Menstrual disorders Flashcards
Amenorrhea : Primary definition
2
Failure to establish menstruation by;
⦁ 15 years of age in girls with normal secondary sexual characteristics (such as breast development)
⦁ 13 years of age in girls with no secondary sexual characteristics
Amenorrhea : Secondary definition
2
Cessation of menstruation ;
⦁ 3-6 months in women with previously normal and regular mense
⦁ 6-12 months in women with previous oligomenorrhoea
Amenorrhea : Primary causes
5
- gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
Amenorrhea : Secondary causes
5
- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- Premature ovarian failure - ovaries stop functioning and producing hormones before the age of 40
- thyrotoxicosis / Hypothyroidism
- Sheehan’s syndrome
Amenorrhea : Initial investigations
5
- urinary or serum bHCG } Exclude pregnancy
- Full blood count, urea & electrolytes, coeliac screen, thyroid function tests } General screening
- Gonadotrophins
I. Low levels indicate a hypothalamic cause
II. Raised if suggest an ovarian problem
(e.g. Premature ovarian failure) or gonadal dysgenesis(impaired devlopment of gonads) e.g. Turner’s syndrome
- Prolactin
- Androgen levels - Raised levels may be seen in
PCOS
Amenorrhea : Management
Primary and secondary
Primary amenorrhoea:
I. investigate and treat any underlying cause
⦁ Hormone replacement therapy - with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etc)
Secondary amenorrhea:
1. Exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
2. Treat the underlying cause
Dysmenorrhea : Definition and types
Excessive pain during menstrual period
-Primary dysmenorrhea : No underlying pelvic pathology, affects up to 50% of women after they start having periods
-Secondary dysmenorrhea : Pain during menstruation due to underlying pathology
Dysmenorrhea : Primary dysmenorrhea - Clinical features
2
⦁ Pain typically starts just before or within a few hours of the period starting
⦁ Suprapubic cramping pains which may radiate to the back or down the thigh
Dysmenorrhea : Primary dysmenorrhea - Management
2
- First line : NSAIDs such as mefenamic acid and ibuprofen
- inhibit prostaglandin production as excess prostaglandin release by the endometrium is thought to be the cause - Second line : combined oral contraceptive pills
Dysmenorrhea : Secondary dysmenorrhea - Causes
5
- endometriosis
- adenomyosis
- pelvic inflammatory disease
- intrauterine devices - Copper coil
- fibroids
Dysmenorrhea : Secondary dysmenorrhea - Clinical features
1
In contrast to primary dysmenorrhoea;
The pain usually starts 3-4 days before the onset of the period.
Dysmenorrhea : Secondary dysmenorrhea - Management
1
Refer all patients with secondary dysmenorrhoea to gynaecology for investigation.
Menorrhagia : Investigations
2
- Bloods : FBC ro r/o anaemia
- Transvaginal Ultrasound (routine) indicated if symptoms of;
Intermenstrual or postcoital bleeding, pelvic pain or abnormal pelvic examination } may be structural abnormality
Menorrhagia : Management : If requires contraception
2
- intrauterine system (Mirena) should be considered first-line
- combined oral contraceptive pill
- long-acting progestogens
Menorrhagia : Management : No contraception needed
2
- First line : Tranexamic acid as it an anti fibrinolytic
- Mefanamic acid - NSAID with assoc dysmenorrhea
Postcoital bleeding - Causes
5
- No identifiable pathology is found in around 50% of cases
- Cervical ectropion is the most common
- causing around 33% of cases. This is more common in women on the combined oral contraceptive pill - Cervicitis e.g. secondary to Chlamydia
- Cervical cancer
- Polyps
- Trauma
Physiology of the menstrual cycle : Follicular phase
5
- Hypothalamus : GnRH
- Anterior pituitary : FSH + LH } travel to follicles in the ovaries
Follicles : theca and granulosa cells surrounding to protect the devloping egg - LH : binds to receptors on theca cell } secreting = Androstenedione (precursor of testosterone)
- FSH : bind to granulosa cells } secreting = aromatase enzyme
} Androstenedione via Aromatase enzyme –> Estradiol (oestrogen) - Negative feedback : High oestrogen inhibits FSH } only enough for dominant follicle
- Dominant folicle : keeps releasing oestrogen + peaks
} positive feedback
} LH +FSH surge - Ovulation : ovarian follicle ruptures and releases oocyte
PCOS : Pathophysiology
4
- Anterior pituitary : makes excess LH > x2 of FSH
- Very high levels of LH
- Already very high } no LH surge to trigger ovulation
- more bind to receptors on theca cells } More androstenidione produced
- Granulosa cell } unable to produce enough aromatase to convert it into oestrogen
- Excess Androstenidone enters the bloods stream
PCOS : Etiology
4
Insulin resistance
1. - Body cells resistant to insulin
- Pancreas produces more insulin } hyperinsulinaemia
- Insulin binds to theca cells causing them to divide } increase in number of LH receptors
- In turn } Hypothalamus increases GnRH production to release more LDH
PCOS : Clinical features
6
High androstenidone (testosterone precursor)
1. Hirsuitism and excess body hair
2. Male pattern baldrness
**Lack of ovulation **
1. Amenorrhea and infertility
2. Excess cysts form as follicles are stimulated but egg is not released
Hyperinsulinaemia
Acanthosis nigricans : dark patches on creases
Obesity
PCOS : Investigations
Bloods :5
-
Baseline investigatons:
*FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) *
⦁ raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis
⦁ prolactin may be normal or mildly elevated
⦁ testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
⦁ SHBG is normal to low in women with PCOS
- Pelvic US - multiple cysts in ovaries
PCOS : Diagnostic criteria
3
After performing investigations to exclude other conditions
Rotterdam criteria : diagnosis of PCOS can be made if 2 of the following 3 are present
- Infrequent or no ovulation (usually manifested as infrequent or no menstruation)
- clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
- polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³
PCOS : Management- Hirsuitism and acne
3
- First line : Combined oral contraceptive pill
- Second line : Topical eflornithine - inhibits enzyme causing growth on hair follicles
- Third line : Spirnalactone / Finasterine
PCOS : Management - Infertility
3
- Weight loss
- First line : Clomifene
: induces FSH release by blocking oestrogen receptors on hypothalamus, thus preventing negative feedback inhibition
- Induced ovulation - Second line : Clomifene and Metformin
