Menstrual Disorders

Question 1

Amenorrhea and types

Answer 1

= lack of menstrual bleeding

1’ = pt never developed periods
- D/T dysfuntion of hypothalmus/pituitary gland or gonads, structural pathology, imperforate hymen.

2’ = pt previously had periods but subsequently stopped
- pregnancy, menopause, physiological stress (low BW, excessive exercise, weight loss, chronic disease, psychosocial factors), PCOS, POI, thyroid hormone issues, cushings, excessive prolactin

Question 2

irregular menstruation

Answer 2

abnormal uterine bleeding
- abnormal frequency, duration, regularity and length of cycle, volume of bleeding

• indicates anovulation/irregular ovulation

D/T
- extremes of reproductive age
- PCOS
- physiological stress
- medications PO contraception, antidepressants and antipsychotics
- hormonal imbalances

Question 3

Intermenstrual bleeding

Answer 3

any bleeding between periods

can be a red flag for cancer but may also be d/t
- hormonal cont.
- cervical ectropion (delicate cells lining cervical canal spread out to the surface of cervix)
- cervical/endometrial polyps, cancer
- vaginal pathology
- pregnancy
- ovulation
- medications SSRIs or anticoags

Question 4

Dysmenorrhoea

Answer 4

PAINFUL periods
D/T
- 1’ dysmenorrhea (no underlying pathology)
- endometriosis/adenomyosis (lining of endometrium grows into uterine muscle wall)
- fibroids
- PID
- copper coil
- cervical/ovarian cancer

Question 5

Menorrhagia

Answer 5

HEAVY menstrual bleeding

D/T
- dysfunctional uterine bleeding (no identifiable cause)
- extremes of reproductive age
- fibroids
- endometriosis and adenomyosis
- PID
- contraceptives, copper coil
- Anticoags
- bleeding disorders VWD
- endocrine disorders
- connective tissue disorders
- endometrial hyperplasia
- PCOS

Question 6

postcoital bleeding

Answer 6

red flag for cancers, often no cause found

D/T
- cervical cancers
- trauma
- atrophic vaginitis (tissues lining the inside of the vaginal become thin, dry inflamed.
- polyps
- endometrial cancer
- vaginal cancer

Question 7

Pelvic Pain

Answer 7

acute or chronic

D/T
- UTI
- dysmenorrhea
- IBS
- ovarian cysts
- endometriosis
- PID
- Ectopic pregnancy
- appendicits
- mittelschmerz (cyclical pain during ovulation)
- pelvic adhesions
- ovarian torsion
- IBD

Question 8

Vaginal Discharge

Answer 8

D/T
- BV
- candidiasis
- chlamydia
- gonorrhoea
- trichomonas vaginalis
- foreign body
- cervical ectropion
- polyps
- malignancy
- pregnancy
- ovulation
- hormonal contraception

Question 9

Pruritus Vulvae

Answer 9

itching of vulva and vagina

D/T
- irritants
- atrophic vaginitis
- infections
- skin conditions e.g eczema
- vulval malignancy
- pregnancy-related vaginal discharge
- urinary or faecal incontinence
- stress

Question 10

Hormones in the menstrual cycle

Answer 10

FSH : stimulates development of egg and release of oestrogen

LH : stimulates release of egg and oestrogen and progesterone

Oestrogen : growth of uterine lining,
- inhibits FSH = no egg development
- promotes LH = egg release
- inhibits LH after ovulation

Progesterone : maintains uterine lining
- inhibits LH after ovulation

Question 11

Primary Amenorrhea

Answer 11

not starting menstruation:
- by 13 when there is no other evidence of pubertal development
- by 15 when no other signs of puberty

Hypogonadism
- HYPOgonadotrophic hypogonadism = deficiency of LH and FSH
- HYPERgonadotrophic hypogonadism = lack of response to LH and FSH by gonads

Question 12

Androgen insensitivity syndrome

Answer 12

results in female phenotype (except for internal pelvic organs), as tissues do not respond to androgen hormones = typical male characteristics do not develop.

pts have normal female external genitalia and breast tissue, but internally there are testes in abdo or inguinal canal and absent uterus, upper vagina, fallopian tubes and ovaries.

Question 13

Congenital Adrenal Hyperplasia

Answer 13

congenital deficiency of 21-hydroxylase enzyme
= underproduction of cortisol + aldosterone
= over production of androgens

severe cases = neonate unwell shortly after birth with electrolyte disturbances + hypoglycaemia

mild cases = female patients can present later in childhood
- tall
- facial hair
- primary amenorrhea
- deep voice
- early puberty

Question 14

Structural pathologies

Answer 14

• imperforate hymen
• transverse vaginal septae
• vaginal agenesis
• absent uterus
• FGM

Question 15

management of primary amenorrhea

Answer 15

• replacement hormones where necessary
• reassurance and observation for pts with constitutional delay in growth and development
• reduce stress, CBT and healthy weight gain
• pulsatile GnRH for pts with hypogonadotrophic hypogonadism or Kallman syndrome (avoids down regulation of GnRH receptor)
• in the case where pregnancy is not wanted, replacement hormones can be given via COCP to induce regular menstrual cycles
• ovarian causes of amenorrhea (PCOS, damage to ovaries) COCP may be used to induce regular menstruation and prevent symps of oestrogen deficiency

Question 16

Hormone Testing for secondary amenorrhea

Answer 16

HCG - rule out pregnancy

high FSH - Primary ovarian failure
high LH or LH:FSH = PCOS

prolactin = hyperprolactinaemia

TSH = hyper/hypothyroid

Raised testosterone = PCSO, Androgen insensitivity syndrome, congenital adrenal hyperplasia