Menstrual Disorders Flashcards
What is primary amenorrhoea?
Failure to commence menses (absence of menarche):
Girls aged 16+, in the presence of secondary sexual characteristics such as pubic hair growth and breast development
Girls aged 14+, in the absence of secondary sexual characteristics
What is secondary amenorrhoea?
Cessation of periods for more than six months after the menarche (after excluding pregnancy)
What can the causes of primary amenorrhoea be divided into?
Hypothalamic - low GnRH Pituitary Ovarian Genital tract Other
What are the hypothalamic causes of amenorrhoea?
Functional disorders e.g. eating disorders or exercise, suppress GnRH = low oestradiol via ghrelin and leptin
Severe chronic conditions
Kallmann syndrome
What is Kallmann syndrome?
Genetic condition X linked recessive Failure of migration of GnRH cells Leads to hypogonadotrophic hypogonadism Failure to start puberty Absent or reduced sense of smell (anosmia)
What pituitary issues can lead to amenorrhoea?
Prolactinomas - secrete high levels of PL, inhibiting GnRH so no LH and FSH
Other pituitary tumours e.g. acromegaly or cushings, leads to mass effect
Sheehan’s - post partum pituitary necrosis following massive obstetric haemorrhage
Destruction of pituitary gland e.g. radiation, autoimmune
Post contraception can cause irregularities
What ovarian issues can cause amenorrhoea?
PCOS - causes high androgen levels
Turner’s 45 XO
Premature ovarian failure
What are adrenal causes of amenorrhoea?
Congenital adrenal hyperplasia
Androgen insensitivity syndrome - tissues unable to respond to androgen hormones e.g. testosterone
female phenotype
What is congenital adrenal hyperplasia?
Congenital deficiency of 21-hydroxylase enzyme leading to underproduction of cortisol and aldosterone, and overproduction of androgens
Autosomal recessive
Women present - early development of pubic hair, irregular or absent periods
Hirsutism and acne
What are the causes of primary amenorrhoea?
Abnormal functioning of hypothalamus or pituitary
Abnormal functioning of the gonads
Genital tract abnormalities
What genital tract abnormalities can cause amenorrhoea?
Ashermann’s - secondary to instrumentation causes adhesions
Imperforate hymen
Transverse vaginal septum
Mayer Rokitansky Kuster Hauser syndrome - agenesis of Mullerian duct system, congenital absence of uterus and upper two thirds of vagina
What is oligomenorrhoea?
Infrequent
Occurring at intervals greater than 35 days
But less than 6 months in length
What are some of the causes of oligomenorrhoea?
pcos contraception hormonal treatments perimenopause thyroid disease diabetes eating disorders excessive exercise medications e.g. anti-psychotics, anti-epileptics prolactinomas Prader-Willi
What are the investigations for primary amenorrhoea?
Focused. detailed history: when periods began, cycle length, development of secondary sexual characteristics, associated symptoms, past MH, SH, DH
FBC and ferritin - anaemia
U&Es - CKD
Anti TTG or anti EMA coeliac
FSH and LH - low in hypogonadotrophic hypogonadism, high in hypergonadotrophic hypogonadism
TFTs
Insulin like GF I screening for GH deficiency
Prolactin levels - PL raised in hyperprolactinaemia
Testosterone raised in PCOS, androgen insensitivity syndrome and congenital adrenal hyperplasia
Karyotyping if suspect genetic abnormality
Progesterone challenge test to elicit withdrawal bleed or measure serum oestradiol levels
Imaging
XRay of wrist assess bone age; constitutional delay
Pelvic USS
MRI of brain to look for pituitary pathology and assess olfactory bulbs for Kallmans
What is the progesterone challenge test?
Progesterone IM given or provera
If any bleeding more than light spotting occurs after progestin given - withdrawal bleed
Test demonstrates she has built up lining in uterus which is causing the bleed
Therefore oestradiol levels present, demonstrates lack of ovulation causing no periods
If no withdrawal bleed, either very low oestrogen or problem with outflow tract - genital abnormalities
What is the management of primary amenorrhoea?
Establish and treat underlying cause
If needed, replacement hormones
Constitutional delay - reassurance and observation
Reduce stress, CBT, healthy weight gain if due to diet, exercise etc
Optimise treatment for chronic condition e.g. thyroid
Hypogonadotrophic hypogonadism e.g. hypopituitarism or Kallman’s use of pulsatile GnRH or replacement sex hormones using COCP
Ovarian causes - use of COCP
Clomifene stimulates ovulation as a means to treat infertility
Metformin for PCOS to induce ovulation
IVF last resort
Surgery for pituitary tumours, genital tract abnormalities
Refer girls with no sexual characteristics or menstruation at 13, or if have some but no menstruation - 15.
Refer if growth retardation, galactorrhoea, genital tract malformation.
What is hypogonadotrophic hypogonadism?
Due to problems with the hypothalamus or pituitary
Deficiency in release of GnRH = hypothalamic
Deficiency in release of gonadotropins from anterior pituitary = pituitary
GnRH to hypophyseal portal system to gonadotropins in AP to LH and FSH on gonads.
Can be congenital or acquired.
What is hypergonadotropic hypogonadism?
Primary hypogonadism
Impaired response of gonads to gonadotropins FSH and LH
Due to chromosomal abnormalities e.g. Turner’s, Klinefelter’s, resistence
What is Klinefelter’s?
47 XXY
Male has additional X
Infertile, small poorly functioning testicles
Less facial, body hair
Broader hips
Breast tissue
What are the causes of secondary amenorrhoea?
Pregnancy Menopause Premature ovarian failure Hormonal contraception Hypothalamic or pituitary pathology PCOS Asherman's Thyroid pathology Hyperprolactinaemia
What are hypothalamic causes of secondary amenorrhoea?
hypothalamus reduces GnRH production, leads to hypogonadotrophic hypogonadism, amenorrhoea
Excessive exercise Low body weight EDs Chronic disease Psychological stress
What are the pituitary causes of secondary amenorrhoea?
Pituitary tumours e.g. prolactin secreting prolactinoma
Pituitary failure
Trauma, radiotherapy, surgery or Sheehan syndrome
What are the investigations for secondary amenorrhoea?
History and examination
Exclude physiological causes; pregnancy, menopause, lactation
Ask about contraceptives, hot flushes and vaginal dryness, headaches, acne, hirsutism, stress, symptoms of thyroid disease, any obstetric procedures
Examine for features of cushing’s, thyroid disease, excess androgens (hirsutism, acne, deep voice, clitoromegaly) visual fields
Hormonal blood tests
USS pelvis for PCOS
What hormonal tests are available for secondary amenorrhoea?
Beta HCG - pregnancy
LH and FSH:
High FSH primary ovarian failure
High LH or LH:FSH PCOS
PL - hyperprolactinaemia
MRI for pituitary tumour
Causes of raised PL - pituitary adenoma, hypothyroidism drugs e.g. SSRIs, antiemetics
Pregnancy, breast feeding, needle phobia, PCOS, renal impairment
High TSH, low T3/4 hypo
Low TSH, high - hyperthyroid
Raised testosterone in PCOS, androgen insensitivity, congenital adrenal hyperplasia
Why are those with amenorrhoea at risk of osteoporosis?
Low levels of oestrogen
Where amenorrhoea lasts more than 12 months:
Adequate Vit D and calcium
HRT or COCP
What are the causes of high FSH in primary amenorrhoea?
46 XX premature menopause, primary ovarian failure
45 XO Turner’s
What are the causes of low FSH in primary amenorrhoea?
Constitutional delay ED Exercise induced Stress induced Chronic illness
What are the causes of normal FSH in secondary amenorrhoea?
Do pelvic USS
PCOS
Uterine adhesions
What is PMS
Premenstrual syndrome
Occurs during luteal phase and resolve in menstruation
Not present before menarche, during pregnancy, after menopause.
What is the cause of PMS?
Fluctuation in oestrogen and progesterone
May be due to increased sensitivity to progesterone or interaction between sex hormones and serotonin, GABA.
What are the symptoms of PMS?
Low mood, anxiety, mood swings, irritability
Bloating, fatigue, headaches, breast pain
Reduced confidence, cognitive impairment, reduced libido
What is the management of PMS?
General healthy lifestyle Improve diet, exercise, alcohol, smoking, stress, sleep COCP SSRIs CBT
RCOG recommends COCPs containing drospirenone first line e.g. Yasmin
Continuous transdermal oestrogen patches can be used
GnRH analogues to induce menopausal state; but for severe cases, adverse effects e.g. osteoporosis.
Hysterectomy and bilateral oophorectomy if severe and medical management failed, HRT needed.
Danazole and tamoxifen for cyclical breast pain.
Spironolactone for physical symptoms e.g. breast swelling, water retention and bloating.
What is premenstrual dysphoric disorder?
A severe and disabling form of premenstrual syndrome
On average, the symptoms last six days but can start up to two weeks before menses, meaning symptoms can be felt for up to three weeks out of a cycle.
Pattern of mood symptoms (depressed mood, irritability), somatic symptoms (lethargy, joint pain, overeating), or cognitive symptoms (concentration difficulties, forgetfulness)
Treatment - SSRIs e.g. fluoxetine, CBT
If medical management ineffective; oophrectomy, hysterectomy and oestrogen patch to reduce symptoms from surgically caused menopause.
What defines HMB?
More than 80ml blood lost
e.g. changing pads every 1-2 hrs, bleeding lasting more than 7 days, passing large clots.
What are the causes of HMB?
Dysfunctional uterine bleeding (no identifiable cause) Extremes of reproductive age Fibroids, endometriosis, adenomyosis PID (infection) Contraceptives, particularly copper coil Anticoagulant medications Bleeding disorders e.g. VWD Endocrine disorders; diabetes, hypothyroidism Connective tissue disorders Endometrial hyperplasia or cancer PCOS
What should be asked in the history for HMB?
Age at menarche
Cycle length, days menstruating, variation
Intermenstrual bleeding, post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy, plans for future pregnancies
Cervical screening history, any treatment
Migraines with or without aura - for the pill
PMH and PDH
Social history, family history
What are the investigations for HMB?
Pelvic examination with speculum and bimanual
Unless straightforward history, or young and not sexually active
FBC check for iron deficiency anaemia
Outpatient hysteroscopy if
suspected submucosal fibroids, suspected endometrial pathology e.g. endometrial hyperplasia or cancer, or persistent intermenstrual bleeding
Pelvic and transvaginal USS if
large fibroids, possible adenomyosis - associated pelvic pain or tenderness on exam, exam hard to interpret e.g. obese, hysteroscopy declined
Swabs if evidence of infection; abnormal discharge or sexual history suggestive
Coagulation screen; history of clotting disorders, VWD, periods heavy since menarche
Ferritin if clinically anaemic
Thyroid function tests if additional features of hypothyroidism
What is the management of heavy menstrual bleeding?
Exclude any underlying pathology, if identified then manage.
Could be due to copper coil, so remove coil.
If does not want contraception, tranexamic acid if no associated pain
Mefenamic acid if there is associated pain
If want contraception - mirena coil first line (IUS)
COCP
Cyclical oral progestogens e.g. norethisterone 5mg 3x daily
POP or depo injection can be tried as suppresses
Referral to specialist if treatment unsuccessful, symptoms are severe or large fibroids present
If medical management failed
Endometrial ablation e.g. balloon thermal ablation
Hysterectomy
How does tranexamic acid work?
Antifibrinolytic so reduces bleeding
Inhibits plasminogen activation
Low incidence of thrombotic disorders
How does mefenamic acid work?
NSAID so reduces bleeding and pain
What is the best way to define HMB?
Impact on QOL plus anaemia Impact on work and social life Bleeding through clothing Bed soiling Disrupted sleep due to heavy bleeding
Any symptoms of anaemia
Who are low risk vs high risk patients with HMB?
Low risk - <45, no IMB, no risk factors for endometrial cancer, will have history, exam and FBC with first line treatment
High risk - >45, IMB, suspected pathology, risk factors for endometrial cancer
Will have history, exam, FBC, USS, hysteroscopy and biopsy, first line treatment.
What medical management is available if fibroids are diagnosed?
GnRH analogues
Esmya - ullipristal acetate
What is the surgical management if polyps are diagnosed?
Myosure
Hysteroscopic removal of polyps
What is the surgical management if fibroids are diagnosed?
Myomectomy for fibroids
Uterine artery embolisation
What short term emergency control of HMB is available?
Norethisterone: 5mg po tds for up to 7 days. Can be used in a 3-weeks-on, 1-week-off pattern for 3-4 months to temporise, for example where patient is on waiting list for treatment.
GnRH analogues: Monthly (or quarterly, depending on preparation) injection to downregulate the cycle and induce temporary ‘medical menopause’. Often used to stop very heavy periods in the presence of fibroids, to allow for correction of anaemia and iron stores in preparation for another intervention.
What are the side effects of tranexamic acid?
nausea, dizziness, tinnitus, rash, abdominal cramps
What are the key causes of intermenstrual bleeding?
Hormonal contraception Cervical ectropion, polyps or cancer Sexually transmitted infection Endometrial polyps or cancer Vaginal pathology, including cancers Pregnancy Ovulation can cause spotting Medications e.g. SSRIs and anticoagulants
What are the causes of dysmenorrhoea?
Primary dysmenorrhoea - no underlying pathology Endometriosis or adenomyosis Fibroids Pelvic inflammatory disease Copper coil Cervical or ovarian cancer
What are the causes of post-coital bleeding?
Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer
What are the causes of pelvic pain?
UTI Dysmenorrhoea IBS Ovarian cysts Endometriosis Pelvic inflammatory disease Ectopic pregnancy Appendicitis Mittelschmerz Pelvic adhesions Ovarian torsion IBD
What are the causes of vaginal discharge which is abnormal?
Bacterial vaginosis Candidiasis Chlamydia Gonorrhoea Trichomonas vaginalis Foreign body Cervical ectropion Polyps Malignancy Pregnancy Ovulation - cyclical Hormonal contraception
What are the causes of pruritus vulvae?
Itching of the vulva and vagina
Irritants e.g. soaps, detergents, barrier contraception
Atrophic vaginitis
Infections e.g. candidiasis and pubic lice
Skin conditions e.g. eczema
Vulval malignancy
Pregnancy related vaginal discharge
Urinary incontinence or faecal incontinence
Stress
What are the types of dysmenorrhoea?
Primary is menstrual pain occurring with no underlying pelvic pain pathology.
Secondary is pain that occurs with associated pelvic pathology.
What is the pathology of primary dysmenorrhoea?
No fertilisation - corpus luteum regresses, so decline in oestrogen and progesterone.
Endometrial cells sensitive to decline in progesterone and release PGs.
PGs in uterus cause spiral artery vasospasm leading to ischaemic necrosis, and shedding of superficial layer.
Increased myometrial contractions.
So due to excessive release of prostaglandins.
What are the risk factors for primary dysmenorrhoea?
Early menarche Long menstrual phase Heavy periods Smoking Nullparity
What are the clinical features of dysmenorrhoea?
Lower abdominal pain
Pelvic pain, can radiate to lower back or anterior thigh
Pain is crampy, 48-72 hours
Malaise, nausea, vomiting, diarrhoea
Examinations pelvic and speculum usually unremarkable, uterine tenderness present
What are the differentials of secondary dysmenorrhoea?
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Adhesions
Non gynaecological e.g. IBD, IBS
What are the investigations for dysmenorrhoea?
Work up on ruling out pathology
If at risk of STI - high vaginal swab and endocervical swab
If mass palpated, transvaginal US
What is the management of dysmenorrhoea?
Symptomatic improvement
Lifestyle changes; stop smoking
Pharmacological; analgesia with NSAIDs first line, 3-6 month trial of hormonal contraception like COCP or Mirena.
Non-pharmacological
Heat, water bottles, TENS
What are fibroids?
Uterine leiomyoma
Smooth muscle of the uterus
Oestrogen sensitive so they grow in response to oestrogen
What are the types of fibroids?
Intramural within myometrium (muscle of uterus) and distort uterus as they grow.
Subserosal are just below layer of uterus, grow outwards and fill abdominal cavity.
Submucosal below lining of utetus - endometrium.
Pendunculated - on a stalk.
What is the presentation of fibroids?
Often asymptomatic Heavy bleeding Prolonged bleeding more than 7 days Abdominal pain worse in menses Bloating Urinary or bowel symptoms due to pelvic pressure or fullness Deep dyspareunia Reduced fertility
Abdominal and bimanual examination may reveal palpable pelvic mass or enlarged firm non tender uterus.
What are the investigations of fibroids?
Hysteroscopy for submucosal fibroids with HMB.
Pelvic USS for larger fibroids.
MRI scanning before surgical options if need more info on size, shape, blood supply.
Bloods usually reserved for patients where diagnosis is unclear or as pre-operative work up if surgery needed.
What is the management of fibroids?
For those less than 3cm - medical management same as HMB.
Mirena coil first lime - must be less than 3cm and no distortion
Symptomatic management with NSAIDs and tranexamic acid
COCP
Cyclical oral progestogens
GnRH analogues can be used to reduce size prior to surgery e.g. Zolidex
What surgical management is available for smaller fibroids?
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
What management is available for fibroids greater than 3cm?
Referral to gynaecology Symptomatic management with NSAIDs and tranexamic acid Mirena coil COCP Cyclical oral progestogens
What surgical management is available for larger fibroids?
Uterine artery embolisation
Myomectomy
Hysterectomy
How do GnRH analogues work?
Agonists - prolonged activation of GnRH receptors leads to desensitisation and suppressed gonadotropin secretion.
Can induce menopause like state, reduce amount of oestrogen maintaining fibroids,
For fibroids, used short term to shrink before myomectomy.
Also used in endometriosis, menorrhagia, cancer, endometrial hyperplasia.
Can be used for 6 months only, due to risk of osteoporosis.
What are the complications of fibroids?
Heavy menstrual bleeding, iron deficiency anaemia
Reduced fertility
Pregnancy complications e.g. miscarriages, premature labour, obstructive delivery
Constipation
Urinary outflow obstruction
Urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid - usually pedunculated
Malignant change to leiomyosarcoma
What is red degeneration of fibroids?
Ischaemia, infarction, necrosis of fibroid
Due to disrupted blood supply
More likely in larger fibroids above 5cm, during 2nd and 3rd trimester.
Also if fibroid rapidly enlarges during pregnancy and outgrowing blood supply.
Due to kinking in blood vessels as uterus changes shape and expands in pregnancy.
How does red degeneration of fibroids present?
Severe abdominal pain
Low grade fever
Tachycardia
Vomiting
Look out for pregnant women with history of fibroids, with severe abdominal pain and low grade fever.
What is the management of red degeneration of fibroids?
Supportive; fluids, rest and analgesia.
What are the risk factors of fibroids?
Obesity Early menarche Increasing age Family history - women with first degree affected carry 2.5x increased risk Ethnicity - African Americans 3x more
