Lecture 7 - Menstrual Disorders Flashcards
What is Amenorrhoae?
The absence or cessation of menstruation
What are the 2 types of amenorrhoea?
Primary
Secondary
What is primary amenorrhoea?
The failure to start menstratuion by 15yrs or in girls with normal secondary sexual characteristics (breast development
Or by 13yrs or in girls with no secondary sexual characteristics
What is secondary amenorrhoea?
The stopping of menstruation for 3-6 months in women with previously normally and regular menstruation
Or for 6-12 months in women with no previous oligomenorrhoea
What can cause amenorrhoea?
Anything that can disrupt the cycle anyway along
So anything affecting GnRH, FSH, LH, oestrogen or progesterone production
Can have issues with ovaries (polycystic ovaries)
Issues with vagina (imperforate hymen or absent vagina)
What is indicated in a patient with primary amenorrhoea when their FSH and LH levels are low and they dont have secondary sexual characteristics?
Issue with the HPG axis
(Hypogonadotropic hypoogonadism)
What is indicated in a patient with primary amenorrhoea when their FSH and LH levels are high when there are no secondary sexual characteristics ?
Hypergonadtropic hypogondism which can be cause by Turner’s syndrome, premature ovarian failure or swyer syndrome
What is indicated in a patient with primary amenorrhoea when their are secondary sexual characteristics present when the uterus is present?
If the outflow is obstructed then could be an imperforate hymen or transverse vaginal septum
If no obstruction could be secondary amenorrhoea
What is indicated in a patient with primary amenorrhoea when their are secondary sexual characteristics and theres no uterus present?
Could be androgen insensitivity syndrome or mullerian agenesis
What is the most common cause of primary amenorrhoe with secondary sexual characteristics?
Genitourinary malformations:
Imperforate hymen
Vaginal Setum
Absent vagina
Absent uterus
What is an imperforate hymen?
Congenital disorder where a hymen without an opening completely obstructs the vagina
What part of the body is typically affected in patients who have amenorrhoea and have low FSH and LH levels?
Hypothalamus/Pituitary
What part of the body is typically affected in patients who have amenorrhoea and have high FSH and LH levels?
Problem with Gonads so a chromosomal dysfunction like Turner’s syndrome
What are some diseases that cause amenorrhoea that affect the hypothalamus and pituitary meaning there’s no secondary sexual characteristics?
Genetic = Kallmann syndrome
Isolated gonadotropin deficiency
Acquired = CNS tumours, brain injury/infection
Functional = systemic disease like hypothyroidism
Stress
Weight loss (anorexia)
What causes the lack of sexual characteristic development alongside primary amenorrhoea?
Hypothalamus may not make GnRH
This means lack of Pituitary stimulation
Lack of LH and FSH production
Lack of uterine / ovarian function
No oestrogen so not secondary sexua charcateristiic development
What are the 3 main physiological causes of secondary amenorrhoea?
Pregnancy
Breastfeeding
Menopause
What is the first cause that is suspected if a woman has amenorrhoea?
Pregnancy if she is reproductive age
What are some pathological causes of secondary amenorrhoea of the ovary and uterus?
Scarring (cervical stenosis, Asherman syndrome)
Primary ovarian insufficiency (premature menopause)
Polycystic ovaries syndrome `
How does Ashermans syndrome cause secondary’s amenorrhoea?
The scarring of the uterus leads to the uterus being unable to grow and shed
What happens to the levels of hormones in the menopause?
Low oestrogen
Low inhibin
High FSH (the inhibin was what inhibited the levels of FSH)
What is oligomenorrhea?
Infrequent periods
What is thought to be the cause o Polycystic ovarian syndrome?
Raised insulin levels
What is the triad of presentation for polycystic ovary syndrome?
Menstrual irregularity
Androgen excess
Obesity
What is the mechanism by which elevated glucose leads to the triad of presentations for Polycystic ovary syndrome?
Insulin resistance causes elevated insulin levels
Inc insulin leads to ovaries making more androgens
More androgens = acne, Hirsutism and polycystic ovaries
This leads to higher levels of LH but the increased androgens/testosterone stopp the follicle from developing causing irregular periods
How is polycystic ovary syndrome diagnosed?
Infrequent or no ovulation (menstruation)
Clinical/biochemical signs of hyperandrogenism (Hirsutism, acne or elevated testosterone)
Ultra sound
How is polycystic ovary syndrome managed?
Lifestyle advice
Screen for T2DM (due to insulin resistance)
Give contraceptive to treat (cyclic progesterone)
What are some endocrine causes of secondary amenorrhoea?
Thyroid disease
Hyperprolactinaemia
How can Thyroid disease lead to secondary amenorrhoea?
Is hyper or hypothyroidism associated with amenorrhoea?
The thyroid hormones interacts with the HPG axis
Sevre hyperthyroidism more classically associated with amenorrhoea
What gland produces prolactin?
Anterior pituitary
What is the physiological function of prolactin?
Initiatives and maintains lactation
What affect does Hyperprolactinaemia have on hormones in the menstrual cycle?
What hormones are affected?
High prolactin levels supress LH and FSH
What can cause Hyperprolactinaemia?
Prolactinomas (pituitary tumours))
Hypothyroidism
Medicines for depression, high BP and psychosis
What type of Amenorrhea can pituitary necrosis cause?
What is this pituitary necrosis also called?
Secondary amenorrhea
Sheehan syndrome
What is functional hypothalamic amenorrhea?
When the hypothalamus secretes less GnRH due to things like weight loss, excessive exercise, emotional stress and stress induced by illness
What is of concern when a patient has Functioanl hypothalamic amenorrhea?
Risk of bone loss/osteoporosis since less GnRH is made meaning less oestrogen is made which means osteoclast activity is enhanced
What is the definition of oligomenorrhoea?
Infrequent menstruation defined by a cycle length between 6weeks - 6months
What can cause oligomenorrhoea?
Polycystic ovary syndrome
Ovarian insuffiency
Perimenospause (just before menopause)
Thyroid dysfunction
Excessive exercise or anorexia
Hormonal contraception
What is menorrhagia?
Excessive/heavy menstrual bleeding
How is menorrhagia defined?
Interferes with woman’s quality of life
Excessive bleeding 80ml >
Needing to change menstrual products every 1-2 hours
Passage of clots
What is menorrhagia called when theres no underlying pathological cause?
Dysfunctional uterine bleeding
What are the 3 types of causes of menorrhagia?
Uterine and ovarian pathologies
Systemic disease
Iatrogenic causes
What are some uterine and ovarian pathologies that cause menorrhagia?
Fibroids
Endometrial polyps (inc SA to bleed from)
Endometrial hyperplasia
Endometrial cancer
Adenomyosis
Polycystic ovary syndrome
How can polycystic ovary syndrome cause menorrhagia?
The follicular stage is much longer with PCOS so lots of OESTROGEN
Oestrogen causes proliferation of endometrium, so longer the levels of oestrogen are high the thicker the lining of the uterus gets so there is more to lose when they shed the lining
What are some systemic causes of menorrhagia?
Coagulation disorders like Von Willebrands
Hypothyroidism
Diabetes Mellitus
Hyperprolactinaemia
Liver or renal disease
What are some iatrogenic causes of menorrhagia??
Anticoagulation treatment (warfarin)
Intrauterine contraceptive device (copper coil irritates lining)
What is a Leiomyoma?
Benign tumour (hard and round) of the myometrium which is caused by the proliferation of a mixture of smooth muscles cells and fibroblasts
When do leiomyomas devolop and when do they normally regress?
Develop at reproductive age
Regress after menopause
What are the risk factors of leiomyomas?
Getting older
Early menarche (starting menstrual bleeding)
Older age at first pregnancy
Black and Asian ethnicity
FH
If a women has menorrhagia what is considered abnormal bleeding and should be a cause for concern?
Intermenstrual bleeding (in between periods)
Postcoital bleeding (after sex)
Post menopausal bleeding
Should always be referred if they have any of these red flags
What is the first step in managing menorrhagia whether it’s abnormal bleeding or not (Dysfunctional uterine bleeding)?
Why?
FBC
The bleeding could lead to anaemia
What are some ways of treating menorrhagia that is dysfunctional uterine bleeding (not abnormal bleeding)?
Give Levonorgestrel intrauterine system (coil containing progesterone)
NSAID or tranexamic acid
Combined pill or progesterone only
What is endometriosis?
Where theres ectopic endometrial tissue (glands and stroma) outside of the uterus/endometrial cavity
How does ectopic endometrial tissue lead to problems in endometriosis?
An oestrogen dependant chronic inflammatory process happens leading to fibrosis and scarring
This can affect other intraperitoneal structures due to the Fimbriae opening out into the peritoneum
Why does it take a long time for women to be diagnosed with endometriosis?
Often incorrectly diagnosed as primary dysmenorrhea
What are some risk factors of endometriosis?
Early menarche
Late menopause
Nulliparity
Delayed childbearing
FH
White
low BMI
Late first sexual encounter
Smoking
What is adenomyosis?
Where ectopic endometrial tissue is found deep within the myometrium
What are some complications of endometriosis?
Endometriomas (ovarian cysts containing blood)
Adhesions
Bowel obstructiwith painful bowel movements around menopause
Infertile (scarring in fallopian tubes)
Chronic pain
How is endometriosis diagnosed?
Laparoscopy
What is dysmenorrhoea?
Painful periods (cramping in lower abdomen normally shortly before or during menstruation)
What are the 2 types of dysmenorrhoea?
Primary and secondary
What is primary dysmenorrhoea?
No identifiable pelvic pathology
Usually starts after menarche
Uterine prostaglandins made during menstruation (prostaglandins causes strong uterine contractions)
What is secondary dysmenorrhoea?
When the painful periods start after having several years of painless periods
What is secondary dysmenorrhoea?
When the painful periods start after having several years of painless periods
What causes secondary dysmenorrhoea?
Pelvic pathology:
-endometriosis/adenomyosis
-fibroids
-endometrial polyps
-pelvic inflammatory disease
-intrauterine device insertion (IUD)
How is primary dysmenorrhea treated?
NSAIDs, paracetamol and analgesia
Oral contraceptives
How is secondary dysmenorrhea managed?
Refer if any red flags of severe symptoms
Manage symptoms with:
-NSAIDs
-hormonal contraceptives
-SURGICAL MANAGEMTN IF FERTILITY A PRIORITY
What is a GnRH analogue?
Induces menopause
What is the term for:
Heavy menstrual bleeding
Infrequent periods
Absence of periods
Painful periods
Irregular periods
Heavy = menorrhagia
Infrequent = oligomenorrhoea
Absence = amenorrhoea
Painful = dysmenorrhoea
Irregular = metrorrhagia
Can endometriosis affect anywhere in the body?
Yes
What are the levels of FSH and LH at the start of menopause?
High
What is the consequence of disruption to hypothalamic pituitary portal system?
High circulating prolcatin and low FSH/LH
What stage of the ovarian cycle is what contributes the variation in menstrual cycle length?
Follicular phase since its the point which ovulation occurs that varies
