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
Endometriosis : defintion
Growth of ectopic endometrial tissue outside of the uterine cavity.
Endometriosis : Clinical features
4
- Chronic pelvic pain
- secondary dysmenorrhoea } pain often starts days before bleeding
- Deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
Endometriosis : Investigations
1
laparoscopy is the gold-standard investigation
Endometriosis : Primary management
2
Analgesia / Hormonal treatment
1. First line : NSAIDs and/or paracetamol
1. Second line : Combined oral contraceptive pill
Endometriosis : secondary management
2
Referred if fertility is a priority / symptoms not improving
1. GnRH analogue : induce pseudomenopause
2. Surgery : Laproscopic excision or ablation of endometriosis by adhesiolysis
- helps improve chance of conception
Menopause : definition
1
- Permanent cessation of menstruation
- Caused by loss of follicular activity
Menopause : Diagnosis
1
Clinical diagnosis when a woman has not had a period for 12 months
Menopause : What is the average age?
1
51 years old
2
Menopause : Contraception
2
- 12 months after the last period in women > 50 years
- 24 months after the last period in women < 50 years
Menopause : HRT regimes
- Continous oestrogen and cyclical progesterone - produces monthly bleed
- Contínuos combine oestrogen and progesterone HRT - post menopausal women as it stops menses
- Oestrogen only - used in women who have had a hysterectomy or Mirena which gives progesterone cover
Menopause : HRT CI
- Current or past breast cancer
- Oestrogen sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
Menopause : HRT and its risks
6
Indication : To treat menopausal symptoms
- Endometrial cancer risk - only in oestrogen only HRT } give Combined HRT if woman has a uterus as progesterone reduces the risk
- VTE risk increased - only with oral HRT, not with transdermal
- Stroke risk increased : only with oral HRT
- Coronary artery disease increased
- Breast cancer risk increased
- Ovarian cancer risk increased
Menopause : Management of symptoms
4
- Vasomotor symptoms : fluoxetine, citalopram or venlafaxine
- Vaginal dryness : vaginal lubricant or moisturiser
- Mood : CBT or antidepressants
- Vaginal dryness : vaginal oestrogen and moisturisers
- Tibolone - converted to an active metabolite and reduced menopausal symptoms
- Testosterone patches - used to increase libido
Premature ovarian insufficiency : Definition
2
- Onset of menopausal symptoms
- Elevated gonadotropin level
- Before the age of 40 years
Premature ovarian insufficiency : Causes
3
- idiopathic
- the most common cause
- there may be a family history
- Bilateral oophorectomy
- having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
- radiotherapy / chemotherapy
- infection: e.g. mumps
Premature ovarian insufficiency : Investigations
2
- Raised FSH, LH levels
- elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
- Low oestradiol
- e.g. < 100 pmol/l
Premature ovarian insufficiency : Management
1
Offer;
* Hormone replacement therapy (HRT) or a combined oral contraceptive pill until 51 years (average age of menopause)
Atrophic vaginitis : Definition
- Thinning and drying of the vaginal mucosa
- Due to reduction in oestrogen most commonly in post menopausal women
Atrophic vaginitis : Incidence
50-60 years
What is the impact of oestrogen on vaginal tissues
- Maintains thickness and elasticity of the vagina
- Stimulates mucus and lubrication
- Maintains acidic pH within the vagina
Atrophic vaginitis : Pathophysiology
Lack of oestrogen leads to ;
* Thin, dry and atrophies vaginal mucosa
* Reduced acidity, leads to more alkaline environment making infection more likely to develop
* Urinary symptoms : painful due to dryness or changes to urogenital tissue and loss of vaginal muscle tone
Atrophic vaginitis : Causes
Any condition which reduces levels of oestrogen
1. Menopause
2. Premature ovarian failure
3. Oestrogen blocker : tamoxifen
4. Post partum hormone changes
Atrophic vaginitis : Clinical features
- Dryness of the vagina
- Local irritation : pruritus, burning pain
- Painful intercorse, post coital bleeding
- Urinary symptoms : recurrent UTI, painful urination, increased freqeuency
Atrophic vaginitis : Vaginal discharge
- External examination
- Reduced pubic hair
- Loss of labial fat pad
- Thinning of labia minora
- Internal examination
- Smooth, shiny vaginal mucosa with loss of skin folds
- Dryness of mucosa
- Loss of vaginal muscle tone
- Erythema or bleeding
Atrophic vaginitis : First line management?
Topical oestrogens :
* Treatments will take around 3 weeks to have any effect, with maximal effect noticeable within 3 months of starting
- Long-term topical oestrogens are considered safe, with no effect on endometrial proliferation
Atrophic vaginitis : Second line management?
Systemic HRT
-25% may experience vaginal dryness on HRT may require topical oestrogens additionally
Uterine fibroids : Definition
Benign smooth muscle growths of the myometrium of the uterus
Uterine fibroids : Incidence
- Women of African decent
- Pre-menopausal female
Uterine fibroids : Risk factors
Uterine fibroids : Risk factors
Oestrogen ;
-Bind to fibroids and stimulate mitosis and thus promoting further growth
* Pregnancy
* Late menopause
* Exogenous oestrogen
Uterine fibroids : Clinical features
- Menorrhagia
- may result in iron-deficiency anaemia
- Bulk-related symptoms
- lower abdominal pain: cramping pains, often during menstruation
- bloating
- urinary symptoms, e.g. frequency, may occur with larger fibroids
- Increase risk of Miscarriage
Uterine fibroids : Investigation for diagnosis
Transvaginal Ultrasound
Uterine fibroids : Management
Only indicated if symptomatic
Only indicated if symptomatic
1. Menorrhagia - Levonestrogel IUS (progesterone releasing IUS)
- Reduce size of fibroids
- Medical : GnRH agonist
-Blocks release of oestrogen from anterior pituitary gland - MOST EFFECTIVE ESPECIALLY IF WANTING TO GET PREGNANT : Myomectomy - removal of fibroids
PMS
- First line : Lifestyle changes
- Second line : COCP
Progesterone only contraception is not affective
Infertility : Causes
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
Infertility : Investigations
- semen analysis
- serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done onday 21.
< 16 - repeat
16-30 - repeat
> 30 - ovulation
If consistently < 16, consider referral to a specialist
Infertility : Management
- folic acid
- aim for BMI 20-25
- advise regular sexual intercourse every 2 to 3 days
- smoking/drinking advice
Urinary incontinence : Types
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Urinary incontinence :Initial investigation
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Urge incontinence - Management
- Bladder retraining
- Bladder stabilising - Antimuscarininc
* Oxybutynin, Tolterodine
* Mirabegron - beta 3 agonist if SE are intolerable
* Avoid oxybutynin in old frail women
Stress incontinence - Mx
- Pelvic floor training
- Surgery - retropubic mid urethral tape procedure
