Menstrual disorders Flashcards
What is amenorrhoea?
- The absence or cessation of menstruation
What is primary amenorrhoea?
- Failure to establish menstruation
- by 15 years of age in girls with normal secondary sexual characteristics
- Or by 13 years of age in girls with no secondary sexual characteristics
What is secondary amenorrhoea?
- Cessation of menstruation
- for 3-6 months in women with previously normal and regular meses
- or for 6-12 months in women with previous oligomenorrhoea
- primary amenorrhoea is rarer
Why is there an overlap in presentation of primary and secondary amenorrhoea?
- Secondary causes may present as primary if they happen early enough in life
Outline how you would investigate primary amenorrhoea
- If no pubertal development, investigate as for delayed puberty
- If normal pubertal development, exclude genital tract abnormalities and investigate as for secondary amenorrhoea
- If incongruous pubertal development, exclude chromosomal abnormalities and causes of hyperandrogenism
What is the most common cause of primary amenorrhoea?
- Genitourinary malformations:
- imperforate hymen
- a vaginal septum
- absent vagina (logitudinal or transverse absent uterus)
What is an imperforate hymen?
- Hymen without an opening completely obsrtucts vagina
- Caused by failure of hymen to perforate during fetal development
- Menstrual blood accumulates in vagina and uterus
What are the possible causes of primary amenorrhoea with no secondary sexual characteristics?
- An underlying chromosomal or hormonal cause
- E.g. Turner syndrome or hypothalamic-pituitary dysfunction
Outline Turners syndrome
- 45XO (missing an X chromosome)
- 1/2500 live female births
- Ovary doesn’t complete normal development - streak ovaries
- Low estradiol
- High FSH and LH
- No oestrogen = no pubertal changes
What happens if there’s no GnRH produced by the hypothalamus?
- No pituitary stimulation
- No LH/FSH
- No ovarian or uterine function
- No oestrogen
- No secondary sexual development
Which diseases in the hypothalamus and pituitary prevent secondary sexual characteristics from developing?
- Isolated GnRH deficiency
- Idiopathic hypogonadotropic hypogonadism
- Autosomal dominant or X-linked autosomal recessive
- Poor development of secondary sexual characteristics
- With anosmia = Kallman syndrome - Constitutional delay of puberty
What is androgen insensitivity syndrome?
- X-linked recessive disorder
- Normal female external genitalia but 46XY
- Have testes but these are undescended (excised after puberty)
- Absence of upper vagina, uterus, and fallopian tubes
- Androgen receptor fails so resistant to testosterone
- Testosterone converted to oestrogen
How does androgen insensitivity syndrome lead to a female phenotype in spite of the XY chromosome?
- XY causes testes to grow
- Anti-mullerian hormone and testosterone produced
- Mullerian structures regress
- Androgen receptor fails
- Absence of virilization
- Testosterone converts to oestrogen
- Female phenotype
What physiological conditions can cause secondary amenorrhoea?
- Pregnancy
- Breastfeeding
- Menopause
What are some ovarian and uterine causes of secondary amenorrhoea?
- Scarring due to cervical stenosis or Asherman syndrome (intrauterine adhesions)
- Primary ovarian insufficiency (premature menopause) - depletion of oocytes before age 40. No oestrogen, no inhibin = high FSH
- PCOS
What is the most common cause of oligomenorrhoea?
- PCOS (causes up to 50% of oligomenorrhoea)
- Also causes 20% of amenorrhoea
What is the triad of PCOS?
- Menstrual irregularity
- Androgen excess
- Obesity
How is PCOS diagnosed?
- Infrequent or no ovulation
- Clinical and/or biochemical signs of hyperandrogenism (hirsutism, acne, elevated levels of testosterone)
- Polycystic ovaries on ultrasound
How is PCOS managed?
- Lifestyle advice e.g. weight loss
- Screening for type 2 diabetes mellitus
- Combined pill or cyclical progesterone
Other than oligomenorrhoea, what else can PCOS lead to?
- Raised insulin resistance
- This combined with obesity can result in type 2 diabetes
What are the signs and symptoms of PCOS?
- Hair loss
- Hirsutism
- Pelvic pain
- Overweight
- Acne
- Irregular periods
- Infertility
- High testosterone levels
What are the endocrine causes of secondary amenorrhoea?
- Thyroid disease (both hyper and hypothyroidism)
- Hyperprolactinaemia
How do thyroid diseases lead to amenorrhoea?
- Severe hyperthyroidism classically associated
- May be proceeded by oligomenorrhoea
- Complex interplay between thyroid hormones and HPG axis
How does hyperprolactinaemia cause amenorrhoea?
- Raised prolactin levels
- Interferes with normal production of hormones such as oestrogen and progesterone
- Can change or stop ovulation
- Leads to irregular or missed periods
What are some of the causes of hyperprolactinaemia?
- Pituitary tumours (prolactinomas)
- Hypothyroidism
- Medicines given for depression, psychosis, high blood pressure
What hypothalamic and pituitary diseases can lead to amenorrhoea?
- Prolactinoma
- Pituitary necrosis - Sheehan syndrome
- Functional hypothalamic amenorrhoea
How do hypothalamic and pituitary diseases lead to amenorrhoea?
- Lead to abnormal GnRH secretion
- LH surge absent
- Anovulation
- Low estradiol
What are some causes of functional hypothalamic amenorrhoea?
- Weight loss and excessive exercise e.g. gymnasts/athletes, anorexia
- Emotional stress and stress induced by illness
- Risk of bone loss due to low oestrogen
What is oligomenorrhoea?
- Infrequent menstruation defined by a cycle length between 6 weeks and 6 months
- Usually due to a prolonged follicular phase
- Can be constitutional
- Most causes directly or indirectly rooted in hormonal imbalance
What are the causes of oligomenorrhoea?
- PCOS
- Ovarian insufficiency
- Perimenopause
- Thyroid dysfunction
- Excessive exercise
- Eating disorders
- Hormonal contraception
What is menorrhagia?
- Excessive (heavy) menstrual blood loss
- Occurs regularly and interferes with a woman’s physical, emotional, social, and material quality of life
How is excessive menstrual blood loss classified?
- 80 ml or more
- Duration of 7+ days
- Need to change menstrual products 1-2 hourly
- Passage of clots
- Very heavy periods reported by woman
What is dysfunctional uterine bleeding?
- Menorrhagia with no underlying cause
What does abnormal uterine bleeding involve other than menorrhagia?
- Intermenstrual bleeding
- Postcoital bleeding
- Post-menopausal bleeding
Which uterine and ovarian pathologies can cause menorrhagia?
- Uterine fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease and pelvic infection
- Endometrial polyps
- Endometrial hyperplasia/carcinoma
- PCOS
Which systemic diseases can cause menorrhagia?
- Coagulation disorders
- Hypothyroidism
- Diabetes mellitus
- Hyperprolactinaemia
- Liver or renal disease
What are the iatrogenic causes of menorrhagia?
- Anticoagulant treatment
- Intrauterine contraceptive device
What are uterine fibroids?
- Also called leiomyomas
- Benign tumours
- Caused by proliferation of smooth muscle cells and fibroblasts
- These form hard, round tumours in myometrium
- Develop in women of reproductive age
- Regress after menopause
What are the risk factors of leiomyomas?
- Increasing age
- Early menarche
- Older age at first pregnancy
- Black and Asian ethnicity
- Family history
How is menorrhagia managed?
Dysfunctional uterine bleeding:
- Ievonorgestrel intrauterine system (IUS)
- Tranexamic acid or NSAID (mefenamic acid)
- Combined pill or progesterone only
- All women should have an FBC
- Fibroids <3cm need referral
What are some red flag symptoms of dysfunctional uterine bleeding?
- Postmenopausal bleeding
- Persistent intermenstrual bleeding
- Post-coital bleeding
- Pelvic mass
- Bloating
- Early satiety
- Ascites
What is dysmenorrhoea?
- Painful cramping, usually in the lower abdomen, which occurs shortly before or during menstruation, or both
What is primary dysmenorrhoea?
- Occurs in young females
- In absence of any identifiable underlying pelvic pathology
- Starts 6-12 months after menarche once cycles are regular
- Thought to be caused by production of uterine prostaglandins during menstruation
What is secondary dysmenorrhoea?
- Often starts after years of painless periods
- Caused by underlying pelvic pathology e.g. endometriosis, adenomyosis, fibroids, endometrial polyps, pelvic inflammatory disease
- Also caused by IUD insertion
What is endometriosis?
- Growth of endometrium-like tissue outside the uterus
- Commonly on ovaries, uterosacral ligaments, pouch of Douglas, rectum, sigmoid colon, bladder, distal ureter
- Extra-pelvic deposits are rare
- Hormone mediated and associated with menstruation
- Hormone changes of menstrual cycle induce bleeding, chronic inflammation and scar tissue formation
Give some statistics about endometriosis
- Affects 1/10 women
- Affects 1.5 million women
- Second most common gynaecological condition
- Takes 7.5 years to get a diagnosis
How is endometriosis diagnosed?
- Laparoscopy
What are the risk factors for endometriosis?
- Early menarche
- Late menopause
- Delayed childbearing
- Nulliparity
- Family history
- White ethnicity
- Low BMI
- Smoking
What are the complications of endometriosis?
- Endometriomas
- Adhesion formation
- Bowel obstruction
- Chronic pain
- Reduced quality of life
- Infertility
- Potential association with ovarian cancer
What is primary management of dysmenorrhoea?
- NSAID or paracetamol
- Oral contraceptive trial for 3-6 months
- Conservative advice
What is secondary management of dysmenorrhoea?
- Referral if any red flags or severe symptoms
- Management of symptoms - NSAID, hormonal contraceptive
- Surgical management
