Menstrual Disorders Flashcards
What does amenorrhea mean?
Absence of menstruation
What is primary amenorrhea?
When a patient has never had a period by the age of 16 years
What are some causes of primary ammenorrhea?
Turner’s syndrome - most common
Anatomical causes
Complete androgen insensitivity syndrome
Hypothalamic and pituitary disease
What is turner’s syndrome?
Female-only genetic condition where there is a missing X chromosome
What is the karyotype for turner’s syndrome?
45XO
What happens in turner’s syndrome?
The ovary doesn’t complete its normal development (dysgenesis) so you will have low estrogen
What would the lab results show with turners syndrome (oestrogen and FSH/LH)
Low oestrogen and high FSH/LH
Why would FSH and LH be high in turners syndrome?
ovarian failure and reduced ovarian feedback causes the AP gland to release FSH and LH as nothing is telling it not to
What happens if there is no oestrogen?
You get no pubertal changes
What would someone with turners present with?
- short stature
- short neck
- lack of secondary sexual characteristics
- horseshoe kidney on scan
- brown spots
What will girls with turners syndrome need?
HRT when older to get breasts, female characteristics and periods
What are some of the health problems associated with turners syndrome?
- coarctation of the aorta
- horseshoe kidney
- streak ovaries
- infertility
- osteoporosis
What anatomical causes can cause primary amenorrhea?
imperforate hymen - problem with the outflow tract (the hymen completely blocks the vagina as failed to perforate in fetal development)
What is mullerian agenesis?
Failure of the mullerian duct to formed resulting in a missing uterus - also called MRKH syndrome
What is complete androgen insensitivity syndrome?
It is an x-linked recessive disorder where you become resistant to testosterone due to a defect in the androgen receptor
What affects happen in CAIS?
A child born with this is genetically male but will have female phenotypes
-testes may be palpable in the labia or inguinal area
What is the treatment for CAIS?
Testes should be surgically excised after puberty
How is primary amenorrhea caused by hypothalamic and pituitary disease?
- Isolated GnRH deficiency
- no GnRH produced so no pituitary stimulation so no FSH/LH so no ovarian or uterine function so no oestrogen so no secondary sexual development
Why do CAIS have female phenotype?
XY chromosome so have testes developed
- Anti-mullerian hormone and testosterone produced causing regression of mullerian structures
- failure of androgen receptors so absence of male physical characteristics
- Testosterone converts to oestrogen causing female phenotype
What is secondary amenorrhea?
no periods for more than 6 months after previously having them
What are physiological causes of secondary amenorrhea?
- pregnancy (always rule out pregnancy)
- contraception
- menopause (periods may become irregular before stopping completely but it is still possible to get pregnant)
What are some physiologically causes of secondary amenorrhea?
Anatomical causes, PCOS, Endocrine
What are some anatomical causes of secondary amenorrhea?
- Scarring
- Ovarian disorders
How does scarring cause secondary amenorrhea?
Cervical stenosis can cause scarring
- also asherman syndrome
- scarring can be caused by repeated infections or operations
What is asherman syndrome?
scarring of the uterus (not the cervix)
What ovarian disorders cause secondary amenorrhea?
Primary ovarian insufficiency
-premature menopause - depletion of oocytes before 40
What does a depletion of oocytes cause (hormones)?
no oestrogen so no inhibin so high FSH
What is PCOS?
Polycystic ovary syndrome - it is a group of symptoms e.g. hyperandrogegism and chronic anovulation
What would a patient with PCOS present with?
secondary amenorrhea, infertility, hirsutism (hair growth on face), obesity
Why does PCOS occur?
lack of pulsatile GnRH - many follicles begin to develop but a dominant follicle is not selected to mature - these follicules respond to pituitary hormones by secreting abnormal oestrogen pattern
Why are PCOS women at risk of endometrial malignancy?
Abnormal oestrogen can cause over proliferation of the endometrium
What do tests show with PCOS?
- raised insulin resistance
- elevated LH
- need to do USS
What does raised insulin resistance cause?
diabetes risk
What is the treatment for PCOS?
- COCP
- lifestyle advice
Why does thyroid disease cause secondary amenorrhea?
Thyroid imbalances causes hyperthyroidism - don’t know why though
How does hyperprolactinemia cause amenorrhea?
too much prolactin supresses GnRH so don’t get FSH or LH so no oestrogen so amenorrhea
Why would someone get hyperprolactinemia?
- physiological (breastfeeding raises prolactin and so does pregnancy)
- Dopamine inhibits anterior pituitary to inhibit secretion of prolactin but if you have drugs which target dopamine receptors, the effect will increase prolactin release
- side effect of hypothyroidism (will increase TRH and stimulate AP to release TSH but also prolactin)
- Tumours on the AP causing prolactin to be realeased
What is a prolactinoma?
adenoma in the pituitary causing release of prolactin
How is prolactinoma treated?
instead of surgery, give a drug that acts like dopamine to inhibit prolactin release from the AP
What is sheehan syndrome and when would it develop?
Necrosis of pituitary secretory cells - it would develop if a women suffers a sever haemorrhage during childbirth resulting in a blood pressure drop due to volume loss - due to the increased size of the pituitary gland in pregnancy it is much more sensitive to hypotension and hypoxia
When would functional hypothalamic amenorrhea?
Occurs if there is weight loss, excessive exercise, emotional stress - gymnasts, anorexics
How does functional hypothalamic amenorrhea occur?
abnormal GnRH causes absence of the LH surge so you get annovulation and therefore decreased oestrogen
What can the decreased oestrogen cause?
osteoporosis and risk of bone loss
What is AUB?
abnormal uterine bleeding
What is frequency?
how often a women is having her period - 24-38 days
if reduced - too frequent
if prolonged - infrequent
What is regularity?
Calculating the difference between longest and shortest cycle in 6 months
regular - less than 7-9 days
irregular - more than 7-9 days
What is Duration of flow?
How many days is the woman bleeding for?
normal - less than 8 days
prolonged - more than 8 days
What is volume?
how much is the woman bleeding?
it can be subjective
5-80ml is normal
What is the medical term for the following words;
- irregular
- heavy
- absent
- infrequent
- metrorrhagia
- menorrhagia
- amenorrhea
- oligomenorrhoea
What is acute presentation of symptoms of AUB?
episode of heavy bleeding that is of sufficient quantity to require immediate clinical intervention to stop further blood loss
What is chronic presentation of symptoms of AUB?
bleeding oh abnormal volume, duration, regularity or frequency that has been present for most of the previous 6 months
What are some underlying causes of AUB?
PALM-COIEN Polyps Adenomyosis Leiomyoma (fibroid) Malignancy/hyperplasia Coagulopathy Ovulatory dysfunction Endometirual Iatrogenic Not yet classified
What other symptoms of bleeding could a woman get?
post-coital (bleeding after sex) or intermenstural (bleeding in-between periods)
What is the most common cause of AUB?
fibrous - leiomyoma - benign tumour of uterine smooth muscle
Why do fibroids get work during pregnancy?
because they are oestrogen dependent and will shrink after pregnancy and even more after menopause
Can fibroids affect fertility?
Yes if they impinge on the uterine cavity
What are the complications of fibroids?
heavy menstrual bleeding. fertility, torsion of fibroids causing pain (not normally painful)
Who is most at risk of fibroids?
african descent women, no pregnancy before
What is dysfunctional uterine bleeding?
diagnosed by ruling out everything else (diagnosis of exclusion)
What are the subdivisions of DUB?
anovulatory and ovulatory
What is the anovulatory DUB?
problems with ovulation - impaired positive feedback (not well understood)
What is the ovulatory DUB?
secondary to increased prostaglandins and reduced vasoconstrictors - genetic
What is dysmenorrhea?
painful menstruation - crampy and intermittently intense OR continuous dull ache
Where is the pain with menstruation?
Lower abdomen and suprapubic area
When do you get pain and what other symptoms can you get?
with the onset of menses - nausea, diarrhoea, general malaise
Why do you get dysmenorrhea?
can either be primary or secondary - primary is when you have had pain since menses started and is unlikely to have a cause, secondary is the you have developed painful periods over time and likely to be due to cysts or endometriosis
What is endometriosis?
When the lining grows outside the uterus - severity and extent has no correlation to the symptoms
What are the risk factors of endometriosis?
early menarche, short cycles, heavy bleeding, low BMI
What are some factors about endometriosis?
estrogen-dependent, benign, inflammatory disease
What can endometriosis cause?
painful sex (dyspareunia), infertility chronic pain
Where are the most common causes of endometriosis?
ovaries (looks like a chocolate cysts), bladder, rectum, peritoneal lining and pelvic side walls
What is adenomyosis?
endometrial tissue found deep within myometrium - tends to cause heavy bleeding more than pain
How can you manage dysmenorrhea?
NSAIDs, COCP, intrauterine device, Surgery (hysterectomy or take away scar tissue), alternative medicine (heat and ginger)
