Menstrual Disorders Flashcards
Define primary amenorrhoea
Primary amenorrhoea is menstruation has not started by the age of 16
Define Delayed puberty
Delayed puberty is when secondary sexual characteristics are not present by age 14
Define secondary amenorrhoea
Secondary amenorrhoea is when menstruation ceases for 3 months
Define Oligomenorrhoea
Oligomenorrhoea is when menstruation occurs every 35 days to 6 months
Classification of causes amenorrhoea
- Physiological- pregnancy , lactation and menopause
- Constitutional delay
- Pathological- hypothalamus, pituitary, thyroid, adrenals, ovary or uterus and out flow tract
- Drugs- GnRH analogues, progestogens, antipshycotics
Causes of amenorrhoea due to Hypothalamic hypogonadism
- Psychological factors
- Low weight
- Anorexia nervosa
- Excessive exercise
- Tumours are rare- craniopharyngiomas
GnRH /FSH/LH / oestradiol are low
What is Kallmann’s syndrome?
Rare congenital absence of GnRH neurons
Amenorrhoea associated with anosmia and colour-blindness
Treatment of Hypothalamic causes of amenorrhoea
- Supportive
- Bone density needs monitoring
- Oestrogen replacement with progesterone for endometrial protection – COC or HRT
- Psychiatric treatment for anorexia nervosa
Pituitary causes of amenorrhoea
- Hyperprolactinemia- pituitary hyperplasia or benign adenomas
- MRI – Micro or macroadenomas of pituitary
- Treatment with dopamine agonists like bromocriptine /cabergoline /surgery
- Sheehan’s syndrome- severe postpartum haemorrhage causes pituitary necrosis and hypopituitarism
Adrenal and thyroid gland causes of amenorrhoea
- Over and under active thyroid both can cause amenorrhoea
- Hypothyroidism causes hyperprolactinemia and amenorrhoea
- Congenital adrenal hyperplasia and some virializing tumours cause amenorrhoea
Ovarian causes of amenorrhoea
- PCOS- usually causes oligomenorrhoea and can cause amenorrhoea
- Virilizing tumours of ovary are rare
Investigations for Premature menopause
- autoantibody screen for ovarian autoantibodies
- screening for other autoimmune disease
- possible infection (including mumps and HIV)
- baseline bone densitometry scan.
Congenital causes of amenorrhoea
- Turner’s syndrome
- outflow tract obstructions
- Gonadal agenesis and androgen insensitivity (46XY with female phenotype) are rare
Core features of Turner’s Syndrome
X chromosome is absent 45 XO •Short stature •Under developed secondary sexual characters •Normal intelligence
Out flow tract problems causing amenorrhoea
CONGENITAL:
•Imperforate hymen and transverse vaginal septum. Note: normal secondary sexual characters and amenorrhoea
Treatment: Treatment is surgical resection and use of vaginal dilators
ACQUIRED
•Cervical stenosis- hematometra
•Asherman’s syndrome-uterine synaechia due to excessive curettage
•Treatment-hysteroscopic lysis of adhesions
Define haematocolpos
Blood accumulates in the vagina due to Imperforate hymen and transverse vaginal septum –obstruct menstrual flow
Define haematometra
Blood accumulates in the uterus due to Imperforate hymen and transverse vaginal septum –obstruct menstrual flow
Rokitansky syndrome
- Rokitansky syndrome- absence of the vagina with or without a functioning uterus.
- Complete müllerian agenesis is the second most common cause of primary amenorrhoea (10%) after gonadal dysgenesis (40%)
- Also known as Mayer-Rokitansky-Kuster-Hauser syndrome
- Ovarian development and function is normal.
- Vaginal dilators
Primary Amenorrhea-History
- evidence of psychological dysfunction or emotional stress
- mother and sister’s gynaecological and obstetric history
- family history of genetic disorders or diabetes
- family history of delayed puberty
- pubertal development
- the presence of galactorrhoea
- symptoms of hypothyroidism
- weight loss or gain
- hirsutism virilisation
- menopausal symptoms
- sexual activity
- headache or visual disturbance, poluria, polydipsia
- anosmia
- chronic systemic illness, chemotherapy, radiotherapy.
Relevance of pubertal development history to primary amenorrhea
lack of pubertal development suggests deficient estradiol secretion, which could be due to a hypothalamic or pituitary disorder, ovarian failure, and/or a chromosomal abnormality
Relevance of galactorrhea history to primary amenorrhea
may be due to hyperprolactinemia
Relevance of thyroid history to primary amenorrhea
Hypo and hyper can alter menstruation
Relevance of hirsutism or virilisation history to primary amenorrhea
virilisation may be due to due to an androgen-secreting ovarian or adrenal tumor, or 5-alpha-reductase deficiency
Relevance of visual disturbance history to primary amenorrhea
suggestive of CNS tumor such as craniopharyngioma
Relevance of polyuria history to primary amenorrhea
Relevance of visual disturbance history to amenorrhea
Relevance of anosmia history to primary amenorrhea
anosmia – one of the causes is Kallmans syndrome
Secondary Amenorrhea -History
- Pregnancy
- irregular menstrual cycles
- malaise, fatigue, anorexia, weight loss
- heterotopic ossification (h/o) following head injury
- headaches
- galactorrhoea
- h/o postpartum haemorrhage
- h/o dilation and curettage
- medications – contraception, antidepressants and antipsychotics, chronic opioid use.
Secondary Amenorrhea Red flag symptoms
- rapid virilisation – may be due to androgen-secreting tumors
- hyperprolactinemia – may be associated with intracranial tumors.
Relevance of h/o dilation and curettage history to secondary amenorrhea
may be associated with Ashermans syndrome
Relevance of h/o postpartum haemorrhage history to secondary amenorrhea
may be associated with Sheehans syndrome
Relevance of headaches history to secondary amenorrhea
may be suggestive of CNS tumor
Relevance of galactorrhoea history to secondary amenorrhea
may be due to prolactinoma
Relevance of irregular menstrual cycles history to secondary amenorrhea
associated with polycystic ovary syndrome
General Examination – Primary Amenorrhea
•Weight, height, body mass index (BMI) •Shortened height may suggest a chromosomal abnormality. Women with gonadal dysgenesis and hypoestrogenaemia are at risk of a shortened final adult height •Clinical thyroid status •Dysmorphic signs •Any hirsuitism, acne etc. •Tanner breast and axillary hair stages •Low hairline, webbed neck, widely spaced nipples etc are suggestive of Turners syndrome Abdomen/pelvis- •Mass arising from pelvis •Groin node/herniae
Pelvic examination - Primary Amenorrhea
Perineum-
Inspection is often all that is required, especially in women who are not sexually active. Note the presence and distribution of pubic hair, clitoral size, configuration of hymen, relationship of anus, vagina and urethra to hymen, the degree of estrogenisation and perineal hygiene.
The hymen and vestibule may be visualised with gentle lateral spread of the labia majora with two fingers and a deep inspiration/valsalva manoeuvre by the patient
Speculum examination - Primary Amenorrhea
The hymen must be assessed first. A blind vaginal pouch is seen in patients with Mullerian agenesis, transverse vaginal septum, or androgen insensitivity syndrome (along with inguinal hernias).
The uterine cervix should be noted on examination if able o see.
In which conditions would you see a blind vaginal pouch on speculum examination?
A blind vaginal pouch is seen in patients with Mullerian agenesis, transverse vaginal septum, or androgen insensitivity syndrome (along with inguinal hernias).
General Examination – Secondary Amenorrhea
- High BMI-PCOS
- Reduced BMI with stress or anorexia nervosa.
- Male pattern baldness and features of virilisation may be due to androgen secreting tumors of the ovary.
- Assess for galactorrhoea by doing a breast examination.
- Look out for features of hypothroidism.
Investigations for amenorrhea
- Pregnancy test
- FSH/LH
- Prolactin
- Testosterone
- Thyroid function tests
- Oestrogen and progesterone challenge test
- Sex Hormone Binding Globulin
- Free androgen index
- Dehydroepiandrostenindione
Imaging: •Ultrasound •MRI pelvis •HSG /Sonohysterography •Karyotyping
Key investigation in amenorrhoea
FSH
- Secondary sexual characters normal-obstructed outflow tract as in haematometra and haematocolpos
- Raised LH/FSH ratio and normal secondary sexual charecters-PCOS
Amenorrhea, Absence of secondary sexual characters, High FSH and hypertension is suggestive of which condition?
17-alpha hydroxylase deficiency.
Check blood levels of 17-alpha hydroxyprogesterone in these patients (low values expected)
Amenorrhea, Absence of secondary sexual characters, High FSH and short stature is suggestive of which condition?
Turners
Request karyotyping
Amenorrhea, High FSH and LH and normal height is suggestive of which condition?
ovarian failure or male karyotype.
Amenorrhea, low FSH and LH and short statue is suggestive of which condition?
intracranial lesions such as craniopharyngioma tumors
Amenorrhea, low FSH and LH and normal statue is suggestive of which condition?
Low LH and FSH which is low or normal, with normal height, may indicate weight loss, celiac disease, type 1 diabetes, anorexia nervosa or exercise
Normal prolactin level?
- normal prolactin levels are <500 mIU/ml
- If >1000 mIU/ml), the woman should be referred to an endocrinologist and MRI of the brain should be performed to diagnose pituitary adenomas
Amenorrhea and Raised Testosterone is suggestive of which conditions>?
Testosterone >5 nmol/l is found with: • androgen insensitivity, •androgen secreting tumors, •Cushings syndrome and • late onset congenital adrenal hyperplasia
Use of ultrasound in patients with Amenorrhea?
- Test for polycystic ovaries
- normal uterine anatomy
- Ashermans syndrome
Use of MRI Pelvis in patients with Amenorrhea?
•uterus is absent – may indicate complete Mullerian agenesis or Mayer-Rokinstanksy-Kustner-Hauser syndrome, or androgen insensitivity
If the uterus is present – may show streak ovaries as in Turners syndrome or outflow tract obstruction
Use of Sonohysterography or hysterosalpingography- in patients with Amenorrhea?
To rule out Asherman’s syndrome
Treatment of amenorrhoea in hyperprolactinemia?
Bromocriptine
Treatment of amenorrhoea in outflow obstruction?
cruciate incision
Treatment of amenorrhoea in asherman’s?
Hysteroscopic resection of adhesions
Treatment of amenorrhoea in XY female?
Gonadectomy in XY female
Define Heavy Menstrual Bleeding
Excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and /or material quality of life.
Define Abnormal Uterine Bleeding
Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration or heavy), regularity, timing (delayed or frequent) or is non-menstrual (IMB, PCB or PMB)
Define Inter Menstrual Bleeding
Uterine bleeding that occurs between clearly defined cyclic and predictable menses. Such bleeding may occur at random times or may manifest in a predictable fashion at the same day in each cycle
Pathophysiology of abnormal uterine bleeding
- In majority no demonstrable pathology
- The precise cause is at the level of endometrium
- Abnormalities in the prostaglandin and fibrinolytic systems in the endometrium
Aetiology abnormal uterine bleeding
Aetiology Uterine fibroids (20–30%)
Uterine polyps (5–10%)
Adenomyosis (5%)
Endometriosis rarely presents as AUB, but is identified in <5% of cases of AUB.
Gynaecological malignancy rarely presents as HMB, but can present as prolonged intermenstrual bleeding (IMB), postcoital bleeding (PCB), postmenopausal bleeding (PMB)
PALM-COEIN clarification of AUB
Structural P Endometrial polyps, cervical polyps A Adenomyosis L Leiomyoma M Pre-malignancy(endometrialhyperplasia) Malignancy of genital tract (cervical, endometrial, ovarian, vaginal, vulval, sarcoma of endometrium or myometrium)
Non-structural
C -Systemic coagulopathy, e.g. thrombocytopenia, von Willebrand’s disease, leukaemia, warfarin
O -Disorders of ovulatory function, e.g. polycystic ovary syndrome, congenital adrenal hyperplasia, hypothyroidism, Cushing’s disease, hyperprolactinaemia
E- Primary endometrial disorders, e.g. disturbances of local endometrial haemostasis, vasculogenesis or inflammatory response (chronic endometritis)
I -Iatrogenic causes, e.g. exogenous sex steroid administration (combined oral contraceptives, progestins, tamoxifen), intrauterine contraceptive device, traumatic uterine perforation
N- Generally rare causes, e.g. arteriovenous malformations, myometrial hypertrophy, sex steroid secreting ovarian neoplasm, chronic renal or hepatic disease, endometriosis
Investigations for AUB
- full blood count (FBC)
- cervical smear
- pelvic infection swabs and pelvic ultrasound • coagulation screen
Management of AUB
- Initial step should be to exclude pregnancy
- Undertake relevant gynaecological history and examination
- Referral to secondary care (one-stop or rapid access clinic) if malignancy is suspected, endometrial biopsy is required, pathology suspected/identified or medical treatment deemed unsuccessful; collectively termed ‘red flag’ features
Red flags for AUB
- PCB: postcoital bleeding
- PMB: postmenopausal bleeding
- IMB: intermenstrual bleeding;
- uterus>10wks
- FBC: full blood count (anaemia tends to indicate severe HMB).
Indications for endometrial biopsy for AUB
o Persistent intermenstrual bleeding
o Aged more than 45
o Treatmentfailure
o Ineffective treatment
Indications for imaging – for AUB
o Uterus palpable abdominally
o Pelvic mass of uncertain origin
o failure of medical treatment
Investigations for AUB
o Ultrasound is the first line diagnostic tool
o Hysteroscopy should be used only when ultrasound is inconclusive
o MRI, Dilatation and Curettage and saline infusion sonography are not used
Treatment for AUB
Depends on • Age • Pathology found • Desire for fertility • Informed choice
Medical Hormonal
Non hormonal Surgical
Endometrial ablation procedures Uterine artery embolisation Hystrectomy /myomectomy
Medical Treatment of AUB
First line treatment-
Treatment
Levonorgestrel releasing intrauterine system LNG-IUS
Second line treatment-
Tranexamic acid / non steroidal anti inflammatory agents / Combined
oral contraceptive pills
Third line treatment-
Norethisterone 15mg daily from day 5 to 26 of the cycle of injectable
long acting progestogens
NICE Guideline January 2007
Mirena IUS advantages and disadvantages
• Advantages- Ease of application Lack of need for anaesthesia Contraceptive benefit Fertility preserving benefit Mirena IUS • Side effects- Irregular bleeding for 6months, Breast tenderness, acne, headaches . Uterine perforation at the time of insertion No risk of PID , ectopic
Which patients would be suitable for Endometrial ablation techniques
- No desire for fertility
- Advised effective contraception
- Normal histology
- Uterus <10wk
- Fibroid <3cm
contraindications • Wishes to retain fertility • Genital tract malignancy • Unexplained vaginal bleeding • Active pelvic infection • Uterine abnormalities • Previous uterine surgery leaving uterine wall < 8 cm
Types of hystrectomy
• Totalorsubtotal
• Oopherecotmyathystrectomy
• Laparoscopic assisted vaginal hystrectomy
• •
Not remove healthy ovaries
Family history of ovarian/breast cancer- should have genetic counseling
What is Adenomyosis?
• Adenomyosis is a benign, common gynaecological condition causing heavy, painful periods Treatment- Medical Surgical OC pills Mirena Ablation Hystrectomy premenopausal women multiparous 40 and 50 years of age
Define Postmenopause
the time after the complete cessation of menstruation. After 12 months of amenorrhoea.
Define Premature menopause
menopause that occurs before the age of 40 years.
Define Menopause
is the last menstrual period. The average age at menopause is approximately 51 years. A family history of early menopause (heritability 30–70%), type 1 diabetes mellitus and smoking might cause earlier onset of menopause.
Define Peri menopause or climacteric
- Greek word klimakter, meaning literally a rung of a ladder or, figuratively, a critical point
- It is the time period from when the ovaries start to fail (and symptoms such as irregular periods or hot flushes may begin) until 12 months after the last menstrual period.
Key Physiology underlying menopause
- Decrease in primordial follicles after age 40
- Decrease in oestrogen
- Decrease in inhibin B
- Negative feedback on FSH is lost
- Hence increase in FSH
- Stimulate synthesis of androgens
Define osteopenia vs osteoporosis
Based on Bone mineral density (BMD) T score- is the number of standard deviations (SD) by which a particular bone differs from the young normal mean.
Osteopenia - between T score -1 to -2.5
Osteoporosis is T score lower than -2.5
Most common sites of osteoporotic fractures
most common site is wrist or Colles’fracture , hip and spine
Risk factors for osteoporosis
Low BMI early menopause Smoking/alcohol Sedentary life/ low calcium intake Steroids Rheumatoid arthritis/ chronic liver disease/hyperthyroidism/ hypogonadism/hyperparathyroidism
Investigations for menopause
- FSH levels give an estimate of the degree of ovarian reserve remaining
- Women over 45 years can be diagnosed by symptoms
- Anti-Mullerian hormone (AMH)-Direct measure of ovarian reserve
- AMH-interpretation in diagnosis of menopause should be made in context of clinical features
- Thyroid function tests –if there is no response to treatment
- Dual energy X ray absorptiometry (DEXA)- is used to measure BMD
Main types of HRT and indication
- Oestrogen –alone in women with out uterus
* Oestrogen and progesterone – in women with uterus
What is Tibilone?
- Synthetic steroid
- Converted in the body into oestrogenic/progestogenic/androgenic metabolites
- Treats vasomotor/psychological/libido /reduces risk for fractures
- Androgens- can be used to increase libido
Benefits of HRT
- Menopausal symptoms-oestrogen is effective in treating hot flushes
- Vaginal dryness/dyspareunia/urinary symptoms response to tropical oestrogens
- Testosterone to improve libido
- HRT reduces risk of spine and hip fracture
Risks of HRT
- Breast cancer- combined HRT increases risk -4 per 1000 after use of 5 years. Risk falls after stopping the HRT
- Endometrial cancer-unopposed oestrogen therapy increases risk of endometrial cancer.
- Oral HRT increases venous thromboembolism by two fold from background. Transdermal and gel HRT have less risk,
- Gall bladder disease – increased
HRT and Cardiovascular disease Risk
- does not increase cardiovascular disease risk when started in women aged under 60 years
- does not affect the risk of dying from cardiovascular disease.
- the baseline risk of coronary heart disease and stroke for women around menopausal age varies from one woman to another according to the presence of cardiovascular risk factors
- HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease
- HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease.
- Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke.
Duration of HRT
- Treatment is continued for 5 years and stopped to evaluate symptoms
- Osteoporosis- is effective in women before age 60 years or within 10 years of menopause and may need life long
Non hormonal treatments for menopause
- Clonidine (alpha agonist)– may be used for hot flushes
- Selective Serotonin reuptake inhibitors (SSRIs)-Fluoxetine
- Vaginal lubricants
Prevention and treatment of osteoporosis
Bisphosphonates-alendronate
•Inhibits bone resorption
•Gastrointestinal irritation is the main side effect
Raloxifene (Selective oestrogen receptor modulator ) SERM-reduces incidence of vertebral fractures
Calcium and Vitamin D supplements- useful if insufficiency exists
