Menstrual Disorders

Question 1

What is the difference between primary and secondary dysmenorrhoea?

Answer 1

Primary - menstrual pain occurring with no underlying pelvic pathology.

Secondary - Menstrual pain that occurs with an associated pelvic pathology.

Question 2

What is the function of prostaglandin? What releases it?

Answer 2

• When progesterone levels decrease after corpus lute regresses, endometrial cells are sensitive to this and release prostaglandin.
• 2 functions:
  1) Spina artery vasospasm - leading to ischaemic necrosis and shedding of the superficial layer of the endometrium.
  2) Increased myometrial contractions.
• Primary Dysmenorrhoea is thought to occur secondary to the excessive release of prostaglandins (PGF2a and PGE2) by endometrial cells.

Question 3

Risk factors of primary dysmenorrhoea?

Answer 3

1) Early menarche
2) Long menstrual phase
3) Heavy periods
4) Nuliparity
5) Smoking

Question 4

Clinical features of primary dysmenorrhoea?

Answer 4

1) Lower abdominal/PELVIC pain that can radiate to lower back and anterior thigh.
2) Crampy in nature lasting for 48-72 hours around the menstrual period and is characteristically worst at the onset of menses.
3) Nausea/vomiting, diarrhoea, dizziness
4) Abdominal and pelvic examinations (including speculum cervial exam) are unremarkable, UTERINE TENDERNESS may be present.

Question 5

Ddx of primary dysmenorrhoea?

Answer 5

1) Endometriosis
2) Adenomyosis
3) Pelvic inflammatory disease
4) Adhesions

Question 6

Investigations of primary dysmenorrhoea?

Answer 6

1) None specific - clinical diagnosis
2) Exclusion - high vaginal swab and endocervical swab for infection
3) If pelvic mass palpated - transvaginal ultrasound

Question 7

Management of primary dysmennorhoea?

Answer 7

SYMPTOMATIC Tx:

1) Stop smoking
2) Pharmacological:
- Analgesia (1st line) - NSAIDs (ibuprofen, naproxen) work by inhibiting prostaglandins AND/OR Paracetamol.
- 3-6month trial of hormonal contraception (2nd line) - COCP or intrauterine system (Merina coil).
3) Non-pharmacological - water bottles/heat patch
- Transcutaneous Electrical Nerve Stimulation (TENS)

Question 8

What is primary amenorrhoea, secondary amenorrhoea and Oligomenorrhoea?

Answer 8

Primary: Failure to commence menses (absence of menarche):

• Girls aged 16+, in the presence of secondary sexual characteristics such as pubic hair growth and breast development.
• Girls aged 14+ in the absence of secondary sexual characteristics.

Secondary: Cessation of periods for more than 6 months after the menarche (AFTER EXCLUDING PREGNANCY)

Oligomenorrhoea: Refers to irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods per year.

Question 9

Aetiology of amenorrhoea? 5 main causes?

Answer 9

1) Hypothalamic causes
2) Pituitary causes
3) Ovarian causes
4) Adrenal gland
5) Genital tract abnormality

Question 10

Hypothalamic causes of amenorrhoea?

Answer 10

Disease of hypothalamus can reduce GnRH secretion - reducing secretion of LH and FSH from APH - anovulation.

1) Functional disorders - high level exercise and eating disorders.
2) Severe chronic conditions - psychiatric, thyroid disease or sarcoidosis.
3) Kallman syndrome - an X-linked recessive disorder characterised by failure of migration of GnRH cells.

Question 11

Pituitary causes of amenorrhoea?

Answer 11

1) Prolactinoma - 40-50% of pituitary tumours - secrete high levels of prolactin, suppressing GnRH secretion. This causes anovulation, amenorrhoea and galactorrhea.
2) Other pituitary tumours (Acromegaly or Cushing’s) - gonadotropin (FSH/LH) deficiency from mass effect of tumour (+/- hyperprolactinaemia) induces menstrual irregularities.
3) Sheehan’s syndrome - Post-partum pituitary necrosis secondary to massive obstetric haemorrhage (varying degree of APH deficiency).
4) Destruction of pituitary gland - due to radiation or autoimmune
5) Post-contraception amenorrhoea - Prolonged use of contraceptives can cause long-term down regulation of the pituitary gland and irregular/absent periods or lack of ovulation persists (most commonly in Depo-Provera - 18m for menses to resume).

Question 12

Ovarian causes of amenorrhoea?

Answer 12

1) Polycystic Ovarian Syndrome - commonly causes oligomenorrhoea, amenorrhoea is possible. High androgen levels - hirsutism, weight gain, and acne.
2) Turner’s syndrome - a genetic condition that causes amenorrhoea, failure to develop secondary sexual characteristics and universal infertility. (Other Sx include short stature, webbed neck and aortic coarctation).
3) Premature ovarian failure - Primary ovarian insufficiency before the age of 40 associated with menopausal symptoms such as hot flushes and night sweats. (Hormone profile shows low oestrogen and high FSH).

Question 13

Adrenal gland related causes of amenorrhoea?

Answer 13

• Late onset/mild congenital adrenal hyperplasia is an autosomal recessive inherited condition - caused by partial deficiency of 21 hydroxylase required for synthesis of cortisol and aldosterone.
• Early development of pubic hair, irregular/absent periods, hirsutism and acne. HIGH LEVELS of 17- hydroxyprogesterone present in blood.

Question 14

Genital Tract abnormalities - causing amenorrhoea?

Answer 14

1) Ashermann’s syndrome - Can occur secondary to instrumentation of the uterus typically following SMM (surgical management of miscarriage. Damages basal layer of endometrium causing intrauterine adhesions which fail to respond to oestrogen stimulus.
2) Imperforate hymen/Transverse vaginal septum - mechanical obstruction
3) Mayer-Rokitansky-Kuster-Hausen syndrome - (genesis of mullein-duct system) - congenital absence of the uterus and upper 2/3rds of the vagina - primary amennorhoea.

Question 15

Aetiology of Oligomenorrhoea?

Answer 15

1) PCOS
2) Contraceptive/hormonal therapy
3) Perimenopausal
4) Thyroid disease/Diabetes
5) Eating disorders/high level exercise
6) Medications - anti-epileptics and anti-psychotics

Question 16

What would a focused detailed history need to cover, regarding a patient with amenorrhoea?

Answer 16

1) Details of period (including age of menarche)
2) Cycle length
3) Development of secondary sexual characteristics
4) Associated Sx, PMH and PSH (surgical)

Question 17

What is the step-wise approach of amenorrhoea?

Answer 17

1) Pregnancy test
2) Blood tests:
- TFTs and Prolactin
- FSH, LH, oestradiol, progesterone, testosterone
- 17 hydroxyprogesterone (congenital adrenal hyperplasia)
3) Karyotyping - genetic cause suspected
4) Ultrasound scan - visualise ovaries and pelvic anatomy
5) Progesterone challenge test (to elicit withdrawal bleed):
- A bleed suggests there are adequate levels of oestrogen however the patient is not ovulating (PCOS e.g.)
- No bleed could mean very low levels of oestrogen or an outflow obstruction.

Question 18

Management of amennorhoea?

Answer 18

1) Regulating periods: COCP or POCP helps regulate periods and keeps lining of the womb thin (reducing long term risk of endometrial cancer.
IUS can be useful in stopping or significantly reducing duration and flow of menses.

2) Hormone replacement - Women with premature ovarian failure should receive cyclic hormone replacement therapy with oestrogen (and progesterone if they have a uterus). This treats the symptoms of menopause, decreases risk of cardiovascular disease and maintains bone density (prevent osteoporosis). Calcium and vitamin D recommended following scan.
3) Symptom Control - medication for hair growth, antibiotics, topical treatment, topical retinoids and Isotretinoin.
4) Treat underlying disorder - Hypo and hyperthyroidism both affect menstruation, assessment of TFT’s and appropropriat treatment with levothyroxine or carbimazole necessary, radioactive iodine may be suitable in some cases.
5) Improving fertility - Clomifene is used to stimulate ovulation as a means to treat infertility. Metformin can be used in PCOS to induce ovulation, as well as treating insulin resistance commonly associated with this condition. IVF available as a last resort.
6) Surgery - Primary treatment for pituitary tumours and genital tract abnormalities. Pituitary adenomas commonly removed by trans-sphenoidal approach.

Question 19

What is heavy menstrual bleeding?

Answer 19

• Excessive menstrual loss which interferes with quality of life, with those 40-51yrs most likely to resent to healthcare services.
• Refers to bleeding NOT related to pregnancy and only occurs during the woman’s reproductive years (i.e. not post-menopausal bleeding).
• Majority cannot be attributed to any uterine, endocrine, haematological or infective pathology - these are Abnormal Uterine Bleeding cases.

Question 20

Ax, PPx and RF of HMB?

Answer 20

PALM-COEIN system:

• PALM (Structural):
  1) Polyp
  2) Adenomyosis
  3) Leiomyoma (fibroid)
  4) Malignancy and hyperplasia
• COEIN (nonstructural):
  1) Coagulopathy
  2) Ovarian dysfunction
  3) Endometrial
  4) Iatrogenic
  5) Not yet classified

RF: AGE AND OBESITY, previous caesarian RF for adenomyosis

Question 21

Clinical features of HMB?

Answer 21

1) Excessive bleeding during menstruation
2) Fatigue
3) Shortness of Breath

Signs:

1) Pallor (anaemia)
2) Palpable uterus or pelvic mass - smooth or irregular (fibroids), tender uterus/cervical excitation - adenmyosis/endometriosis
3) Inflamed cervix/cervical polyp/tumour
4) Vaginal tumour

Question 22

Ddx of HMB?

Answer 22

1) Pregnancy (vaginal bleeding - miscarriage/ectopic)
2) Endometrial/cervical polyps
3) Adenomyosis (bulky uterus o/e)
4) Fibroids (pressure Sx - frequency, bulky uterus)
5) Malignancy/hyperplasia -
6) Coagulopathy (vWD common, or warfarin/anticoagulant)
7) Ovarian dysfunction - PCOS and hypothyroid
8) Endometriosis
9) Iatrogenic (Copper IUD, contraceptive)

Question 23

Investigations for HMB?

Answer 23

Blood tests:

1) FBC (Anaemia after menstrual blood loss >120ml)
2) TFT (other thyroid signs)
3) Coagulation screen + vWD test (clotting disorde suspected)

Imaging/histology/micro:

1) Ultrasound pelvis - transvaginal US for endometrium and ovaries, considered if uterus/pelvic mass palpable on examination/Tx (pharmacological) failed
2) Cervical smear - No need if up to date
3) High vaginal and endocervical swab - infection
4) Pipelle endometrial biopsy - persistant bleeding, >45yrs, failure of Tx (pharmacological)
5) Hysteroscopy and endometrial biopsy - when ultrasound identifies pathology or is inconclusive.

Question 24

Pharmacological Management of HMB?

Answer 24

If no suspicion of pathology: 3 tiered approach to pharmacological treatment.
1) Levonorgestral-releasing intrauterine system (LNG-IUS) - contraceptive, licensed for 5 years, thins endometrium and can shrink fibroids

2) Tranexemic acid, Mefanamic acid, COCP: tranexamic acid mefanamic acid (also NSAID can help dysmenorrhoea) have no effect on fertility, taken during menses to reduce bleeding.
3) Progesterone only: Oral Norethisterone (5-26days of cycle), deep, or implant: Oral norethisterone does not work as a contraception in this manner, depo and implant progesterone are long active reversible contraceptives.

Question 25

Surgical Management of HMB?

Answer 25

• Two main surgical treatments for heavy menstrual bleeding: Endometrial ablation or hysterectomy. (Myomectomy and uterine artery embolisation are only used to treat HMB caused by fibroids).

1) Endometrial ablation - endometrial lining obliterated - if women no longer wish to conceive (they will need to carry on using contraception), can be performed in outpatient setting with local anaesthetic.
2) Hysterectomy - only definitive treatment - offers amennorhoea and end to fertility: Subtotal (partial) - removal of uterus but not cervix, total - removal of uterus AND cervix. (abdominal incision or via vagina + ovaries not removed unless abnormal).