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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

Transvaginal 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
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
26
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
27
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
28
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
29
PCOS
Common endocrine disorder characterised by excess androgen production & presence of multiple immature follicles within the ovaries
30
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
31
PCOS risk factors
Diabetes Irregular menstruation FHx of PCOS
32
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
33
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
34
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
35
PCOS oligoemnorrhoea/amenorrhoea mx
At least 3 bleeds a year (otherwise endometrial hyperplasia) COCP Dydrogesterone - COCP contraindicated
36
PCOS obesity mx
Healthy lifestyle - diet & exercise Severe cases → orlistat (pancreatic lipase inhibitor
37
PCOS infertility mx
Clomifene +/- metformin Laparoscopic ovarian drilling
38
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
39
Fibroids
Benign smooth muscle tumours of the uterus
40
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)
41
Fibroids risk factors
Obesity Early menarche Increasing age FHx African-Americans 3x more likely than caucasians
42
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
43
Fibroids ix
Pelvic USS MRI - sarcoma suspected Blood tests - diagnosis unclear, pre-op work up if surgery indicated
44
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
45
Fibroids surgical mx
Hysteroscopy & transcervical resection of fibroid - useful for submucosal fibroids Myomectomy - preserve uterus Uterine artery embolisation Hysterectomy
46
Fibroids complications
IDA Compression of pelvic organs - recurrent UTIs, incontinence, hydronephrosis, urinary retention Subfertility/infertility Degeneration Torsion
47
Cervical polyps
Benign growths protruding from the inner surface of the cervix
48
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
49
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
50
Cervical polyps ix
Definitive diagnosis - histological examination after removal Triple swabs Cervical smear - rule out CIN 27% of women → associated endometrial polyps → USS
51
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
52
Complications of polyp removal
Infection Haemorrhage Uterine perforation (very rare)
53
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
54
Endometrial hyperplasia mx
Treated by a specialist using progestogens with either: - IUS (Mirena coil) - continuous oral progestogens
55
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
56
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
57
Perimenopausal symptoms
Hot flushes Emotional lability/low mood Premenstrual syndrome Irregular periods Joint pains Heavier/lighter periods Vaginal dryness & atrophy Reduced libido
58
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
59
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
60
Pre-menstrual dysphoric syndrome
Describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle
61
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
62
Pre-menstrual dysphoric syndrome clinical features
Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced libido
63
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
64
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

Y4 reproductive health (11 decks)

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