Gynae: Menstrual disorders Flashcards
hpg axis
What is primary amenorrhea?
Not starting menstruation:
- By 13 years with no evidence of pubertal development
- By 15 years of age where there are other signs of puberty, such as breast bud development
when does puberty usually start?
- starts 8-14 in girls and have growth spirt earlier than boys. periods start around 2 years from start of puberty
- starts 9-15 in boys
What is hypogonadism and what are the 2 types?
lack of sex hormones oestrogen and testosterone that normal rise before and during puberty (lack of causes delay in puberty)
hypOgonadotropic hypogonadism = deficiency of LH and FSH
hypERgonadotropic hypogonadism = lack of response to LH and FSH by gonads
What is hypogonadotrophic hypogonadism?
deficiency of FSH and LH leading to a deficiency of the sex hormones (oestrogen) as no stimulation of the ovary to produce oestrogen
Hypogonadotropic hypogonadism
Deficiency of LH & FSH is due to abnormal functioning of hypothalamus or pituitary gland. What are some causes fo this?
- Hypopituitarism
- Damage to hypothalamus or pituitary (radiotherapy, cancer surgery)
- Significant chronic conditions can temporarily delay puberty (CF, IBD)
- Excessive exercise of dieting
- Constitutional delay in growth and development
- endocrine disorders ie growth hormone deficiency, hypothyroidism, Cushing’s, hyperprolactinaemia
- Kallman syndrome
What is Kellman Syndrome?
genetic condition causing hypogonadotropic hypogonadism with failure to start puberty. associated with anosmia
What is hypergonadotropic hypogonadism?
where the gonads fail to respond to stimulation from the gonadotropins
no negative feedback from the sex hormones so you get high LH and FSH but low oestrogen
hypergonadotropic hypogonadism is due to abnormal function of the gonads. What could be some causes of this?
- previous damage to the gonads (torsion, cancer, infections)
- congenital absence of the ovaries
- Turner’s syndrome (XO)
what is congenital adrenal hyperplasia?
autosomal recessive, caused by a congenital deficiency of the 21-hydroxylase enzyme causing under production of cortisol and aldosterone and over production of androgens from birth (can be 11B hydroxylase in rare cases)
severe - neonate unwell shortly after birth with electrolyte disturbance and hypocalcaemia, females have ambiguous genitalia
in milder - female pt present later in childhood/puberty with: tall for age, facial hair, primary amenorrhoea, deep voice, early puberty
what is androgen insensitivity syndrome?
condition occurring in males where the tissue is unable to respond to androgens so male sexual characteristics do not develop. female phenotype other than the internal pelvic organs. have female external genitalia and breast tissue but testes inside the abdomen or inguinal canal. no uterus, upper vagina, fallopian tubes or ovaries
describe the pathophysiology of structural pathology in primary amenorrhoea and name some examples?
if ovaries are unaffected there will be typical secondary characteristics but no menstrual periods. may be cyclical abdominal pain and menses build up but unable to escape through the vagina
causes = imperforate hymen, transverse vaginal space, vaginal agenesis, absent uterus, FGM
what is the threshold for investigating someone with primary amenorrhoea and what is done to investigate it?
no evidence of pubertal changes in a girl aged 13 or some evidence of puberty but no progression after 2 years
initial investigations:
- FBC and ferritin - anaemia
- U&E - CKD
- anti-TTG or anti-EMA - ceoliac
hormonal blood tests
- FSH & LH
- TFT
- insulin-like growth factor I is used as a screening test for GH deficiency
- prolactin (hyperprolactinaemia)
- testosterone - raised in PCOS, AIS, CAH
genetic testing with a microarray test to assess for underlying genetic conditions - turners
imaging - XRAY of wrist to asses bone age, pelvic US to assess ovaries and pelvic organs, MRI of brain to look for pituitary pathology
how is primary amenorrhoea managed?
- treat underlying cause
- replacement hormones can induce menstruation and improve symptoms
- reassurance and observation for constitutional delay in growth and development
- stress/low body weight - reduce stress, CBT, weight gain
- chronic/endocrine condition = optimise treatment
- hypogonadotropic hypogonadism - pulsatile GnRH to induce ovulation and menstruation, COCP where pregnancy not required
- ovarian cause - COCP induce menstruation and prevent symptoms of oestrogen deficiency
What is secondary amenorrhoea and what is the criteria for considering assessment?
- Defined as no menstruation for more than 3 months after previous regular periods
- Assessment after 3-6 months and 6-12 in women with infrequent irregular periods
What are some causes of secondary amenorrhoea?
- Pregnancy = most common
- Menopause & premature ovarian failure
- Hormonal contraception (e.g. IUS or POP)
- Hypothalamic or pituitary pathology
- Ovarian causes such as PCOS
- Uterine pathology ie Asherman’s syndrome
- Thyroid pathology
- Hyperprolactinaemia
Hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress leading to hypogonadotropic hypogonadism to prevent pregnancy in situations where the body may not be fit for it. What are some examples?
- excessive exercise
- low body weight and eating disorders
- chronic disease
- psychological stress
What are some pituitary causes of secondary amenorrhoea?
- pituitary tumours such as prolactin secreting prolactinoma
- pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
how is secondary amenorrhoea investigated?
- hormonal blood tests
- bHCG
- LH & FSH - high FSH suggests primary ovarian failure, high LH or LH:FSH ratio suggests PCOS
- prolactin and MRI for pituitary tumour
- TSH and TFTs
- testosterone
- ultrasound scan of pelvis to diagnose PCOS
how is secondary amenorrhoea managed?
establish and treat underlying cause
hormone replacement therapy if necessary
(PCOS pt need withdrawl bleed every 3-4 months)
how to assess a woman with HMB?
low risk - can start first line treatment having only done an FBC and arrange a follow up appointment and if no improvement then do further tests
how do we treat HMB?
mirena is 1st line recommend by NICE
tranexamic acid
mefenamic acid
