metrorrhagia mean?
Menstruation at irregular intervals/variation in cycle length of more than 7/9 days (dependent on source)
What does hypomenorrhea mean?
Very light, sometimes scanty, periods
What does oligomenorrhea mean?
Irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods per year
State some potential causes of oligomenorrhoea
- Extremes of reproductive age (early periods or perimenopause)
- PCOS
- Physiological stress e.g. excessive exercise, low body weight, chronic disease, psychosocial factors
- Medications
- Progesterone only contraception
- Antidepressants
- Antipsychotics
- Hormonal imbalances
- Thyroid abnormalities
- High prolactin
- Cushing’s syndrome
- Diabetes
Explain why high prolactin can cause oligomenorrhea
- Prolactin inhibits GnRH release from hypothalamus
- Decreased GnRH decreases FSH/LH secretion from anterior pituitary
- Decreased oestrogen production by ovaries
- No oestrogen surge, no ovulation
Explain what menstrual disturbances usually occur in hypothyroid and hyperthyroid women
Both hypothyroid and hyperthyroid women have been reported to have a greater prevalence of menstrual disturbances compared with euthyroid women. Specifically:
- Hypothyroid women are more likely to experience oligomenorrhea and menorrhagia
- Hyperthyroid women are more likely to experience hypomenorrhea compared with euthyroid women
Explain why hypothyroidism can lead to oligomenorrhoea
- Low T3 & T4 feed back to hypothalamus to increase TRH
- TRH increases TSH secretion but also increases prolactin secretion from AP
- Prolactin inhibits GnRH
- Less FSH and LH
- Less oestrogen
- Irregular ovulation or anovulation
- Oligomenorrhoea or amenorrhoea
What is intermenstrual beleeding?
It is a _________?
- IMB is any bleeding that occurs between menstrual periods
- Red flag for cervical and other gynaecological cancers (although other causes more common)
State some potential causes of menorrhagia
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes reproductive age
- Fibroids
- Endometriosis
- Adenomyosis
- Pelvic inflammatory disease
- PCOS
- Endometrial hyperplasia
- Endometrial cancer
- Contraceptives- particularly copper coil/IUD
- Anticoagulant medications
- Bleeding disorders
- Endocrine disorders:
- Diabetes
- Hypothyroidism
- Connective tissue disorders
Discuss the NICE guidance for investigation menorrhagia
- *Highlighted as red in workbook to check with Prof Tincello*
