Menstrual disorders Flashcards
Primary amenorrhoea
Defined as not starting menstruation:
- by 13 years when there is no other evidence of pubertal development
- by 15 years of age where there are other signs of puberty (eg. breast bud development)
Hypogonadism
Lack of the sex hormones, oestrogen & testosterone
Lack of these hormones causes a delay in puberty
Due to one of two reasons:
- hypogonadotropic hypogonadism - deficiency of LH & FSH
- hypergonadotropic hypogonadism - lack of response to LH & FSH by the gonads
Hypogonadotropic hypogonadism
Deficiency of LH & FSH → deficiency of sex hormones
Could be due to:
- hypopituitarism
- damage to hypothalamus or pituitary
- chronic conditions - CF, IBD
- excessive exercise or dieting
- endocrine disorders - GH deficiency, hypothyroidism
- Kallman syndrome
Hypergonadotropic hypogonadism
Gonads fail to respond to stimulation from the gonadotrophins (LH & FSH)
Could be due to:
- previous damage to gonads (eg. torsion, cancer or infections eg. mumps)
- congenital absence of the ovaries
- Turner’s syndrome (XO)
Kallman syndrome
Genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty
Associated with reduced or absent sense of smell
Congenital adrenal hyperplasia
Caused by a congenital deficiency of the 21-hydroxylase enzyme → underproduction of cortisol & aldosterone and overproduction of androgens
Autosomal recessive, can involve deficiency of 11-beta-hydroxylase
Severe cases → neonate unwell shortly after birth with electrolyte disturbances & hypoglycaemia
Female patients can present at puberty with typical features:
- tall for their age
- facial hair
- absent periods (primary amenorrhoea)
- deep voice
- early puberty
Androgen insensitivity syndrome
Tissues are unable to respond to androgen hormones, so typical male sexual characteristics do not develop
Results in a female phenotype, other than internal pelvic organs
Normal female external genitalia, internally, absent female internal genitalia (testes in abdomen or inguinal canal)
Primary amenorrhoea structural pathology
If ovaries are unaffected, there will be typical secondary sexual characteristics, but no menstrual periods
May be cyclical abdominal pain as menses build up but are unable to escape through the vagina
Causes include:
- imperforate hymen
- transverse vaginal septae
- vaginal agenesis
- absent uterus
- FGM
Primary amenorrhoea ix
Detailed history & examination
Initial - FBC, ferritin, U&Es, anti-TTG/anti-EMA antibodies
Hormonal blood tests - FSH, LH, TFTs, ILGF-1, prolactin, testosterone
Genetic testing for Turner’s syndrome
Imaging - wrist x-ray (assess bone age), pelvic USS, MRI brain
Primary amenorrhoea mx
Establishing & treating the underlying cause
Replacement hormones can induce menstruation
Stress/low body weight → reduction in stress, CBT, healthy weight gain
Hypogonadotrophic hypogonadism = pulsatile GnRH, COCP
Ovarian cause → COCP
Secondary amenorrhoea
The cessation of previously established menstruation for 3 cycles or for 6 or more month
Secondary amenorrhoea causes
Pregnancy, breastfeeding
Menopause & premature ovarian failure
Hormonal contraception
Pituitary gland pathology, eg. Sheehan syndrome or hyperprolactinaemia
PCOS
Asherman’s syndrome - intrauterine adhesions leading to outflow tract obstruction
Thyroid pathology
Physical stress, excess exercise & weight loss
Hyperprolactinaemia
High prolactin levels act on the hypothalamus to prevent the release of GnRH
This means no release of LH & FSH → hypogonadotropic hypogonadism
Most common cause = pituitary adenoma secreting prolactin
Often no treatment required; dopamine agaonists (eg. bromocriptine or cabergoline) can be used to reduce prolactin production
Secondary amenorrhoea ix
Detailed H&E
Hormonal blood tests
- b-HCG to rule out pregnancy
- LH & FSH
- prolactin
- TSH
- testosterone
USS pelvis to diagnose PCOS
Hysteroscopy - when intrauterine adhesions are suspected
Secondary amenorrhoea mx
Establishing and treating the underlying cause
Replacement hormones can induce menstruation & improve symptoms
Amenorrhoea > 12 months, treatment indicated to reduce the risk of osteoporosis:
- vit D & calcium intake
- HRT or COCP
Irregular menstrual bleeding causes
Physiological changes - menarche or menopause
GUM infections
Endometrial hyperplasia
Endometrial/cervical cancer
Fibroids
Pregnancy
Irregular menstrual bleeding ix
Pelvic examination - including speculum examination +/- cervical smear if overdue
Pregnancy test
Pelvic USS
Cervical biopsy if examination/smear abnormal
Endometrial biopsy if endometrial pathology is suspected
Irregular menstrual bleeding mx
If underlying pathology has been ruled out:
- COCP
- IUS
- norethisterone - taken on days 5-26 to prevent bleeding
- progestogens - can induce amenorrhoea but cannot be used long term
Dysmenorrhoea
Severe or debilitating pain that occurs in conjunction with menstruation
Dysmenorrhoea causes
Primary - idiopathic & occurs in absence of pelvic pathology
Secondary - associated with underlying pathology
- endometriosis
- PID
- uterine fibroids
Dysmenorrhoea ix
Rule out STIs
Examination for abdominal tenderness/mass, bimanual examination assessing for cervical tenderness
Transvaginal USS if investigations suggest underlying pathology
Dysmenorrhoea mx
NSAIDs
Tranexamic acid
COCP, POP, IUS, injection, implant
Surgical interventions - endometrial ablation or hysterectomy
Menorrhagia
Description of excessive menstrual loss which interferes with a woman’s quality of life
Menorrhagia aetiology
Abnormal uterine bleeding - diagnosis of exclusion
PALM-COEIN
PALM - structural causes
- polyp
- adenomyosis
- leiomyoma (fibroid)
- malignancy & hyperplasia
COEIN - non-structural causes
- coagulopathy
- ovulatory dysfunction
- endometrial
- iatrogenic
- not yet classified
Menorrhagia clinical features
Bleeding during menstruation deemed to be excessive for the individual woman
Fatigue
Shortness of breath
O/E - pallor, palpable uterus/pelvic mass, inflamed cervix/cervical polyp/cervical tumour, vaginal tumour
Menorrhagia ix
Urine pregnancy test
Bloods - FBC, TFTs, other hormone testing (PCOS), coagulation screen + test for VWD
USS pelvis - transvaginal US
Cervical smear
High vaginal/endocervical swabs for infection
Pipelle endometrial biopsy
Hysteroscopy & endometrial biopsy
Menorrhagia pharmacological mx
LNG-IUS: contraceptive, thins endometrium & can shrink fibroids
Tranexamic acid, mefenamic acid or COCP: choice dependent on wishes for fertility
- tranexamic - taken during menses
- mefenamic acid - NSAID → offers analgesia for dysmenorrhoea
Progesterone only - oral norethisterone (does not work as contraceptive), depo or implant
Menorrhagia surgical mx
Endometrial ablation - suitable for women who no longer wish to conceive & can reduce HMB
Hysterectomy - definitive treatment → amenorrhoea & end to fertility
- partial or total
PCOS
Common endocrine disorder characterised by excess androgen production & presence of multiple immature follicles within the ovaries
PCOS pathophysiology
Excess LH - produced by the anterior pituitary gland in response to an increased GnRH pulse frequency
- stimulates ovarian production of androgens
Insulin resistance - high levels of insulin secretion
- suppresses hepatic production of sex hormone binding globulin → higher levels of free circulating androgens
Increased circulating androgens suppress the LH surge → follicles are arrested at an early stage & remain visible as cysts within ovary
PCOS risk factors
Diabetes
Irregular menstruation
FHx of PCOS
PCOS clinical features
Oligomenorrhoea/amenorrhoea
Infertility
Hirsutism
Obesity
Chronic pelvic pain
Depression
O/E - hirsutism, acne, acanthosis nigricans (darkened skin, which occurs secondary to insulin resistance), male pattern hair loss, obesity, HTN
PCOS diagnostic criteria
Rotterdam criteria
PCOS if:
1) oligo and/or anovulation
2) clinical and/or biochemical signs of hyperandrogenism
3) polycystic ovaries on imaging
PCOS ix
Blood tests - testosterone, SHBG, gonadotrophins, progesterone, TFTs, serum prolactin, oral glucose tolerance test
- testosterone - raised
- SHBG - low
- LH - raised, FSH - normal
- progesterone - low
Transvaginal USS - numerous peripheral ovarian follicles
PCOS oligoemnorrhoea/amenorrhoea mx
At least 3 bleeds a year (otherwise endometrial hyperplasia)
COCP
Dydrogesterone - COCP contraindicated
PCOS obesity mx
Healthy lifestyle - diet & exercise
Severe cases → orlistat (pancreatic lipase inhibitor
PCOS infertility mx
Clomifene +/- metformin
Laparoscopic ovarian drilling
PCOS hirsutism mx
Cosmetic treatment - waxing or laser
Anti-androgen medication (cyproterone, spironolactone, finasteride) → avoid in pregnancy during teratogenicity
Eflornithine cream - reduce growth rate of facial hair
Fibroids
Benign smooth muscle tumours of the uterus
Fibroids positions
Intramural (most common) - confined to the myometrium of the uterus
Submucosal - develops immediately underneath the endometrium of the uterus & protrudes into the uterine cavity
Subserosal - protrudes into & distort the serosal (outer) surface of the uterus; may be pedunculated (on a stalk)
Fibroids risk factors
Obesity
Early menarche
Increasing age
FHx
African-Americans 3x more likely than caucasians
Fibroids clinical features
Asymptomatic
Pressure symptoms +/- abdominal distention → urinary frequency/chronic retention
HMB
Subfertility
Acute pelvic pain → may occur in pregnancy due to red degeneration: rapidly growing fibroid undergoes necrosis & haemorrhage/pedunculated fibroids can undergo torsion
O/E - solid mass/enlarged non-tender uterus
Fibroids ix
Pelvic USS
MRI - sarcoma suspected
Blood tests - diagnosis unclear, pre-op work up if surgery indicated
Fibroids medical mx
Tranexamic/mefanamic acid
Hormonal contraceptives - control menorrhagia
GnRH analogues - suppress ovulation, useful pre-op to reduce size, 6 months only due to risk of osteoporosis
Selective progesterone receptor modulators - reduces size of fibroid & menorrhagia
Fibroids surgical mx
Hysteroscopy & transcervical resection of fibroid - useful for submucosal fibroids
Myomectomy - preserve uterus
Uterine artery embolisation
Hysterectomy
Fibroids complications
IDA
Compression of pelvic organs - recurrent UTIs, incontinence, hydronephrosis, urinary retention
Subfertility/infertility
Degeneration
Torsion
Cervical polyps
Benign growths protruding from the inner surface of the cervix
Cervical polyps pathophysiology
Develops as a result of focal hyperplasia of the columnar epithelium
Chronic inflammation
Abnormal response to oestrogen
Localised congestion of the cervical vasculature
More common in multigravidae, peak incidence in 50-60 year olds
Cervical polyps clinical features
Asymptomatic
Abnormal vaginal bleeding - HMB, IMG, PMB, PCB
Increased vaginal discharge
Infertility - grow large enough to block the cervical canal
O/E - cervical polyps are usually visible as polypoid growths projecting through the external os
Cervical polyps ix
Definitive diagnosis - histological examination after removal
Triple swabs
Cervical smear - rule out CIN
27% of women → associated endometrial polyps → USS
Cervical polyps mx
Small risk of malignant transformation → common practice to remove them whenever they are identified
Small polyps → polypectomy forceps, bleeding cauterised with silver nitrate
Large polyps/difficult to access → diathermy loops excision in the colposcopy clinic
Any excised polyps should be sent for histological examination to exclude malignancy
Complications of polyp removal
Infection
Haemorrhage
Uterine perforation (very rare)
Endometrial hyperplasia
Irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium
Precancerous condition
Two types - hyperplasia without atypia, atypical hyperplasia
Endometrial hyperplasia mx
Treated by a specialist using progestogens with either:
- IUS (Mirena coil)
- continuous oral progestogens
Menopause
Point at which menstruation stops, woman has had no period for 12 months
Perimenopause - refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms & irregular periods, woman > 45 years
Premature menopause - menopause < 40 years
Menopause physiology
Process begins with a decline in the development of the ovarian follicles
Without the growth of follicles → reduced production of oestrogen
Absence of negative feedback on pituitary gland, causing increasing levels of LH & FSH
Failing follicular development means ovulation does not occur → irregular menstrual cycles
Without oestrogen, endometrium does not develop, leading to lack of menstruation
Lower levels of oestrogen also cause perimenopausal symptoms
Perimenopausal symptoms
Hot flushes
Emotional lability/low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier/lighter periods
Vaginal dryness & atrophy
Reduced libido
Menopause diagnosis
Can be made in women > 45 years with typical symptoms, without performing any investigations
FSH to help with diagnosis in:
- women < 40 years with suspected premature menopause
- women aged 40-45 years with menopausal symptoms/change in cycle
Management of perimenopausal symptoms
Vasomotor symptoms are likely to resolve after 2-5 years without any treatment
HRT
Tibolone (only after 12 months of amenorrhoea)
Clonidine
CBT
SSRIs
Testosterone - treat reduced libido
Vaginal oestrogen - help with vaginal dryness & atrophy
Vaginal moisturisers
Pre-menstrual dysphoric syndrome
Describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle
Pre-menstrual dysphoric syndrome pathophysiology
Fluctuation in oestrogen & progesterone hormones during the menstrual cycle
May be due to increased sensitivity to progesterone or interaction between the sex hormones & neurotransmitters serotonin & GABA
Pre-menstrual dysphoric syndrome clinical features
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced libido
Pre-menstrual dysphoric syndrome diagnosis
Symptom diary → demonstrate cyclical symptoms that occur just before & resolve after the onset of menstruation
Definitive diagnosis (under a specialist) → administering GnRH analogues to halt the menstrual cycle & temporarily induce menopause
Pre-menstrual dysphoric syndrome mx
General healthy lifestyle changes
COCP - containing drospirenone as first line
SSRI antidepressants
CBT
Severe cases managed by MDT
GnRH analogues/hysterectomy & bilateral oophorectomy → induce menopause
