Lecture 8 - Menstrual disorders Flashcards
Primary amenorrhoea
Absence of menstruation
Never had a period by the age of 16
Secondary amenorrhoea
Started periods but the periods have stopped for more than 6 months
Causes:
- pregnancy
- weight loss
- menopause
- birth control
- hypothyroidism
- hyperprolactinaemia
Oligomenorrhoea
Reduced menstruation
Cycle length is more than 35 days
Menorrhagia
Heavy menstrual bleeding
More than 80ml
Causes:
- benign or malignant growth in the endometrium
- clotting disorders
- anticoagulation therapy
- look for anaemia
- can be objective
How to measure menorrhagia
How many pads used
Changes in menstruation pattern
Cups
Dysmenorrhea
Painful periods
Causes:
- endometriosis
Turner’s syndrome
45XO - missing sex chromosome
Dysgenesis of ovary:
- less oestrogen
- high FSH and LH - lack of negative feedback
- no oestrogen - no pubertal changes
Symptoms and signs
- primary amenorrhoea
- short
- brown spots
- widely displaced nipples
- aortic constriction
Structural causes of primary amenorrhoea
Imperforate hymen - fusion of Müllerian duct and urogenital ridge so hymen closes off vagina
Transverse vaginal septum
Mullerian agenesis - no cervix therefore pouch of blood in uterus
Hormonal causes of primary amenorrhoea
Complete androgen insensitivity
Isolated GnRH deficiency
Complete androgen insensitivity pathophysiology
- XY
- Testes develop
- Testes produces mullerian inhibiting hormone supressing the Müllerian duct development (paramesonephric)and testosterone
- Due to androgen insensitivity, the mesonephric duct (wolffian) duct is not produced
- Testosterone is converted to oestrogen - female phenotype
Complete androgen insensitivity syndrome presentation
- Male genotype with female phenotype
- X linked recessive - 46 XY
- Resistant to testosterone due to defect3 androgen receptor
- testes palpable in the labia or inguinal area - surgically removed after puberty
- abscence of the upper vagina, uterus and fallopian tubes
Isolated GnRH deficiency
- idiopathic hypogonadotrophic hypogonadism
- delayed puberty
- autosomal dominant
- X linked autosomal recessive - more common in males
- poor development of secondary sexual characteristics
- with anosmia (lack of smell) - Kallmann syndrome
Pathophysiology of isolated GnRH deficiency
- Lack of GnRH from hypothalamus
- No pituitary stimulation
- No release of FSH and LH
- No sex hormones released
- No secondary sexual characteristics
Anatomical causes of secondary amenorrhoea
Scarring
- cervical stenosis
- Asherman syndrome - intrauterine adhesions and uterine scarring due to surgery, infection or instrument
Primary ovarian insufficiency (POI) = premature menopause
- depletion of all oocyte before 40 yrs old
- no oestrogen or inhubin - high FSH as no negative feedback
Polycystic ovarian syndrome
Idiopathic
Elevated LH - hyperandrogenism Raised insulin resistance - Diabetes Secondary amenorrhoea Infertility Hirsutism Obesity
Investigation: USS and blood test
Risks: COCP and obesity
Treatment: remove uterus
Endocrine cause of secondary amenorrhoea
Hypothyroidism
Hyperthyroidism - also get oligomenorrhoea
Hyperprolactinaemia
Hyperprolactinaemia
- Hypothyroidism can cause increased TSH and prolactin secretion from the anterior pituitary
Breastfeeding and drugs can also inhibit dopamine. Dopamine normally inhibits prolactin release therefore more prolactin is secreted.
Can get prolactin secreting tumours.
- This causes negative feedback on the hypothalamus which decreases the release of GnRH
- Amenorrhoea and nipple discharge
Sheehan syndrome
Pituitary necrosis
How long should menses last
7 - 9 days
Structural causes of abnormal uterine bleeding
Polyps
Adenomyosis
Leimyoma (fibroid)
Malignancy /hyperplasia
Non structural causes of abnormal uterine bleeding
Coagulopathy Ovulatory disorder Endometrial Iatrogenic Not classified
Leiomyoma
Benign tumour of uterine smooth muscle in myometrium
Oestrogen dependent - regresses after menopause
- menorrhagia and oligomenorrhoea
- bulk pressure effects
- recurrent pregnancy loss
- pain
Dysfunction uterine bleeding
Diagnosis of exclusion
Primary dysmenorrhea
Since menarche
