Menstrual Disorder

Question 1

Define dysmenorrhoea

Answer 1

Painful periods

- crampy lower abdominal pain which starts with onset on menstruation

Question 2

Classification of dysmenorrhoea

Answer 2

Primary - occurring without any underlying pelvic pathology

Secondary - associated with pelvic pathology

Question 3

Pathophysiology of dysmenorrhoea

Answer 3

In absence of fertilisation of egg corpus luteum regresses and decline of oestrogen and progesterone
Endometrial cells release prostaglandin
- spiral artery vasospasm -> ischemic necrosis and shedding of superficial endometrium
- increased myometrial contractions
Thought to be due to excessive release of prostaglandins

Question 4

Risk factors for primary dysmenorrhoea

Answer 4

Early menarche
Long menstrual phase
Heavy periods
Smoking
Nulliparity

Question 5

Clinical features of primary dysmenorrhoea

Answer 5

Lower abdo/pelvic pain - radiate to lower back/thigh
Pain is crampy
Associated with malaise, nausea, vomiting, diarrhoea and dizziness

Question 6

Differential diagnosis of primary dynsemorrhoea

Answer 6

Secondary dysmenorrhoea
- endometriosis
- adenomyosis
- PID
- adhesions
IBD
IBS

Question 7

Investigations for primary dysmenorrhoea

Answer 7

Rule out underlying pathology

• high vaginal and endocervical swabs
• TV USS

Question 8

Management of primary dysmenorrhoea

Answer 8

Lifestyle
- stop smoking
Pharmacological
- analgesia
    - NSAIDs - ibuprofen, naproxen, mefenamic acid inhibit prostaglandins
    - paracetamol
- hormonal contraception 
    - monophasic COCP
    - IUS
Non-pharmacological
- local application of heat
- TENS - transcutaneous electrical nerve stimulation

Question 9

Define heavy menstrual bleeding

Answer 9

Excessive blood loss which interferes with a woman’s quality of life

Question 10

Causes of HMB

Answer 10

Structural
- polyp
- adenomyosis
- leiomyoma
- malignancy and hyperplasia
Non-structural 
- coagulopathy
- ovulatory dysfunction
- endometrial 
- iatrogenic
- not yet classified

Question 11

Risk factors for HMB

Answer 11

Age - more likely at menarche and approaching menopause

Obesity

Question 12

Clinical features of HMB

Answer 12

Bleeding deemed excessive
Fatigue
SOB - anaemia

Question 13

Differential diagnosis of HMB

Answer 13

Pregnancy - pregnancy test
Endometrial or cervical polyps - not usually associated with dysmenorrhoea
Adenomyosis - associated with dysmenorrhoea, bulking uterus on examination
Fibroids - pressure symptoms and bulking uterus
Malignancy or endometrial hyperplasia
Coagulopathy - HMB since menarche, bleeding gums, epistaxis
Ovarian dysfunction - PCOS and hypothyroidism
Iatrogenic - contraceptive hormones, copper IUD
Endometriosis

Question 14

Investigations for HMB

Answer 14

Blood tests
- FBC 
- TFT
- coagulation + Von Willebrand's
Imaging
- USS pelvis
Histology
- Cervical smear
- Pipelle endometrial biopsy
- Hysteroscopy and endometrial biopsy
Microbiology
- high vaginal and endocervical swabs for infection

Question 15

Management of HMB

Answer 15

Pharmacological
- Levonorgestral-releasing intrauterine system
- thins endometrium and shrink fibroids
- tranexamic acid
- taken during menses
- mefanamic acid
- NSAID so also analgesic
- only taken during menses
- COCP
- progesterone only - oral norethisterone, depo or implant
- take norethisterone on days 5-26 so not contraceptive
Surgical
- endometrial ablation
- suitable for those no longer wishing to conceive
- outpatient with local anaesthetic
- hysterectomy

Question 16

Define amenorrhoea

Answer 16

Absence of menstrual periods

Question 17

Categories of amenorrhoea

Answer 17

Primary - failure to commence menses
- girls 16+ in presence of secondary sexual characteristics - pubic hair growth and breast development
- girls 14+ without secondary sexual characteristics
Secondary - cessation of periods for more than 6 months after menarche

Question 18

Define oligomenorrhoea

Answer 18

Irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods a year

Question 19

Causes of amenorrheoa

Answer 19

Hypothalamic - reduced GnRH secretion
- functional - eating disorders, exercise
- severe chronic conditions - psychiatric, thyroid, sarcoidosis
- Kallmann syndrome - X-linked recessive disorder characterised by failure of migration of GnRH cells
Primary causes
- prolactinomas
- other pituitary tumours
- Sheehan’s syndrome - post-partum pituitary necrosis secondary to massive haemorrhage
- destruction of pituitary gland
- post-contraception amenorrhoea
Ovarian
- PCOS
- Tuners syndrome - 45XO
- premature ovarian failure
Adrenal gland
- late onset/mild congenital adrenal hyperplasia
Structural abnormalities
- Ashermann’s syndrome
- imperforate hymen

Question 20

Causes of oligomenorrhoea

Answer 20

PCOS
Contraceptive/hormonal treatments
Perimenopause
Thyroid disease
Diabetes
Eating disorders / excessive exercise
Medications - anti-psychotics, anti-epileptics

Question 21

Hormone levels in causes of amenorrhoea

Answer 21

Hypothalamic
- low GnRH
- normal FSH
- low/normal LH
- low LH:FSH ratio
- low oestrogen
Prolactinoma
- low GnRH
- high prolactin
PCOS
- normal FSH
- high LH
- high LH:FSH ratio
- normal or high testosterone
Premature ovarian failure
- high FSH
- high LH
- low oestrogen

Question 22

Managment of oligo/amenorrhoea

Answer 22

Regulate periods
- COCP, POP, IUS
Hormone replacement
- premature ovarian failure = cyclical hormonal replacement therapy with oestrogen
Symptom control
- excessive hair growth = COCP
- acne = antibiotics, benzoyl peroxide and topical retinoids
Treat underlying disorder
Improve fertility
- Clomifene - stimulates ovulation
- Metformin - PCOS to induce ovulation
Surgery