Menstrual Disorders Flashcards
abnormal menstruation, including PCOS, fibroids, endometriosis, polyps, endometrial hyperplasia and infections
What is Oligomenorrhoea?
Infrequent periods (less than 6-8 periods a year)
Cycle > 35 days but less than 6 months in length
Oligomenorrhoea Causes?
Annovulation:
PCOS
Thyroid disease
Prolactinoma
CAH
Constitutional: not pathological
What is PCOS?
Heterogenrous endocrine disorder with unknown aetiology
Familial clustering
90% of cases of amenorrhoea
Usually emerges in adolesence
Features of PCOS?
Hyperandrogenism:
Acne
Hirsuitism
Obsesity
Anovulation:
Oligo/amenorrhoea
Multiple ovarian follicles on USS (string of pearls)
and/or ovarian volume >10cm3
Diagnostic criteria for PCOS
Rotterdam Criteria: 2 of the following 3 are present:
Infrequent or no ovulation
Clinical and/or biochemical signs of hyperandrogenism (hirsuitism, acne, or elevated levels of total or free testosterone)
Needs to have 12 or more follicles on one or both ovaries on USS and/or increased ovarian volume > 10cm3
DDx of PCOS?
Simple obsesity
Premature ovarian failure
Thryoid diease
Hyperprolactinaemia
CAH
Androgen secreting tumours
Cushing’s Syndrome
Investigations for PCOS?
In follicular phase:
Sex Hormone Binding Globulin (normal to low)
Total testosterone (normal to raised)
*these two can be used to calculate Free Androgen Index- RAISED is a typical biochemical feature of PCOS
FSH,LH, TFTs and Prolactin- exclude other causes
FSH and LH should be taken at fixed point at cycle
Pelvic USS- multiple ovarian cysts
Check BM for impaired glucose tolerance
PCOS Mangement?
- Weight loss is the primary intervention tool esp in women who are trying to get prgenant and symptoms decrease (EBM)
- Screening for imparied glucose tolerance
- Psych and mental wellbeing and refer appropriately
- Specific management of what the woman wants/ life stage
Specific PCOS management for woman who wants periods?
- COCP- helps with hyperandrogenic effects of PCOS
- OR cyclical progesterone ( POP)
PCOS managment for someone who wants to conceive?
Reduce BMI to <30
Start Folic acid
Baseline fertility assessment incl semen analysis on partner
Refer to fertility services
May need to undergo ovulation induction using clomifene
Metformin is controversial- used often though in conjungtion with clomifene
Treatment for PCOS for someone who wants to control acne and hirsuitism?
COCP
Acne: retinoids, abx etc. as per derm
Hirsuitism: waxing and laser hair removal
IF doesn’t respond to this may try topical eflornithine
spironolactone, flutamide and finasteride may be used under specialist supervision
Long-term implications of PCOS?
- Metabolic disorders e.g. impaired glucose tolerance and T2DM
- CVS disease
- OSA
- Infertility
- Recurrent miscarriage
- Pregnancy complications such as pre-eclampsia and gestational diabetes
- Endometrial cancer
- psychological disorders e.g. anxiety and depression
What are fibroids?
Benign uterine tumour primarily composed of smooth muscle and fibrous connective tissue (leiomyomata)
Risk factors for uterine fibroids?
Increasing age (40s)
Afro-carribean ethnicity
Overweight
Vit D deficiency
Presentation of fibroids?
Mostly asymptomatic
Heavy menstrual bleeding- may result in iron deficiency anaemia
Irregular firm central pelvic mass
Pelvic pain- esp during periods
Dysmenorrhoea
Bloating
fatigue
Subfertility
Urinary complaints
Rare:
polycythaemia secondary to autonomous prodcution of EPO
Investigations for uterine fibroids?
Transvaginal and transabdominal USS
Endometrial biopsy
DDx of fibroids?
Adenomyosis
Endometrial polyp
Endometrial hyperplasia
Endometrial Ca
Uterine sarcoma
Pregnancy
Ovaran Ca
GI Ca
Managment of asymptomatic fibroids?
No treatment needed, other than periodic review to monitor size and growth
Treatment of menorrhagia secondary to fibroids?
Levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
Treatment to shrink/remove fibroids?
MEDICAL:
* GnRH agonists may reduce size of the fibroid but are typically used more short term due to their menopausal like side effects
* Ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxcity
SURGICAL
* myomectomy- abdominally, laparoscopically or hysteroscopically
* hysteroscopic endometrial ablation
* hysterextomy
- uterine artery embolization
Prognosis of fibroids?
Usually regress after menopause
Complications of fibroids?
Subfertility
Recurrence
Iron-deficiency anaemia
Red degeneration- haemorrhage into tumour- commonly occurs during pregnancy
What is endometriosis?
Chronic inflammatory condition defined by endometrial stroma and glands found outside of the uteine cavity.
Most common sites affected: pelvic peritoneum and ovaries
RF for endometriosis?
Reproductive age
Positive fhx
non-parous women
mullerian anomalies
Features of endometriosis?
Dysmenorrhoea
Chronic or cyclic pelvic pain
Dyspareunia
Sub-fertility
non-gynaecological e.g. dysuria, urgency, haematuria, dyschezia
Examination findings in endometriosis?
Pelvic examination:
* reduced organ mobility - fixed retroverted uterus is classical sign
* tender nodularity in the posterior vaginal fornix
* visible vaginal endometriotic lesions may be seen
Investigations for endometriosis?
Laproscopy is the gold-standard investigation
Poor correlation between laparscopic findings and severity of symptoms
Management of endometriosis (before secondary care referral)?
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care
Management of endometriosis in secondary care
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy- not seem to have a significant impact on fertility rates
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
How to treat endometriosis for a pt who wants to get immediate fertility?
Controlled ovarian hyper-stimulation
2nd line: IVF
Complications of endometriosis?
- Endometriomas (ovarian cysts containing blood and endometriosis-like tissue) — if the ovaries are affected, endometriomas may develop. These may rupture and can affect fertility by causing distortion of pelvic anatomy.
- Fertility problems — endometriosis is commonly associated with infertility, with a prevalence of 25–40% in infertile women compared with 0.5–5% in fertile women [NICE, 2017]
- Adhesion formation — may occur due to the endometriosis or secondary to surgery or infection, and may cause chronic pelvic pain.
- Bowel obstruction — partial or complete bowel obstruction can occur due to adhesion formation or a circumferential endometriotic deposit.
- Chronic pain
- Reduced quality of life — symptomatic endometriosis can have a significant and sometimes severe impact on the woman’s quality of life and activities of daily living, including relationships and sexuality, work productivity, fitness, and mental health
What is Peutz-Jeghers syndrome?
Rare
Autosomal dominant disorder characterised by hamartomatous polyposis caused by germline mutation sin the STK11 gene
Increases risk of GI and exra-GI cancers
What is endometrial hyperplasia?
Defined as abnormal proliferation of the endometrium in excess of normal proliferation that occurs during the menstrual cycle.
Minority of pts with this may develop endometrial cancer
Types of endometrial hyperplasia?
Simple
Complex
Simple atypical
Complex atypical
Features of endometrial hyperplasia?
abnormal vaginal bleeding e.g. intermenstrual
Managment of endometrial hyperplasia?
Simple with atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgesterel intra-uterine system may be used
Atypia: hysterectomy is usually advised
Uterine polyps features?
bleeding in between periods
bleeding post menopause
irregular bleeding
heavy periods
Investigations for endometrial polyps?
Hysteroscopy- then biopsied
Treatment of endometrial polyps?
Removed surgically through a hysteroscope
May recur
Polyps vs fibroids?
Fibroids- bengin and non-cancerous
Polyps: occur when that part of the lining doesn’t shed- they may become cancerous of precancerous
