Menstrual Abnormalities Flashcards
What is the definition of menorrhagia?
Heavy menstrual bleeding which interferes with woman’s QoL
What are the main causes of menorrhagia?
- Dysfunctional uterine bleeding = most common
- Local causes: tumour, PID, endometriosis
- Systemic causes: thyroid disease, von Willebrand, immune thrombocytopenia
What is dysfunctional uterine bleeding?
Diagnosed when there is heavy/ irregular bleeding in the absence of obvious pathology
Usually caused by hormonal changes that cause alternating periods of heavy and light bleeding, with unpredictably short/ long cycles
Presentation of menorrhagia…
- Heavy, prolonged bleeding
- Mainly occurs at extremities of reproductive life
- Dsymenorrhoea (pain during menstruation)
- Pallor due to anaemia
- Inter-menstrual and post-coital bleeding
- Sx of clotting disorders e.g. bruising, bleeding gums
Investigations for menorrhagia
- Examination - abdominal and bimanual: feeling for enlarged uterus, obvious masses
- Speculum to identify site of bleeding
- Bloods: FBC, TFT, clotting profile
- Imaging: transvaginal USS
If imaging identifies pathology…
- Endometrial biopsy
- Cervical smear test
Treatment of menorrhagia…
Conservative:
- Weight loss - can be a risk factor for bleeding
Medical:
- Non-hormonal (does not require contraception):
- Tranexamic acid 1g PO 6-8h
- Mefenamic acid (NSAID) 500mh PO 8h
- Hormonal (require contraception):
- 1st line = Mirena (levornogestrel) 500mg PO 8h
- 2nd line = Combined oral contraceptive
- 3rd line = Injectable progesterone (depo provera)
Surgical:
- Endometrial ablation - appropriate for DUB
- Hysterectomy for intrauterine bleeding
- Fibroids = myomectomy or uterine artery ablation
Briefly describe the stages of the menstrual cycle…
Follicular phase:
- Pulsatile GnRH release leads to stimulation of anterior pituitary causing release of LH and FSH
- FSH stimulates the maturation of follicles in the ovaries
- Secondary follicles contain theca cells that produce testosterone which is aromatised by aromatase from the granulosa cells to oestrogen
- Rising oestrogen levels leads to negative feedback on the anterior pituitary therfore decreasing LH and FSH release
* *Oestrogen also causes endometrium to thicken and cervical mucus to thin in the proliferative phase - Low FSH causes competition amongst follicles leading to one dominant follicle
- Dominant follicle continues to secrete more oestrogen which eventually surpasses the threshold level causing the anterior pituitary to become more responsive to GnRH pulses leading to an LH surge
- LH surge leads to ovulation around 36 hours later - occurs 14 days before end of the cycle
Luteal phase:
- When the oocyte has been released from the follicle, the follicle then undergoes luteinisation (due to high LH levels) which forms the corpus luteum
- Corpus luteum begins to release progesterone and oestrogen (progesterone>oestrogen)
- Progesterone secretion causes secretory changes to endometrium and moderate oestrogen levels has negative feedback on the anterior pituitary causing low LH and FSH levels
FERTILISATION OCCURS…
- Fertilised gamete will release B-HCG which maintains the corpus luteum
- Corpus luteum returns to the ovaries and continues to secrete oestrogen and progesterone until the placenta is able to take over
FERTILISATION DOES NOT OCCUR…
- If by day 12 there is no fertilisation - no B-HCG is produced to maintain the corpus luteum
- Corpus luteum degrades into corpus albicans which does not produce hormones
- Therefore lack of progesterone and oestrogen release leads to menstrual phase as spiral arteries collapse leading to ischaemia and shedding of the functional layer of the endometrium
- Fibrinolysis occurs leading to degradation of fibrinogen so clotting cascade is inhibited leading to bleeding during menses
What is the definition of primary amenorrhoea?
Menarche does not occur before age of 16 i.e. female who has never had a period
What are the causes of primary amenorrhoea?
- Constitutional delay: occurs in the family, and tends to be a benign problem which has no real implications
- Isolated delayed menarche with normal secondary sexual characteristics suggests anatomical problem:
- Imperforate hymen may lead to haematocolpos (pooling of menstrual blood in vagina due to obstruction)
- Vaginal agenesis
- Delayed menarche with lack of secondary sexual characteristics suggests a hormonal cause:
- Low gonadotrophin secretion (central): hypothalamic failure from over exercise/ low weight, panhypopituitarism ,intracranial tumour
- High gonadotrophin secretion (peripheral): Turner syndrome, congenital adrenal hyperplasia, accquired gonadal damage
What is the definition of secondary amenorrhoea?
Absence of menstruation for 6 months
What are the causes of secondary amenorrhoea?
- Hypothalamic failure due to physiological stress : excessive exercise, weight loss, chronic disease
- PCOS
- Hyperprolactinaemia (prolactin inhibits GnRH secretion)
- Premature ovarian failure - caused by: smoking, radiation, chemotherapy
- Thyrotoxicosis AND hypothyroidism
- Physiological = pregnancy, lactation, menopause
Investigations of amenorrhoea…
- Always exclude pregnancy in secondary amenorrhoea - urinary/ serum B-HCG
- Gonadotrophin levels: low = central hypothalamic cause, high = ovarian problem likely
- Prolactin levels
- Androgen levels - raised in PCOS
- Thyroid function tests - hypothyroidism can cause amenorrhoea
- Genetic testing in primary amenorrhoea
Treatment of amenorrhoea…
- Need to treat the underlying cause
- E.g. in primary amenorrhoea if there is a genetic syndrome - it cannot be cured but hormone therapy can relieve symptoms
- Thyroid problems can be managed with appropriate hormone therapy
Causes of post-coital bleeding…
- Infection e.g. STI - chlamidiya screen required
- Cervical ectropion
- Benign growths e.g. cervical/ endometrial polyps
- Malignancy- refer all with persistent bleeding
What is cervical ectropion?
Rising oestrogen levels cause columnar epithelium of cervical canal to extend to the outer surface of cervix opening (ectocervix) which exposes it to the acidic vaginal environment
How does cervical ectropion present…
- Discharge (due to secretions from columnar epithelium)
- Post-coital bleeding
What are the common risk factors for cervical ectropion?
Rise in oestrogen levels caused by:
- COC
- Pregnancy
- Puberty
How is cervical ectropion treated?
- Any patient on COC - discontinued
- If sx persist - can use diathermy - silver nitrate or cold coagulation to burn the columnar epithelium of ectocervix
Causes of intermenstrual bleeding…
Vaginal causes: - Vaginitis - Tumours Cervical causes: - Cervical ectropion - Polyps - Infection e.g. TV, chlamidiya - Malignancy Uterine causes: - Fibroids - Polyps - Endometritis - Adenomyosis - Malignancy
Difference between endometriosis and endometritis …
Endometritis = inflammation of the endometrial lining due to infection which can lead to bleeding
Endometriosis = where tissue similar to endometrial lining grows outside of the uterus, leading to pain
What is the mechanism behind anovular dysfunctional uterine bleeding?
Thought to be caused by failure of ovulation which leads to increased oestrogen secretion from unruptured follicle - causing endometrial hyperplasia.
Management of anovular dysfunctional uterine bleeding …
Give progesterones in the 2nd half of the cycle - norethisterone from day 5 to day 26
What is the mechanism behind ovular dysfunctional uterine bleeding?
Caused by failure of the spiral arterioles to constrict and prostaglandin dysfunction.
Management of ovular dysfunctional uterine bleeding …
Management similar to other causes of menorrhagia:
- If contraception is being used - COC or mirena coil
- If no contraception is needed - mefenamic acid (NSAID) or tranexamic acid (anti-fibrinolytic)
