Menstrual disorders Flashcards
What is dysmenorrhoea?
Painful lower abdominal cramping which occurs before or during menstruation and affects QoL.
There are two types:
- Primary = absence of underlying pelvic pathology, occurs in young females. All secondary causes must be excluded.
- Secondary = underlying pelvic pathology e,.g. endometriosis, fibroids, PID, IUD insertion.
Causes of secondary dysmenorrohea
- Endometriosis/adenomyosis = cyclic pain + prior menses
- Fibroids = menorrohage + mass
- PID
- Ovarian Ca
- Cervical Ca
- IUD insertion, usually 3-6m after insertion
Investigations for dysmenorrhoea
- abdo ex
- pelvic ex +/- speculum
- pregnancy test
- HVS + ECS
- cervical smear if due
- USS
Dx criteria for primary dysmenorrhoea (6)
Primary dx is likely if:
1. Pain starts 6-12m after menarche, once cycles are regular.
2. Crampy lower abdo pain may radiate.
3. Pain starts before menstruation and lasts <72hrs, improves as menses progresses.
4. Non-gynae syx: N+V, diarrhoea, fatigue, irritability, dizziness, bloating, headache, lower back pain, emotional syx, are present.
5. Other gynae syx are NOT present.
6. Pelvic ex is normal.
Dx for secondary dysmenorrhoea (4)
- Pain starts after several years of painless periods.
- Pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout + exacerbated by menstruation.
- Other syx present:
- Gynae Syx = dyspareunia, PV discharge, menorrhagia, IMB, PCB
- Non-Gynae Syx = rectal pain, bleeding etc - Abnormal pelvic although absence of findings does not exclude dx.
Management of primary + secondary dysmenorrhoea
Primary
(1.) Non-pharm: heat pack, TENS
(2.) simple analgesia
(3.) mefenamic acid (NSAID)
(4.) Mirena. Note: Copper IUD not used as can cause heavier and painful periods
- Refer if syx are severe and not responded to Rx for 3-6m.
Secondary
(1.) manage depending on underlying cause
(2.) 2ww if ascites, pelvic or abdo mass OR abnormal cervix o/e OR persistent OMB, PCB with no features of infection/PID OR USS suggestive of cancer
What is Premenstrual Syndrome (PMS)? Presentation?
(1.) PMS refers to distressing psychological, emotional and physical syx that occurs prior to menstruation (luteal phase of menstrual cycle i.e. straight after ovulation).
- Syx can impact QoL
- Syx resolve once menstruation begins
- Syx not present before menarche, during pregnancy or after menopause.
(2.) When features are severe + significant effect on QoL = premenstrual dysphoric disorder.
Presentation can vary within individuals
(1.) psychological syx: Low mood, Anxiety, Mood swings, Irritability, loss of libido
(2.) physical syx: breast tenderness, bloating, clumsiness, headache
Dx of PMS
(1.) Syx Diary
- Spans two menstrual cycles.
- Demonstrates cyclical syx that occur before, and resolve after, onset of menstruation
(2.) GnRH analogue initiated by specialist:
- this halts menstrual cycle and temporarily induce menopause, to see if the syx resolve.
- this confirms dx
Management of PMS
(1.) Healthy lifestyle, exercise, diet, smoking cessation, sleep, stress etc.
(2.) Analgesia
(3.) COCP with no pill free interval - this suppresses ovulation + syx. For moderate PMS.
(4.) SSRI non-stop or during luteal phase e.g. day 15-28. For severe PMS.
(5.) Consider CBT
(6.) Hysterectomy + oophorectomy - pt must not want children
What is primary amenorrhoea?
Defined as not starting menstruation:
- By 13y when there is no other evidence of pubertal development
- By 15y where there are other signs of puberty, such as breast bud development
Puberty starts age 8-14 in girls. In girls, puberty starts with the development of breast buds, then pubic hair, and finally menstrual periods about two years from the start of puberty.
Causes of Primary Amenorrhoea
Normal secondary sexual characteristics present
- structural pathology e.g. imperforated hymen, absent uterus, vaginal agenesis, female genital mutilation
No secondary sexual characteristics
- turner’s - ovaries fail to develop
- kallman syndrome (delayed puberty + loss of smell)
- hypothalamic-pituitary dysfunction - e.g. stress, wt loss, and/or excessive exercise
Investigations of Primary Amenorrhoea
(1.) Assess evidence of puberty
(2.) Bloods
- baseline
- hormonal: FSH, LH, IGF1, prolactin, testosterone
(3.) Genetic testing for Turner’s
(4.) Imaging
Management of Primary Amenorrhoea
(1.) Replacement hormones - induce menstruation
- e.g. pulsatile GnRH in hypogonadotrophic hypogonadism (hypopituitarism or Kallman syndrome) to induce ovulation
- e.g. COCP in ovarian cause such as PCOS, absent ovaries
(2.) Manage stress, heathy weight gain if this is the cause
What is secondary amenorrhoea?
Defined as no menstruation for >3m after previous regular menstrual periods.
Causes of secondary amenorrhoea? (4Ps)
4P’s = Pregnancy, PCOS, prolactinoma, premature ovarian insufficiency
Gynae
- Pregnancy (most common)
- Menopause + premature ovarian failure
- Hormonal contraception
- Ovarian causes e.g. PCOS
- Uterine pathology e.g. Asherman’s syndrome
Non-gynae
- hypopituitarism or pituitary pathology
- Thyroid pathology
- Hyperprolactinaemia
Investigations for secondary amenorrhoea
(1.) Pelvic ex + speculum
(2.) Pregnancy test
(3.) Bloods: FSH, LH, testosterone, prolactin, TFT
- FSH, LH: primary ovarian failure (hi FSH), PCOS (hi LH), hypothalamic/pituitary problem (lo)
- Testosterone -> PCOS (hi), androgen tumour
- Prolactin, MRI if tumour suspected
- TSH -> hypo or hyperthyroidism
(4.) USS
Management for secondary amenorrhoea
(1.) Establish Cause (PCOS, hypothyroidism, menopause, preg, wt loss, excessive exercise etc)
- gynae referral if premature ovarian insufficiency, asheman’s syndrome suspected
- endo referral if hyperprolactinoma, hi testerone not due to PCOS
(2.) Manage osteoporosis risk if amenorrhoea for >12m:
- Vit D, Ca, HRT or COCP
What is Polycystic ovarian syndrome? Complications? Presentation?
- Metabolic and reproductive condition.
- Complications: T2DM, CVD, infertility, endometrial ca, OSA, anxiety + depression
Clinical features include:
- Oligomenorrhoea or amenorrhoea
- Infertility
- Obesity
- Hirsutism
- Acne
Dx of Polycystic ovarian syndrome
Rotterdam Criteria - used for making a Dx, requires at least two of three key features:
1. Oligoovulation/anovulation - irregular or absent menstrual periods
2. Hyperandrogenism - hirsutism and acne
3. Polycystic ovaries on USS (>12 cysts per ovary)
Investigations of Polycystic ovarian syndrome
(1.) Bloods:
- raised LH
- raised testosterone
- normal/raised oestrogen
- normal or low sex hormone-binding globulin (SHBG)
- raised insulin
- prolactin
- TSH
(2.) Calculate free androgen index (using SHBG + testosterone)
(3.) TV USS
- Follicles arranged around periphery of ovary - “string of pearls”
- Dx criteria either: 12 or more developing follicle in one ovary OR Ovarian volume >10cm
(4.) OGTT - screening for DM
Management of Polycystic ovarian syndrome
(1.) Mx DM/obesity/CVD risk= wt loss, diet, exercise, smoking cessation, stain if QRISK >10%
(2.) Ameno/oligmenorrhoea = cyclic progesterones or low dose COCP
(3.) TVUS: if ET >7-10mm -> refer
Managing infertility
(1.) Wt loss
(2.) Refer for clomifene (1st line) or metformin. Laparoscopic ovarian drilling or IVF may be considered too.
What is menopause? Postmenopause? Perimenopause? Premature menopause?
(1.) Menopause is the point at which menstruation stops. Average age is 51y. It is caused by lack of ovarian follicular function causing the following:
- Low oestrogen + progesterone levels
- hi LH + FSH due to absence of negative feedback from oestrogen
(2.) Postmenopause = 12m after final menstrual period
(3.) Perimenopause = time around menopause (time leading up to + 12m after), may experience vasomotor syx and irregular periods.
(4.) Premature menopause = menopause <40y (premature ovarian insufficiency)
Perimenopausal syx?
Caused by lack of oestrogen:
- PMS
- irregular menstrual periods
- secondary amenorrhea
- hot flushes, night sweats, vaginal dryness.
Risks associated with menopause?
- CVD + Stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
Dx of menopause?
DX can be made in >45y with typical syx, without performing any investigations.
Consider FSH blood test in following:
- <40y with suspected premature menopause
- 40-45y with syx or change in menstrual cycle
Blood results:
- High FSH + LH
- Low progesterone + oestrogen
Management of menopause?
Contraception for:
- 2y after LMP in <50y
- 1y after LMP in >50y
- until 51y if premature ovarian insufficiency
- note: it does not affect menopause but may mask syx which can make dx hard.
Consider Rx if interfering with life:
(1.) No Rx, syx resolves after 2-5y. Advise healthy lifestyle.
(2.) HRT - cyclic in peri, continous in postmenopausal.
(3.) SSRI (FLuoxetine for FLUshes)
(4.) Topical oestrogen = vaginal dryness and atrophy (can be used alongside systemic HRT)
(5.) CBT
What is Premature Ovarian Failure? Causes?
- Menopause <40y
- Hi risk of CVD, stroke, osteoporosis, cognitive impairment due to lack of oestrogen
- Characterised by hypergonadotropic hypogonadism
- Cause is idiopathic (50%), iatrogenic, AI, genetic, infection e.g. mumps, TB, CMV.
Dx of Premature Ovarian Failure
<40y with
- menopausal syx PLUS
- elevated FSH (must be raised on TWO consecutive samples >4w apart)
Management of Premature Ovarian Failure
HRT + contraception until 51y
When would you give cyclic and continuous HRT
- Cyclic Rx = perimenopausal women (had a period within <1y)
- Continuous Rx = postmenopausal women (no period for 1y or more)
When would you give oestrogen only HRT
Oestrogen only HRT is indicated in those with no uterus only
Menopausal women - should they still be using contraceptives?
Yes!
- 2y after LMP in <50y
- 1y after LMP in >50y
- until 51y if premature ovarian insufficiency
