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Y4 reproductive health > Menstrual disorders > Flashcards

Menstrual disorders Flashcards

1
Q

Primary amenorrhoea

A

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)
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2
Q

Hypogonadism

A

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
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3
Q

Hypogonadotropic hypogonadism

A

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
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4
Q

Hypergonadotropic hypogonadism

A

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)
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5
Q

Kallman syndrome

A

Genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty

Associated with reduced or absent sense of smell

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6
Q

Congenital adrenal hyperplasia

A

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
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7
Q

Androgen insensitivity syndrome

A

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)

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8
Q

Primary amenorrhoea structural pathology

A

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
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9
Q

Primary amenorrhoea ix

A

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

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10
Q

Primary amenorrhoea mx

A

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

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11
Q

Secondary amenorrhoea

A

The cessation of previously established menstruation for 3 cycles or for 6 or more month

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12
Q

Secondary amenorrhoea causes

A

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

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13
Q

Hyperprolactinaemia

A

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

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14
Q

Secondary amenorrhoea ix

A

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

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15
Q

Secondary amenorrhoea mx

A

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
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16
Q

Irregular menstrual bleeding causes

A

Physiological changes - menarche or menopause

GUM infections

Endometrial hyperplasia

Endometrial/cervical cancer

Fibroids

Pregnancy

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17
Q

Irregular menstrual bleeding ix

A

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

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18
Q

Irregular menstrual bleeding mx

A

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
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19
Q

Dysmenorrhoea

A

Severe or debilitating pain that occurs in conjunction with menstruation

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20
Q

Dysmenorrhoea causes

A

Primary - idiopathic & occurs in absence of pelvic pathology

Secondary - associated with underlying pathology

  • endometriosis
  • PID
  • uterine fibroids
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21
Q

Dysmenorrhoea ix

A

Rule out STIs

Examination for abdominal tenderness/mass, bimanual examination assessing for cervical tenderness

Pelvic USS if investigations suggest underlying pathology

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22
Q

Dysmenorrhoea mx

A

NSAIDs

Tranexamic acid

COCP, POP, IUS, injection, implant

Surgical interventions - endometrial ablation or hysterectomy

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23
Q

Menorrhagia

A

Description of excessive menstrual loss which interferes with a woman’s quality of life

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24
Q

Menorrhagia aetiology

A

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
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25
Q

Menorrhagia clinical features

A

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

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26
Q

Menorrhagia ix

A

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

27
Q

Menorrhagia pharmacological mx

A

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

28
Q

Menorrhagia surgical mx

A

Endometrial ablation - suitable for women who no longer wish to conceive & can reduce HMB

Hysterectomy - definitive treatment → amenorrhoea & end to fertility

  • partial or total
29
Q

PCOS

A

Common endocrine disorder characterised by excess androgen production & presence of multiple immature follicles within the ovaries

30
Q

PCOS pathophysiology

A

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

31
Q

PCOS risk factors

A

Diabetes

Irregular menstruation

FHx of PCOS

32
Q

PCOS clinical features

A

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

33
Q

PCOS diagnostic criteria

A

Rotterdam criteria

PCOS if:

1) oligo and/or anovulation

2) clinical and/or biochemical signs of hyperandrogenism

3) polycystic ovaries on imaging

34
Q

PCOS ix

A

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

35
Q

PCOS oligoemnorrhoea/amenorrhoea mx

A

At least 3 bleeds a year (otherwise endometrial hyperplasia)

COCP

Dydrogesterone - COCP contraindicated

36
Q

PCOS obesity mx

A

Healthy lifestyle - diet & exercise

Severe cases → orlistat (pancreatic lipase inhibitor

37
Q

PCOS infertility mx

A

Clomifene +/- metformin

Laparoscopic ovarian drilling

38
Q

PCOS hirsutism mx

A

Cosmetic treatment - waxing or laser

Anti-androgen medication (cyproterone, spironolactone, finasteride) → avoid in pregnancy during teratogenicity

Eflornithine cream - reduce growth rate of facial hair

39
Q

Fibroids

A

Benign smooth muscle tumours of the uterus

40
Q

Fibroids positions

A

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)

41
Q

Fibroids risk factors

A

Obesity

Early menarche

Increasing age

FHx

African-Americans 3x more likely than caucasians

42
Q

Fibroids clinical features

A

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

43
Q

Fibroids ix

A

Pelvic USS

MRI - sarcoma suspected

Blood tests - diagnosis unclear, pre-op work up if surgery indicated

44
Q

Fibroids medical mx

A

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

45
Q

Fibroids surgical mx

A

Hysteroscopy & transcervical resection of fibroid - useful for submucosal fibroids

Myomectomy - preserve uterus

Uterine artery embolisation

Hysterectomy

46
Q

Fibroids complications

A

IDA

Compression of pelvic organs - recurrent UTIs, incontinence, hydronephrosis, urinary retention

Subfertility/infertility

Degeneration

Torsion

47
Q

Cervical polyps

A

Benign growths protruding from the inner surface of the cervix

48
Q

Cervical polyps pathophysiology

A

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

49
Q

Cervical polyps clinical features

A

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

50
Q

Cervical polyps ix

A

Definitive diagnosis - histological examination after removal

Triple swabs

Cervical smear - rule out CIN

27% of women → associated endometrial polyps → USS

51
Q

Cervical polyps mx

A

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

52
Q

Complications of polyp removal

A

Infection

Haemorrhage

Uterine perforation (very rare)

53
Q

Endometrial hyperplasia

A

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

54
Q

Endometrial hyperplasia mx

A

Treated by a specialist using progestogens with either:

  • IUS (Mirena coil)
  • continuous oral progestogens
55
Q

Menopause

A

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

56
Q

Menopause physiology

A

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

57
Q

Perimenopausal symptoms

A

Hot flushes

Emotional lability/low mood

Premenstrual syndrome

Irregular periods

Joint pains

Heavier/lighter periods

Vaginal dryness & atrophy

Reduced libido

58
Q

Menopause diagnosis

A

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
59
Q

Management of perimenopausal symptoms

A

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

60
Q

Pre-menstrual dysphoric syndrome

A

Describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle

61
Q

Pre-menstrual dysphoric syndrome pathophysiology

A

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

62
Q

Pre-menstrual dysphoric syndrome clinical features

A

Low mood

Anxiety

Mood swings

Irritability

Bloating

Fatigue

Headaches

Breast pain

Reduced libido

63
Q

Pre-menstrual dysphoric syndrome diagnosis

A

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

64
Q

Pre-menstrual dysphoric syndrome mx

A

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

Y4 reproductive health (11 decks)

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