Lecture 9– Menstrual disorders Flashcards
Amenorrhoea-
absence of periods
Oligomenorrhoea-
infrequent periods
Menorrhagia-
heavy/ prolonged menstrual bleeding
Dysmenorrhea-
painful menstruation
amenorrhea can be
primary or secondary
primary amenorrhea is defined as
no periods by age 16 and normal secondary characteristics
- or 14 years in abscence of other evidence of puberty
secondary amenorrhea is defined as
as the cessation of regular menses for three months or the cessation of irregular menses for six months.
causes of amenorrhea overview
- Overlap of presentation of primary and secondary is because secondary causes may present as primary if they happen early enough
causes of primary amenorrhea in those with normal secondary characteristics
-
Anatomical cause- Genitourinary malformations
- Imperforate hymen
- A vaginal septum
- Absent vagina
- Absent uterus
-
Imperforate hymen
*
- Congenital disorder where a hymen without an opening completely obstruct the vagina
- Caused by failure of the hymen to perforate during fetal development
- Most often diagnosed in adolescent girls when menstrual blood accumulates in vagina or uterus
- A vaginal septum
- Can be longitudinal or transverse
- Loss of outflow tract
causes of primary amenorrhea in those without normal secondary characteristics
-
Underling chromosomal or hormonal cause
- E.g. Turners syndrome
- Hypothalamic-pituitary dysfunction
- Complete androgen insensitivity disorder
- Disease in the hypothalamus
turners syndrome
- 45XO (female missing a whole/partial X chromosome)
- 1:2500
- Cause incomplete development of the ovary
- Only stroma present at birth= streak ovaries/gonads
- Lab values
- Low oestrogen
- High FSH and LH
- No oestrogen= no pubertal changes
-
Complete androgen insensitivity disorder
*
- X linked recessive
- Resistant to testosterone due to a defect in androgen receptor
- 46XY but normal female phenotype (external)
- actually a boy in a females body
- Testes may be palpable in the labia or inguinal area
- Absence of the upper vagina, uterus and fallopian tubes
- Testes should be surgically excised after puberty
-
Disease in the hypothalamus
-
Isolated GnRH deficiency
*
-
Isolated GnRH deficiency
- Idiopathic hyopgonadotrophic hypogonadism
- Autosomal dominant or X-linked autosomal recessive
- Poor development of secondary sexual characteristic
- With anosmia (smell blindness)= kallman syndrome
clinical checklisrt for primary amenorrhea
causes of secondary emnorrhea
- anatomical causes
- scarring
- ovarian disorders
- PCOS
- thyroid disease
- hyperprolactinemia
- pituitary necrosis
- functional hypothalamic amenorrhea
-
Scarring
*
- Cervical stenosis
- Asherman syndrome (intrauterine adhesions)
- Ovarian disorders
Primary ovarian insufficiency (POI)- “premature menopause”
- Depletion of oocytes before age of 40
No oestrogen, no inhibin= high FSH (loss of negative feedback)
-
Polycystic ovarian syndrome (PCOS)
*
- 20% of amenorrhea (up to 50% of oligomenorrhea)
- Elevated LH
- Raised insulin resistance
- May be asymptomatic
- Polycystic ovaries on ultrasound
- Multiple small follicles
- Treatment (Rx)
- Lifestyle changes
- COCP- change in contraceptive pill
PCOS Triad=
menstrual irregularity + androgen excess + obesity
- Thyroid disease
- Menstrual abnormalities common in both hyper and hypothyroidism
- Severe hyperthyroidism classically associated
- May be proceeded by oligomenorrhea
- Complex interplay between thyroid hormones and HPG axis
-
Hyperprolactinemia
*
- Raised prolactin levels (>800)
- Anterior pituitary hormone has its principles physiological action in initiation and maintenance of lactation
- High prolactin levels interfere with normal production of other hormones , such as oestrogen and progesterone
- Can cause change or stop ovulation and also lead to irregular or missed periods
causes of hyperprlactinemia
- Pituitary tumours (prolactinomas)
- CT head- enhancing pituitary macroadenoma
- Hypothyroidisms
- Medicines given for depression, psychosis and high blood pressure
pituitary necrosis
Sheehan syndrome
Sheehan’s syndrome is a condition that affects women who lose a life-threatening amount of blood in childbirth or who have severe low blood pressure during or after childbirth, which can deprive the body of oxygen. This lack of oxygen that causes damage to the pituitary gland is known as Sheehan’s syndrom
- Functional hypothalamic amenorrhea
*
- Weight loss and excessive exercise
- Emotional stress and induced by illness
- E.g. gymnasts and atheletes
- Risk of bone loss due to hypoestogenmia
dont forget phsyiological amenorrhea
- Pregnancy
- Menopause
- Towards end of women’s repro timespan periods may become irregular before stopping completely
- Still possible to get pregnant in transition
menorrhoea
- Refers to abnormal uterine bleeding outside of parameters noted below
- duration greater than 8 days
- glow greater than 80mL/cycle or subjective impression of heavier-than-normal flow
- occurs more frequently than every 24 days or less frequently than 38 days
- intermenstrual bleeding or postcoital spotting
- absences of menses
acute abnormal uterine bleeding
episodes of heavy bleeding that is of sufficient quantity to require clinical intervention to stop further blood loss
chronic abnormal uterine bleeding
bleeding of abnormal volume, duration, regularity, or frequency that has been present or most of the previous 6 months
symptoms of abnormal uterine bleeding
Types of symptoms
- Heavy
- Irregular
- Infrequently
- Frequent
- Shortened
- Postcoital
- Intermenstrual
underlying causes of abnormal uterine bleeding (menorrhoea)
Underlying causes (PALM- COEIN (FIGO)
- Structural
- Polyp
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy/hyperplasia
- Non-structural
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial
- Iatrogenic
- Not yet classified (DUB)
Abnormal uterine bleeding: Fibroids
- Most common cause
- Benign tumour of uterine smooth muscle= leiomyoma
- Oestrogen dependent
- 40% prevalence
- Complications of fibroids
- Heavy Menstrual Bleeding (HMB) and Intermenstrual bleeding (IMB)
- Subfertility and recurrent pregnancy loss
- Bulk pressure effects
- Heavy Menstrual Bleeding (HMB) and Intermenstrual bleeding (IMB)
rare complication of fibroids
Rare malignant change to leiomyosarcoma 1 in 350
Mostly asymptomatic
Dysfunctional uterine bleeding (DUB) is a type of
Abnormal uterine bleeding
Dysfunctional uterine bleeding (DUB) is the
most common cause of menorrhagia
causes of Dysfunctional uterine bleeding (DUB)
- No apparent local or systemic causes of menorrhagia
- Altered endometrial prostaglandin metabolism seems to play important role in aetiology of DUB
- Prostaglandin inhibitors decrease menstrual blood loss in women with DUB
- Bleeding of endometrial origin
DUB diagnosis is a
diagnosis of exclusion
- PALM-COEIN – “N”- not yet classified
- common at the extremes of repro life
DUB can be subdivided
- Anovulatory
- Inadequate signal
- Impaired positive feedback i.e. adolescence
- Ovulatory DUB- idiopathic
- Secondary to increased prostaglandins and reduced endothelin (vasoconstrictors)
- Genetic?
dysmenorrhoea
- Painful menstruation: crampy and intermittently intense, or continuous dull ache
- 45-95% of women of repro age
- Presentation of dysmenorrhoea
- 1-2 days before or with onset of menses
- Improves 12-72 h
- Lower abdomen and suprapubic area
types of dysmenorrhoea
Dysmenorrhea management
- NSAIDS
- Hormonal contraceptives
- COCP
- Intrauterine device
- GnRH analogues- drives down process
- Surgery
- Adhesiolysis
- Treatment to endometriosis
- Hysterectomy (final option)
- Heat, ginger, acupuncture, TENS
Dysmenorrhea- Endometriosis
- Endometrial glands and stroma that occur outside uterine cavity
- 5-10% prevalence
- Risk factors of endometriosis
- Nulliparity (a woman has never given birth to a child, or has never carried a pregnancy)
- Early menarche
- Short cycles
- Heavy bleeding
- Low BMI
cause of endometriosis
-
Cause
- Not really sure
- Oestrogen dependent, benign inflammatory disease
endometriosis repsonds to
- Responds to cyclical hormonal changes
symptoms and signs of endometriosis
- Can cause dysmenorrhea, dyspareunia (recurring pain in genital area), chronic pain and infertility
endometriosis has a multifactorial pathogenis- could be
retrograde menstruation
Most common sites of endometriosis
Adenomyosis: endometrial tissue found deep within myometrium
- Ovaries
- Endometrioma= chocolate cycst
- Bladder
- Rectum
- Peritoneal lining and pelvic side walls
ALWAYS
RULE OUT PREGNANCY
