Lec 6 - Menstrual disorders

Question 1

What is amenorrhea?

Answer 1

This is the absence of menstruation.

Question 2

What is primary amenorrhea?

Answer 2

• This is the failure to to establish menstruation by 16 years.

Question 3

What is secondary amenorrhoea?

Answer 3

• This is the cessation of a previously normal menstruation for more than or equal to 6 months.

Question 4

What is oligomenorrhoea?

Answer 4

This is infrequent menstruation.

• lasts more than 35 days
• happens 4-9 times a year.

Question 5

What is menorrhagia/ heavy menstrual bleeding (HMB)?

Answer 5

This is the excessive menstrual blood loss over consecutive cycles or > 80 mls per menstruation.

Question 6

What is dysmenorrhea?

Answer 6

This is pain during menses and it is associated with ovulatory cycles.

Question 7

What is intermenstrual bleeding (IMB)?

Answer 7

This is the odd bleeding in between menstrual bleeding.

Question 8

What is dysfunctional uterine bleeding (DUB)?

Answer 8

This is heavy and irregular menstrual bleeding that occurs secondary to an ovulation.

Question 9

What is premenstrual bleeding (PMS)?

Answer 9

This is a cyclical disorder that occurs in the latter half of the menstrual cycle.
- the symptoms can be physical or psychological and can resolve with the onset of menstruation.

Question 10

What is premenstrual dysphoric disorder?

Answer 10

This is the severe end of the spectrum with extreme mood symptoms.

Question 11

Describe the HPO axis.

Answer 11

1. Hypothalamus
   - –> releases GnRH
2. Pituitary
   - –> releases FSH and LH
3. Ovary
   - –> releases oestrogen and progesterone
4. Uterus

Question 12

What are the common causes of the disorders of menstruation?

Answer 12

1. can be hormonal —> HPO axis
2. chromosomal anomalies
3. Structural/ anatomical - uterine or vaginal such as fibroids or polyps.
   ( the uterus may be abnormally formed or have a little opening so just little blood so may present with oligomenorrhoea)
4. bleeding diathesis
5. drugs
6. Thyroid disease
7. Chronic illness

Question 13

What are some of the chromosomal anomalies that cause cause menstrual disorders?

Answer 13

1. Mayer-Rokitansky- Kustner- Hayer (MRHK) syndrome
   - –> This is when the woman looks normal and has a small non-functional uterus.
2. XO- Turner syndrome
   - –> This is when you have a streak of ovarian tissue, which fails.
   - –> The ovary shuts down very quickly so you can get early menstruation.
3. Androgen insensitivity syndrome
   - –> This is when you are physically female but genetically XY.
4. Swyer syndome
   - –> present with amenorrhea
5. Congenital adrenal hyperplasia (CAH)
   - –> This is when the body did not respond to testosterone.

Question 14

What are the physiological causes of amenorrhoea?

Answer 14

• prepubertal
• pregnancy
• menopause

Question 15

What are the structural causes of menstrual disorders?

Answer 15

1. Agenesis/ Hypoplasia at any level of the genital tract.
2. Leiomyoma - uterine fibroids
3. Imperforate hymen, vaginal septae
4. Asherman’s syndrome —> These are adhesions within the uterus which may be due to previous procedures.
   - –> It is either blood doesn’t all come out so the cervix may be stenosed.
5. cervical stenosis.

Question 16

What is an Imperforate hymen?

Answer 16

It is a hymen that has no opening.

Question 17

What are the causes of Menorrhagia?

Answer 17

1. uterine fibroids - leiomyoma
2. Uterine polyps —> These are projections in the endometrium, which increase its SA and therefore have a larger area to bleed.
3. Endometrial cancer
4. Bleeding diathesis
5. Copper IUCD
6. Drugs such as warfarin.

Question 18

What are causes of irregular bleeding?

Answer 18

1. Hormone contraception especially the progesterone-only preparations.
2. STIs/ PID infection
3. Cervical ectopy or pathology usually as postcoital bleed.
4. endometrial pathology such as polyp or cancer.
5. ovarian cyst - the hormone secreting type —> these throw off the HPO axis and cause problems.

Question 19

What are the causes of primary dysmenorrhea?

Answer 19

• primary dysmenorrhea is idiopathic so is due to response of the uterus to local prostaglandins, hence painful contractions.

Question 20

What are causes of secondary dysmenorrhoea?

Answer 20

• endometriosis

- obstructed menses

Question 21

What is endometriosis?

Answer 21

• This is when normal endometrial tissue is in other places so when period happens, all of the areas of endometrial tissue will be activated so there is bleeding from may areas.
• –> As a result you get inflammation in these areas, which can lead to fibrosis.

—–> The lesions tend to look like burn marks and can develop into cysts called chocolate cysts.

Question 22

What will the history be like for menstrual disorders?

Answer 22

1. emphasis on age
   - menarche/ onset of puberty
2. pain - is it cyclical or not.
3. menstrual history - what is the cycle like, volume and changes?
4. sexual history
5. medical history and symptoms of effects etc.

Question 23

What will the examination be like for menstrual disorders?

Answer 23

1. general, abdominal, speculum, bimanual etc.
   - —> e.g if there is a lump in the abdomen it may indicate an imperforate hymen which may be the cause of pain.
2. presence for absence of secondary sexual characteristics, appearance of known chromosomal abnormalities or abnormal facies.
3. swellings/ lumps/ masses, discharge, pattern of hair growth
   - –> may or may not be cancerous.

Question 24

What will be the Investigations be like for menstrual disorders?

Answer 24

1. blood
2. hormone profile for gonadotrophins such as FSH and LH.
3. karyotype
4. Thyroid function test
5. Full blood count
6. Imaging - USS, MRI
7. Hysteroscopy - diagnostic and therapeutic
8. Laparoscopy - diagnostic and therapeutic.

Question 25

What is the management like for menstrual disorders?

Answer 25

• aim is to correct the underlying condition.
• pharmacological management - use of gonadotrophins, progesterone etc
• surgical but depends on the condition.