Menstrual Disorders

Question 1

What’s the difference between primary and secondary amenorrhea? what are some causes?

Answer 1

Primary - never started periods by age 16

Secondary- started and then no periods for over 6 months

Can overlap in presentation bc secondary causes may present as primary if early enough in life

Causes of primary and secondary:
Hypothalamus - kallmann’s syndrome (idiopathic hypogonadotrophic hypogonadism- GnRH deficiency + anosmia), stress
Pituitary gland - pituitary tumour, haemorrhage, necrosis - sheehan s
FSH/ LH - hypothyroidism/hyper or hyperprolactinemia
Uterus - ovarian failure
Primary ovarian insufficiency (menopause before 40)
Asherman’s syndrome - intrauterine adhesions
PCOS

Causes of just primary:
Anatomical abnormalities with genitalia/ genetic disorders of uterus/ ovaries/ genitals e.g. imperforate hymen, Mullerian agenesis, Turners (dysgenesis ovaries), androgen insensitivity syndrome (intersex)

Question 2

What is Turner’s syndrome?

Answer 2

Most common cause of primary amenorrhea

One X chromosome 46X0

Ovary does not complete its normal development (dysgenesis) only storms present at birth (streak ovaries/ gonads)

Low oestradiol, high FSH and LH (no progesterone)

No oestrogen = no pubertal changes e.g. short stature, poor breast development, widely spaced nipples

Other features: construction of aorta, low hairline, shelled shaped thorax, small fingernails, brown spots (nevi), kidney problems, scholisosis, hypothyroidism

Question 3

Anatomical causes of primary amenorrhea

Answer 3

20% cases

• Imperforate hymen (thin mucosal tissue covers vagina)
• transverse vaginal septum rare
• Mullerian agenesis (no uterus and upper vaginal hypoplasia)

Question 4

What is complete androgen insensitivity syndrome?

Answer 4

Cause of primary amenorrhea

X- linked recessive disorder

Resistant to testosterone due to defect in androgen receptor so no mesonephric duct development but do have MIH so no paramesonephric ducts either

46XY so have testis in labia/ inguinal area, a sense of upper vagina/ uterus & Fallopian tubes but normal female phenotype externally (no dihydrotestosterone to cause fusion)

The testes should be surgically excised after puberty

Question 5

What is kallman syndrome?

Answer 5

GnRH deficiency ‘idiopathic hypogonadotrophic hypogonadism’ autosomal dominant or X-linked recessive -> poor development of secondary sexual characteristics can be isolated Or + anosmia = kallman syndrome

Remember could just be a constitutional delay of puberty

Question 6

Anatomical causes of secondary amenorrhea?

Answer 6

Scarring- cervical stenosis or Asherman syndrome (intrauterine adhesions) from repeated ops/ infection

Ovarian disorders- primary ovarian insufficiency ‘premature menopause’ depletion oocytes before 40, no oestrogen/ Inhibin -> high FSH

Question 7

What is polycystic ovary syndrome?

Answer 7

Cause of 20% secondarya amenorrhea and 50% oligomenorrhea, can present as primary

Elevated Lh and testosterone

Raised insulin resistance

Can be asymptomatic or hirsutism/ acne/ anovulatory symptoms/ obesity/ infertility

Multiple small cysts 4-6cms

✅COCP/ lifestyle advice

Question 8

How does thyroid disease cause secondary amenorrhea?

Answer 8

Hypothyroidism (leads to hyperprolactinemia) -> low T3/T4 -> hypothalamus secrete more TRH -> stimulates TSH + prolactin -> prolactin inhibits GnRH release -> nonFSH/ LH -> no oestrogen

Severe hyperthyroidism -> high T3/T4 -> liver produces XS sex-hormone binding globulin -> binds oestrogen so not in free form

Question 9

What two conditions lead to secondary amenorrhea by affecting the pituitary gland?

Answer 9

Prolactinoma non-cancerous adenoma of pituitary gland increases prolactin (high PRL >800) CT head shows enhancing pituitary macroadenoma

Or

Pituitary necrosis - Sheehan syndrome

Question 10

Functional hypothalamic amenorrhea causes

Answer 10

Weight loss
XS exercise
Emotional stress/ induced illness

Question 11

2 causes of physiological amenorrhea

Answer 11

Pregnancy - bHCG

Menopause - FSH increase

Question 12

What different categories fall under abnormal uterine bleeding and what are the limits? What are some terms for when these categories fall outside the normal limits?

Answer 12

Frequency
A period every 24-38 days✅
Absent = amenorrhea
Infrequent = oligomenorrhea

Regularity (variation)
Difference between longest & shortest cycle in 6 months
Less than 7-9days difference✅
Irregular- metrorrhagia

Duration of flow(days)
<8 days✅
Prolonged

Volume (objective)
5-80ml per period✅
Heavy= menorrhagia

Volume (subjective)
Doesn’t interfere quality of life✅

Question 13

What classifies abnormal uterine bleeding as acute or chronic?

Answer 13

Acute- episode of heavy bleeding that is sufficient to require immediate clinical intervention to stop further blood loss

Chronic- bleeding abnormal volume/ duration/ regularity/ frequency for most of previous 6months

Question 14

What are postcoital symptoms?

Answer 14

After sex

Question 15

Causes of abnormal uterine bleeding (there’s a pneumonic)

Answer 15

PALM- COEIN

Structural:
Polyps endometrial

Adenomyosis (endometrium breaks into myometrium of uterus)

Leiomyoma (fibroid) benign smooth muscle tumour

Malignancy/ hyperplasia

Non-structural:
Coagulopathy

Ovulatory dysfunction (includes thyroid)

Endometrial

Iatrogenic (caused by physician)

Not yet classified (dysfunctional uterine bleeding)

Question 16

What are fibroids? Prevalence, complications, risk factors

Answer 16

Benign tumours of uterine smooth muscle = leiomyoma

Oestrogen dependent

40% prevalence

Complications: hMB and IMB (abnormal uterine bleeding), subfertility, recurrent pregnancy loss, bulk pressure effects, rare malignant change to leiomyosarcoma

Risks: African descent, no current children, obesity, older

Question 17

What is dysfunctional uterine bleeding?

Answer 17

Bleeding of endometrial origin

Diagnosis of exclusion - HMB in a sense of pathology

Common at extremes of reproductive life

Subdivided into:

• anovulatory inadequate signal, impaired positive feedback
• ovulatory ‘idiopathic’ secondary to increased prostaglandins and rescued vasoconstrictors or genetic ?

Question 18

What is dysmenorrhea? Typical symptoms and presentation, different types

Answer 18

Painful menstruation

Crampy and intermittently intense or continuous dull ache in lower abdo and suprapubic region

45-95% women of reproductive age

1-2 days before or with inset of menses
Improved 12-72hrs

Primary or
Secondary (more likely caused endometriosis, IBD, ovarian cysts)

Question 19

What is endometriosis? Prevalence, symptoms, common sites

Answer 19

Endometrial glands and storms that occur outside the uterine cavity

5-10% prevalence
Risk factors: nulliparity, early menarche, short cycles, menorrhagia, low BMI

Oestrogen -dependent, benign, inflammatory disease response to cyclical hormonal changes

Common sites: ovaries (chocolate cysts), bladder, rectum, pouch of Douglas, peritoneal lining and pelvic side walls, myometrium (adenomyosis)

-> dysmenorrhea, dyspareunia, chronic pain, infertility

Symptoms not related to severity

Question 20

How to manage dysmenorrhea treatments

Answer 20

Painful periods

NSAIDS
Hormonal contraceptives (COCP/ intrauterine device) 
GnRH analogues 
Surgery (adhesiolysis remove adhesions, treatment for endometriosis, hysterectomy)
Heat
Ginger
Acupuncture 
TENS