Menstrual Disorders Flashcards
1
Q
What is puberty?
A
The onset of sexual maturity marked by the development of 2ndary sexual characteristics
2
Q
How does puberty get triggered?
A
Hypothalamic-pituitary axis - “wakes” then “wakes up” the ovaries
3
Q
What is happening in the body from 8 years of age?
A
GnRH pulses increase => FSH/LH increase => oestrogen increases => responsible for the dev of 2nddary sexual characteristics
4
Q
What is precocious puberty?
A
Secondary sexual characteristics before age 8 and menstruation before age 9
5
Q
What is delayed puberty?
A
No sexual secondary characteristics by age 14 and no mensuration by age 16
6
Q
What are the stages of puberty?
A
7
Q
What hormonal feedback plays a role in puberty?
A
Low estrogen levels have a + feedback on thalamus = encourage secretion of FSH & LH
Intermediate estrogen levels have a - feedback on GnRH = less LH & FSH
Higher estrogen levels have a + feedback on LH & FSH
LH surger happens about …hours before ovulation
Corpus luutheum = produces estrogen and progesterone but relaivtively high levels of progesterone
8
Q
What are the 5 stages of puberty?
A
- growth spurt (~11yrs)
- thelarche = breast dev
- adrenarche = pubic hair dev
- menarche = average 13yrs is reducing
- axillary hair growth
Usually this order but variations can occur
9
Q
When does the growth spurt last till in puberty?
A
Up until 15-16 years
10
Q
How is menstruation at the start of puberty?
A
Irregular at first - anovulatory cycles: prior to maturation of feedback loop between ovaries and pituitary/hypothalamus, then becomes regular
11
Q
What do hormonal changes in the menstural cycle lead to?
A
- ovulation
- endometrial changes (preparing for implantation)
12
Q
What are the stages of the menstrual cycle?
A
13
Q
What part of the menstural cycle is consistently the same length regardless of overall cycle length?
A
Secretory/luteal phase is a constant 14 days
14
Q
What are the different parts of the menstrual cycle?
A
Days 1-4: menstruation: endometrium shed, myometrium contracts
Day 5-13: proliferative/follicular phase:
Days 14-28: secretory/luteal phase:
15
Q
What are the normals for the menstrual cycle?
A
<16 Yrs: Menarche
>45 Yrs: Menopause
3-8 Days: Menstruation
<80 Ml: Blood loss
24-38 Days: Cycle length
16
Q
When is said to be early menopause?
A
40-45
17
Q
When is said to be premature menopause?
A
<40
18
Q
What is menorrhagia?
A
Heavy menstural bleeding
19
Q
What are the two definitions of menorrhagia?
A
- blood loss of >80ml per month in an otherwise normal menstrual cycle
- excess menstrual blood loss that interferes with a woman’s quality of life and can occur alone or in combination with other symptoms (QOL = physical, emotional, social and material)
20
Q
Why is the limit of menorrhagia 80ml?
A
Blood loss of 80ml is the most a woman on a normal diet can loose without becoming iron deficient
21
Q
How common is menorrhagia?
A
5% of women aged 30-49 yrs consult their GP due to heavy periods or menstrual problems
22
Q
What is the etiology of menorrhagia?
A
- uterine
fibroids 30%
polyps 10%
endometrial hyperplasia
endometrial ca
endometriosis/ adenomyosis - cervical
carcinoma
polyp - pelvic
ovarian cancer
chronic pelvic infection - thyroid disease (hypo)
- coagulation disorder
vW, anticoagulants, thrombocytopenia - IUD - esp the copper coil
23
Q
What is a fibroid?
A
Benign tumour of the myometrium
24
Q
What will the majority of women with menorrhagia have?
A
No histological abnormality and regular cycles
25
What may menorrhagia result from in cases where there is no histological abnormalities?
* endometrial haemostasis
* uterine prostaglandin levels
26
What do the prostaglandins cause?
* PG12 and PGE2 = vasodilation
* PGF2 = constriction
27
How does FIGO group the etiologies of menorrhagia?
PALM (structural)
P; Polyp
A; Adenomyosis
L; Leiomyoma (Fibroid)
M;Malignancy / Hyperplasia
COEIN (non-structural causes)
C; Coagulation disorder
O; Ovulatory dysfunction
E; Endometrial (primary disorder of mechanisms regulating haemostasis)
I; Infection / Iatrogenic (medications)
N; Not yet known
28
What are the clinical features you must ask about in the history of women with menorrhagia?
* nature and duration of bleeding (flooding, clots, pads)
* length and regularity of cycle
* associations : IMB, PCB, discharge, pain, urinary symptoms
* effect on QOL, consider symptomatic anaemia, ADLS, sexual function
* investigations: FBC?
* treatments: tried to date (may include contraceptives)
* risk/causation: thyroid, family Hx of coagulation problems
29
What are the guidelines on examination of a woman presenting with menorrhagia?
. NICE guidelines: offer a physical exam if HMB with other related symptoms and in all going for IUS.
RCPI guidelines suggest examination should include abdominal and pelvic examination where feasible (later less so in young women newly sexually active)
30
What signs may be seen on clinical examination of a patient with menorrhagia?
-General –> anaemia (facial, conjunctival, nail bed pallor)
-Abdominal examination: palpable mass (e.g. fibroid or ovarian mass) or tenderness (adenomyosis, endometriosis, PID)
-pelvic-> signs of different issues
31
What clinical features and signs may be seen on pelvic examination in a woman with menorrhagia?
* cervical abnormality
* uterine: tenderness: adenomyosis
* uterine: irregular enlargement: fibroids
* uterine: mobility/retroverted (?PID, endometriosis)
* ovarian mass/adnexal tenderness
* pouch of Douglas assessment - often nil
32
What investigations are done for menorrhagia?
* Labs FBC +/-ferritin/ironstudies +/-tfts & coag no need for hormonal studies in HMB unless other cause for doing them
* TVUS: endometrial thickness, large polyps, fibroids, ovarian mass.
* Endometrial biopsy: indications: RCPI guidelines
* Hysteroscopy:
-if irregular bleeding: IMB/PCB
-u/s suggestion of endometrial polyp or cancer
33
What are the RCPI guidelines for who to endometrial biopsy with menorrhagia?
* >45 yrs
* <45 yrs with obesity or PCOS
* IMB
* failure to respond to treatment
*others:
- endometrial thickness variable (>4 post menopause)
- endometrial polyp on TVUS
- prior to endometrial ablation
34
How dos endometrial thickness appear on TVUS?
35
What biopsy can be used to take a biopsy of the endometrium outside of hysteroscopy?
Pipelle biopsy = suction currette
36
What are the issues with pipelle biopsy?
blind biopsy so if negative not great as could easily have missed
D&C is a diagnostic test not a treatment but some willl bleed less a bit after D&C
37
How is menorrhagia managed?
* treat underlying pathology
* medical
* surgical
* needs to take account of symptoms but also desire for fertility
* Ursula tried for minimum of 3 months
38
What are the first line medical treatments for menorrhagia?
* IUS – progesterone-impregnated coil
* Reduces menstrual flow by> 90%
* Less s/e than systemic tx
* Contraceptive
39
What are the second line medical treatments of menorrhagia?
* antifibrinolytics = tranexamic acid
* NSAIDS = mefanamic acid (ponstan)
* COCP
40
How does tranexamic acid help menorrhagia?
* taken during menstruation
* reduce blood loss by about 50%
41
How does NSAID mefanamic acid treat menorrhagia?
* inhibit prostaglandin synthesis
* reduce blood loss by ~30%
* similar s/e profile to regular NSAIDs
42
When is mefanamic acid used in preference to tranexamic acid for the treatment of menorrhagia?
If a lot of dysmenorrhea
43
How does the COCP help treat menorrhagia?
Lighter periods: reduce blood loss by up to 43%
44
Who has problems with COCP for the treatment of menorrhagia?
Older women
Pelvic pathology
45
How does ponstan (mefanamic acid) work in the treatment of menorrhagia?
Dual effect in inhibiting prostaglandin syntetase but also antagonising at prostaglandin receptor sites
46
What medical treatments are the third line in the treatment of menorrhagia?
* **progestagens (high dose): norethisterone 15mg daily from days 5-26** of cycle (or every day will induce amenorrhoea), injectables
* **GnRH analogues**: induce amenorrhea
47
How do GnRH analgoues work?
* cause pituatiry to down regular it’s receptors causing less of FSH, LH production
= induce a medial menopause
48
How are GnRH analgoues limited in the treatment of menorrhagia?
* limited to 6 months
* unless add back HRT then can use them for 2 years
49
When is surgical treatment for menorrhagia esp good?
In cases of proven pathology
Treat underlying pathology
(Eg endometrial polyp, fibroids)
50
What are the surgical treatments of menorrhagia?
* endometrial ablation techniques
* hysterectomy
51
What is endometrial ablation technique?
Removal or destruction of endometrium
52
What does endometrial ablation usually achieve for menorrhagia treatment?
* lighter periods or amenorrhea
* usually <10 weeks size
53
What are some issues with endometrial ablation that are important to remember?
* reduce fertility but not sterilizing - still need contraceptives
* less satisfied than with hysterectomy
- 20% repeat or later hysterectomy
54
What are the 2 types of endometrial ablation?
* 1st gen
- TCRE - trans cervical resection of endometrium
- TC rollerball ablation
* 2nd gen
- use of microwave probes, thermal balloons, cryotherapy or radiotherapy
55
Why is 2nd generation endometrial ablation better?
safer, easier to perform, shorter hospital stay and can be under local, lower risk of perforation
56
When is a hysterectomy done for menorrhagia?
Last resort
57
What are the different approaches to a hysterectomy?
Transvaginal
Abdominal
Laparoscopic
58
What is removed in a Total hysterectomy?
Uterus and cervix
59
What is removed in a Subtotal hysterectomy?
Uterus
60
What is removed in a Radical hysterectomy?
Uterus, cervix and upper third of vagina
61
Why would a subtotal hysterectomy be done?
Quicker, less blood loss, if cervix has a lot of adhesions, may be better for sexual function BUT ongoing bleeding and cannot be done for cancerous reasons
62
What are possible indicators of significant pathology in menorrhagia that warrant early investigation? (9)
New or worsening over 45 years
High BMI
PCOS
Tamoxifen use
Family history of endometrial or Lynch 2 Ca
Abdominal mass
IMB
PCB
Anaemia not responding to medical management
63
A 45y/o presents with a 6/12 history of menorrhagia, pelvic pain and a pelvic mass. Which one of the following is the most appropriate initial diagnostic investigation
A) Endometrial pipelle
B) CT pelvis
C) MRI pelvis
D) Abdominal u/s
E) TVUS
E) most likely diagnose multiple fibroids or ovarian neoplasm
64
Dysmenorrhoea may be treated with tranexamic acid
False
65
Hysterectomies for DUB are on the increase
False
66
The maximum duration of use for GnRH analogues is 3 months
False its 6 and 2 years if also giving HRT
67
What is amenorrhea?
Absent menstruation
68
What is primary amenorrhea?
Menstruation not started by 16yrs
69
What can primary amenorrhea be accompanied by?
* failure to develop 2ndary sexual characteristics (by 16)
* or if they have 2ndary sexual characteristics then likely outflow tract is the problem
* either way a congenial or acquired anomaly before normal time of puberty
70
What is secondary amenorrhea?
Previously normal menstruation ceases for 3/12 or greater
71
What most commonly causes secondary amenorrhea? (3)
* premature menopause
* PCOS
* hyperprolactinaemia
72
What is infrequent menstrual bleeding (oligomenorrhoea)?
1-2 periods in a 90 day time space
(Old definition = cycle lasting between 35days - 6 months)
73
How is amenorrhea classified?
* physiological = pregnancy, breastfeeding, menopause, familial/genetic delay of menstruation
* pathological = endocrine, anatomical and medications
74
What are the different pathological causes of amenorrhea?
* endocrine = not all, but hypothalamus, pituatiry, thyroid, adrenals and ovaries
* anatomical = uterus and outflow tract
* medications = progesterone, post OCP, GnRH analogues, antipsychotics, H2 receptor antagonists, some antihypertensives (methyldopa, verapamil)
75
What are some causes of amenorrhea due to hypothalamic hypogonadism? (5)
* physiological (stress)
* weight change (<45kg or increase)
* excessive exercise
* tumour
* kallmanns syndrome
76
What is kallmanns syndrome?
Problem with hypothalamic neurons = low GnRH and lack of sense of smell
77
What hormonal changes are seen in hypothalamic hypogonadism causes of amenorrhea?
Low GnRH, FSH/LH, estradiol
78
How is hypothalamic hypogonadism as a cause of amenorrhea managed?
* supportive treatment - psych evaluation if anorexia
* COCP, HRT
* treat low BMD
79
What are pituitary causes of amenorrhea? (3)
* hyperprolactinaemia
* Sheehans Syndrome
* pituitary tumours
80
What is happening in Sheehans syndrome?
Sheehans syndrome (ischaemic necrosis of the ant pituitary gland due to severe primary PPH, you get pituitary hyperplasia in preganncy so you need a greater blood supply, ant. Pituitary has a different blood supply than posterior as it is supplied via the hypothalamus in a portal system so lower pressure system that is more susceptiable to lower pressure ischaemia) (no FSH, LH after delivery wont begin periods again, no prolactin = wont lactate, low ACTH may lose pubic hair)
81
A 21 y/o woman presents with an eight month history of secondary amenorrhoea. She has had a milky white discharge from her breasts in the last four months. General examination is unremarkable. Both breasts appear normal: milk can be expressed from the left breast. Pelvic examination is normal.
What is the likely diagnosis?
What specific physical finding would you look for on examination?
What key investigation would you perform?
What would be your first line treatment?
List one other way this condition might present?
Hyperprolactinaemia
Likely diagnosis - raised prolactin
Physical finding = bitemporal haemianopia (optic chaism cross above pituatiry gland)
Ix = prolactin level, then a CT or MRI
First line treatment= dopamine agonists can shrink prolactin producing tumours
Hypothyroid can cause raised prolactin
ACTH -> cholesterol and then - mineral corticosteroids, glucocorticoids and androgens
The oids are dependent on 21 hydroxyl and in CAH tat is deficient so more gets shoved down the pathway to androgens
82
What is hyperprolactinaemia?
Raised prolactin reduced GnRH release
83
What are some causes of hyperprolactinaemia? (5)
* pituitary adenoma
* pituitary hyperplasia
* PCOS
* hypothyroid
* psychotropic meds (risperidone)
84
What are the symptoms of hyperprolactinaemia? (4)
* Oligo/amenorrhea
* Galactorrhea
* Headaches
* bitemporal hemianopia
(HOG)
85
What investigations would you do for hyperprolactinaemia?
Labs
+/- CT
86
What treatments would you consider with hyperprolactinaemia?
* medications: **dopamine agonist (bromocriptine, cabergoline)** (Dopamine inhibits PRL release)
* surgery
87
What issues with thyroid can cause amenorrhea?
Hypo/hyperthyroid
- hypothyroid leads to raised prolactin levels = amenorrhea
88
What issues with the adrenals can cause amenorrhea?
* congenital adrenal hyperplasia (CAH)
* virilising tumours
89
What is congenital adrenal hyperplasia?
* autosomal recessive
* deficiency of 21-hydroxylase - raised ACTH/androgens
90
What is seen at birth with congenital adrenal hyperplasia? (2)
* ambiguous genitalia
* addisonian crisis
91
What is seen at puberty with congenital adrenal hyperplasia? (2)
* enlarged clitoris
* infrequent or absent menstruation
92
What are the treatments for congenital adrenal hyperplasia?
Replace mineralocorticoid and glucocorticoid
93
What acquired conditions of the ovary can cause amenorrhea? (3)
* PCOS
* premature menopause
* virilising tumours
94
What are congential ovarian causes of amenorrhea? (3)
* turners syndrome (45X0)
* gonadal dysgenesis
* androgen insensitivity
95
What are the issues with the ovaries that cause amenorrhea?
PCOS: primary, secondary, or infrequent menstruation
Turners: one X chromosome absent. Short stature, poor 2 sc, normal intelligence
Gonadal dysgenesis: poorly formed ovary due to abnormalities of X chromosomes
Androgen insensitivity: genetically male. Cell receptor not responsive to androgens. Converted to oestrogens. Phenotypically female – uterus absent, small testes- removed due to possible malignant change. https://ghr.nlm.nih.gov/condition/androgen-insensitivity-syndrome#genes
Gonadal dysgenesis is used to describe those situations in which primordial germ cells reach the ovary but are progressively destroyed so that few remain by the time of puberty.
Virilising tumuors = sex cord tumours eg theca cell tumour
Androgen insentivity is a problem with the cell surface receptor of androgens -> person is genetically male XY, but cell receptors don’t respond to androgens so they become phenotypically female (secondary sexual characteristics a/w/ female -> remove testes as risk of cancer and then allow them to decide)
96
What are the acquired outflow tract issues that cause amenorrhea? (3)
* cervical stenosis
* asherman’s syndrome
* endometrial resection or ablation
(Cervical stenosis: canal occluded by fibrosis after endometrial resection, cone biopsy or carcinoma
Asherman’s syndrome: adhesions within the uterus so the cavity becomes partly obliterated. Pregnancy, infection or trauma: excessive currettage at ERPC or following delivery
Endometrial resection or ablation - intentional)
97
What are the congenital causes of outflow tract issues that cause amenorrhea? (3)
* imperforate hymen
* transverse vaginal septum
* vaginal aplasia +/- uterus (Mayer-Rokitansky syndrome)
(Primary amenorrhea with normal secondary sexual characteristics)
98
What is haematocolpos?
Blood in vagina
99
What is haematometra?
Blood in uterus
100
Causes of secondary amenorrhoea include (T/F)
Hypothyroidism
Turner syndrome
Bulimia
Asherman syndrome
All true except turners syndrome which causes primary amenorrhea
101
What is ashermans syndrome?
intrauterine adhesions (cotton candy cloud appearance in hysterscopy)
102
How may imperforate hymen and transverse vaginal septum present?
Amenorrhea but cramps every month
103
A 16 y/o girl attends the clinic with her mother. They are both worried that she has not started to menstruate yet.
What investigations would you perform
- hormonal screen, ultrasound, karyotype (turners)
- hormonal screen = FSH, LH, prolactin, testosterone, TFTs, estradiol (note if someone was mensturating then do FSH, LH and estradiol at D2-D4 of the cycle
104
Why is it hard to measure GnRH?
GnRH is pulsatile
105
What is dysmenorrhea?
Painful menstruation
106
What is a/w/ dysmenorrhoea?
* high PGs (increased uterine activity)
* ischaemia: hypercontraction - ‘uterine angina’
* ? Role for vasopressin (increases synthesis of prostaglandins and myometrial activity)
* ? Role of psychology (mother puts her expectations of pain onto her daughter
107
What is primary dysmenorrhea?
No organic cause (pelvic pathology) is found
108
What is secondary dysmenorrhea?
Pain is due to pelvic pathology
109
When is primary dysmenorrhea common?
Menarche or 6 months - 1 yr after
Peak age 15-25
110
How common is primary dysmenorrhea?
50% of women
10% severe
111
What are some thoughts about primary dysmenorrhea?
* a/w/ ovulation (can be 1-2yrs after menarche due to delay in ovulatory cycle)
* higher than average PGs in menstrual fluid
112
What are the clinical features of primary dysmenorrhea?
* cramping pain: lower abdo, radiating to thighs/back
* starts around time of period and lasts 24-72 hours
113
What examination should be done for primary dysmenorrhea?
* abdominal examination
* no pelvic exam if not sexually active
114
What are the treatment options for primary dysmenorrhea?
* lifestyle: stop smoking
* reduce PGs - NSAIDs
And/or
* reduce ovulation - COCP
* other options: paracetamol, spasmonal, IUS, tocolytics, TENS, behavioural therapy
115
When is pelvic pathology more likely in cases of primary dysmenorrhea?
If medical treatment fails - need to investigate (10%)
116
Who does secondary dysmenorrhea affect?
Older women - uncommon before 25
117
What are the features of secondary dysmenorrhea?
Pain proceeds onset of period for several days and may last throughout the period (or be relieved by it)
118
What may be seen with secondary dysmenorrhea?
Associated symptoms like menorrhagia, deep dyspareunia, irregular bleeding
119
What are the etiologies of secondary dysmenorrhea? (6)
* fibroids (overgrowth of myometrium, diagnose with u/s)
* adenomyosis (where endometrium grows into myometrium - diagnose with pathology, pelvic MRI)
* endometriosis (laparoscopic surgery)
* PID (high vaginal and endocervical swabs)
* functional ovarian cysts/tumours
* IUCD = intrauterine contraceptive device
Treatment based on cause
120
What are some possible investigations you would do for secondary dysmenorrhea?
* abdominal and pelvic exam
* vaginal exam if sexually active
* high vaginal swab/ endocervical swab
* pelvic ultrasound - if uterine enlargement or adnexal mass present
* transvaginal ultrasound
* MRI scan
* laparoscopy
* laparotomy with biopsy
121
What is postcoital bleeding (PCB)?
Vaginal bleeding following intercourse
122
What is PCB a 🚩 for?
Cervical carcinoma
123
What are the potential causes of PCB? (4)
* cervical ectropion
* cervical polyps
* cervicitis/ vaginitis
* cervical carcinoma
124
When is cervical ectropion more likely?
If pregnant or on OCP as hormonal change, will reverse after it
125
What does the management of PCB involve?
* examine cervix - take smear
* if polyp - removal and send for histology
* if ectropion - cryotherapy
* if abnormal smear - colposcopy
126
What can irregular menstruation and IMB coexist with?
Menorrhagia
127
When is irregular menstruation and IMB common?
At extremes of reproductive age
128
What causes irregular menstruation and IMB?
Anovulatory cycles or pelvic pathology
129
How is irregular menstruation and IMB handled in adolescents?
Often treat medically initially and if not settling investigate
(Eg COCP, progestogens, Mirena)
130
What is the definition of irregular periods?
Periods with cycle to cycle variation of >20 days
131
True/false
Premenstrual syndrome relates to behavioural, psychological and physical symptoms that occur in the follicular phase of a woman’s menstrual cycle
False - luteal phase
132
SBA
Which one of the following characteristically presents with IMB?
A) Intramural fibroid
B) Uterine polyp
C) CIN
D) Moderate dyskaryosis
E) adenomyosis
B
133
SBA
Which one of the following characteristically presents with PCB?
A) Submucosal fibroid
B) Cervical ectropion
C) CIN
D) Moderate dyskaryosis
E) adenomyosis
B
134
What medications can cause amenorrhea? (6)
* progesterone
* post OCP
* GnRH analogues
* antipsychotics
* H2 receptor antagonists
* some antihypertensives (methyldopa, verapamil)
