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)
Patients with amenorrhoea associated with low oestrogen have increased risk of osteoporosis. amenorrhoea > 12 months = treatment is indicated to reduce the risk of osteoporosis. what treatment?
- adequate vitamin D and calcium intake
- HRT or COCP
What is menorrhagia?
heavy menstrual bleeding
excessive menstrual loss involves more than 80ml
changing pads 1-2 hours
name some causes of menorrhagia?
- Dysfunctional uterine bleeding
- Extremes of reproductive age
- Fibroids
- Endometriosis
- Adenomyosis
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease, thrombocytopenia, platelet disorders, coagulation disorders, leukaemia)
- Endocrine disorders (diabetes and hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- PCOS
Key things to ask when investigating menorrhagia? (also for an gynae history)
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
what investigations and examinations are done for menorrhagia?
- pelvic examination with speculum and bimanual
- FBC - iron deficiency anaemia
- outpatient hysteroscopy
- pelvic and transvaginal ultrasound
- additional tests
- swabs if evidence of infection
- coag screen if fhx of clotting disorders
- ferritin if clincally anaemic
- TFT if additional features of hypothyroidism
when does a pelvic examination with a speculum and bimanual not need to be performed when investigating menorrhagia?
straightforward hx of heavy menstrual bleeding without risk factors or symptoms of they are young and not sexually active
when is a hysteroscopy needed when investigating menorrhagia?
- suspected submucosal fibroids
- suspected endometrial pathology such as hyperplasia or cancer
- persistent intermenstrual bleeding
when is a pelvic and transvaginal ultrasoundscan needed when investigating menorrhagia?
- possible large fibroid - palpable pelvic mass
- possible adenomyosis
- examination difficult to inteepret
- hysteroscopy declined
how is menorrhagia managed?
cause dependent - ie fibroids manage as fibroids
some general options
- NSAID, tranexamic acid, COCP
- IUD
- endometrial ablation
- hysterectomy
what is the length of a normal menstrual cycle?
24-32 days (can be some variation)
what is the mean blood loss for a women during her period?
37-43ml mostly in first 24 hour
what age group present most commonly with heavy menstrual bleeding?
40s - those approaching menopause
the more children a woman has had, the more likely she is to have heavy periods? True or false?
true - positive correlation between number of children and heaviness of periods
what is metrorrhagia?
irregular bleeding - no pattern or cycle
what is intermenstrual bleeding? (IMB)
bleeding in between periods, there is a cycle, the cycle may be irregular but there is also bleeding in between the periods
what is postcoital bleeding? (PCB)
bleeding triggered by intercourse.
often cervical pathology
what is polymenorrhea?
menstrual cycle shorter than 21 days
what is Oligomenorrhoea?
infrequent periods
cycle greater than 35 days but less than 6 months in length
what is amenorrhoea?
absent periods, may be primary or secondary depending on whether the woman has ever had periods before
what is dysfunctional uterine bleeding? (DUB)
heavy menstrual bleeding with no recognisable pelvic pathology, pregnancy or general bleeding disorders
aka primary menorrhagia
need to exclude other causes before diagnosis
how to you ask about impact on quality of life regarding heavy menstrual bleeding?
- impact on work/social life - avoid social life/work
- bleeding through clothing
- bed soiling or disrupted sleep due to heavy bleeding
how do you ask/quantify volume when asking a woman how much they bleed?
how often do you change your pad/tampon
how many do you use in a day
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
what are 2 emergency short term methods to control HMB?
Norethisterone: 5mg po tds for up to 7 days. used 3 wks on 1 wk off for 3-4 months whilst on waiting list for treatment
GnRH analogues: months/quarterly, to down regulate the cycle and temporarily induce ‘medical menopause’. often used for fibroids to allow for correction of anaemia and iron stores in preparation for another intervention
tranexamic acid
mefenamic acid
what are some causes of oligomenorrhoea? (infrequent)
- constitutional
- anovulation - PCOS, thyroid disease, prolactinoma, CAH
physiological causes of amenorrhoea
prepubertal
pregnancy
menopause
what is cryptomenorrhoea?
Menstruation occurs but is not visible due to obstruction of outflow tract resulting in either hematometra (blood collection within uterus) or hematocolpos (blood collection within vagina)
long term it may result in endometriosis, urinary retention and infertility
what is the most common cause of amonorrhoea?
pcos
what is Premenstrual dysphoric disorder (PMDD)?
similar to premenstrual syndrome (PMS) but is more serious. PMDD causes severe irritability, depression, or anxiety in the week or two before your period starts. Symptoms usually go away two to three days after your period starts.
