Menstrual Disorders Flashcards
What is puberty?
Onset of hormonal maturity (girls before boys)
What is Precocious puberty?
Early onset of puberty (e.g. girls before 8 and 9 for boys)
What is delayed puberty?
No breast development by 13 and no menstruation by 15. Boys showing no signs by 14
What is Amenorrhoea/Dysmenorrhoea?
no periods/ pain with periods
What is Menorrhagia?
Heavy periods
What is PCOS?
Polycystic ovarian syndrome
What is Premenstrual syndrome?
Physical and emotional symptoms before period
What is Premature ovarian insufficiency?
Early menopause (before 40), linked to too much dieting/exercise and cancer
What is Menopause?
average age 51: women stop having periods
What is postmenopausal bleeding?
aged 70s, other reasons behind this
At what age are chances of concieving reduced?
35
What is Dysmonorrhoea subdivided into?
Primary and Secondary
What is primary Dysmenorrhoea?
- Peak incidence teens to twenties
- Pelvic pain and - Cramping (starts as period starts)
- May radiate to thighs and back
- GI symptoms – nausea, vomiting and diarrhoea
- Headaches, fatigue or faintness
What is secondary dysmenorrhoea?
- Peak incidence thirties, forties
- Consequence of other pelvic pathology
- Pain may begin before menstruation (3-5 days)
How does dysmenorrhoea occur?
- Higher concentrations of prostaglandins in menstrual fluid [mainly PGF and PGE]
- Increased myometrial contractility = cramping
- Other potential mediators (of prostaglandins) include:
- Endothelins – vasoactive peptides
- Role in [local] regulation of prostaglandin synthesis
- Vasopressin – post. Pituitary hormone
- Stimulates uterine activity
- Decreases uterine blood flow [vasoconstriction causes myometrial ischaemia]
- Endothelins – vasoactive peptides
What does progestogen withdrawal trigger?
Production of Arachidonic acid and leukotrienes.
What is Arachidonic acid a precursor to?
Prostaglandins (mainly PGF and PGE)
What do prostaglandins cause?
Vasoconstriction, myometrial ischaemia/hypoxia and myometrial contracility leading to pain (leukotrienes are thought to contribute to this)
What would inhibit formation of prostaglandins (from COX-1)?
NSAIDs e.g. aspirin, piroxicam
What is the pharmacological management of primary dysmenorrhoea?
- NSAIDs – 1st line unless contraindicated
- Ibuprofen, naproxen
- OTC – Feminax Express, Feminax Ultra and measures to manage symptoms
- Oral contraceptive pill – modulate hormone levels
- Inhibits ovulation
- Prevents increased PG synthesis in luteal phase
- Decreased uterine contractility
- Antispasmodics eg hyoscine butylbromide
- Limited by poor oral bioavailability
- Unlicensed OTC – used in IBS
What is the cause of secondary dysmennorhoea?
- PG involvement
- Underlying pelvis pathology
- PID -pelvic inflammatory disease (would require antibiotic treatment)
- Endometriosis
- Menorrhagia
- Fibroids
- Uterine polyps etc…
What is the pharmacological management of secondary dysmenorrhoea?
- Investigate and ascertain underlying cause
- Treat accordingly dependent upon underlying cause
- Options include
- Surgery – ablation (removal of thin uppermost layer of endometrium using heat methods), laser therapy etc
- Symptomatic relief (pain relief)
- Pharmacological interventions (non-analgesic treatments)
- Options include
What are some OTC options for period pain?
Co-codamol, ibuprofen, naproxen, heat wraps, hyoscine (unlicensed)
What is endometriosis?
When endometrial tissue is found outside the uterus
- Outside reproductive tract
- GI tract
- Urinary tract
- lung
How does endometriosis occur?
- Theory 1: embryological – cells de-differentiate back to their primitive form to endometrial cells, have found endometrial cells in peritoneum and post-mortem feotuses
- Theory 2: Retrograde menstruation:
- reflux of menstrual loss?
- Increased prevalance with outflow obstruction
What are the common symptoms of endometriosis?
- Most common: pain, fatigue and subfertility
- Common symptoms
- Dyspareunia
- Dyschezia - Dysuria
- Chronic pelvic pain & menstrual irregularities
- Dyspareunia
What are the rare symptoms of endometriosis?
- Cyclical haematuria
- Cyclical haemoptysis
- Cyclical tenesmus
- Others: ureteric obstruction, rectal bleeding or rectal obstruction
What is Dyspareunia?
painful intercourse
What is Dyschezia?
Difficulty defecating
What is Dysuria?
Similar to UTI, irritation when passing water
What is Cyclical haematuria?
Endometrial tissue in the bladder bleeds in response to hormonal variation
What is Cyclical haemoptysis?
Endometrial tissue in the lungs bleeds in response to hormonal variation
What is Cyclical tenesmus?
Constant need to open bowels
How is endometriosis diagnosed?
- Pelvic exam (lumps, masses, reduced organ mobility – as tissues travel they stick organs together and lose mobility)
- Pelvic ultrasound (transabdominal or transvaginal) to identify/characterise masses
- Diagnostic laparoscopy
- NOT RECOMMENDED – bloods or MRI
How is the severity of endometriosis graded?
Grades 1-4: limited correlation to pain, sub-fertility, prognosis
What is stage 1-2 of endometriosis?
- Minimal to mild, poorly visualised on US
- Common implantation sites – uterine and ovarian
What is stage 3-4 of endometriosis?
- Mod to severe, commonly associated with adhesions
- Rectovaginal endometriosis (tissue grows out of the womb), bowel invasion (adenomyosis)
What are the management options for endometriosis?
Surgical treatment (laparoscopy or hysterectomy*) aims to:
- Restore normal pelvic anatomy
- Divide adhesions
- Ablate endometrial tissue
Medical treatment aims to:
- Aims to provide symptomatic relief and improve
fertility if desired
What 3 recommendations does the NICE quality standard for endometriosis follow?
- Individuals presenting with suspected endometriosis should receive an abdominal and, if appropriate, a pelvic examination.
- Individuals should be referred to a gynaecology service if initial hormonal treatment has not been effective, has not been well tolerated or is contraindicated.
- Individuals with suspected or confirmed deep endometriosis with involvement of bowel, bladder or ureter should be referred to a specialist endometriosis service.
What management option is an option in endometriosis for women who do not plan further/any pregnancy?
Hysterectomy
What is the first line pharmacological management for endometriosis?
Analgesia - NSAIDS +/- paracetamol
What is the second line pharmacological management for endometriosis?
“Shrinkers” treatments utilise the fact that endometrial tissue is oestrogen dependent
- Drugs opposing oestrogen will inhibit growth of
endometrial tissue
- Contraceptives: CHCs, POC, LNG – IUS
- Progestogens
- GnRH analogues – gonadotropin releasing
hormone( buserelin, goserelin, nafarelin, leuprorelin)
- Antiprogestogens - Gestrinone/danazol (last resort)
What are the new treatments for endometriosis?
SARMS (selective androgen receptor modulator), immunomodulators, drugs targeting steroid biosynthetic pathways
What volume of menstrual blood loss per month risks Fe deficiency?
above 80ml per month (menorrhagia)
What are the symptoms of menorrhagia?
- Menstrual blood loss above 80ml per month (risk of Fe deficiency anaemia)
- Subjective – flooding, large clots (bigger than 50p), double sanitary protection, frequent sanitary changes
- 3 days menorrhagia =1 month /year of reduced QOL
What are the causes of menorrhagia?
- DUB (60%): dysfunctional uterine bleeding
- Menopause
- Fibroids, PID
- Miscarriage or ectopic pregnancy
- IUD
- Adenomyosis
- Hepatic, renal or thyroid disease, PCOS
- Blood thinning medication or condition
What is Adenomyosis?
Inner lining of the uterus breaks through myometrium
What symptoms suggest underlying pelvic pathology?
- Irregular bleeding
- Sudden change in blood loss
- Intermenstrual bleeding
- Post coital bleeding
- Dyspareunia (painful intercourse)
- Pelvic pain
- Premenstrual pain
How is Menorrhagia diagnosed?
- Blood tests (FBC, Iron, Ferritin)
- Physical exam (tummy, cervix, enlarged or tender ovaries/uterus)
- Cervical smear (Pap smear/cervical smear)
- Endometrial biopsy
- Ultrasound (pelvic/transvaginal)
uterus, ovaries and pelvis - Sonohysterography
- Hysteroscopy
What is the pharmacological management for menorrhagia if contraception is required?
- CHC, POC
- IUS/parenteral progesterone (IUS most effective) (Mirena – licensed specifically)
What is the pharmacological management for menorrhagia if contraception is NOT required?
- Tranexamic acid – antifibrinolytic (reduces blood loss)
- GnRH analogues/antagonists
- Mefenamic acid (NSAID)
- Oral progestogen (high dose [5mg] norethisterone – not used for contraception)
- Antiprogestogens - Gestrinone/danazol (last resort)
What are the surgical treatment options for menorrhagia?
- UAE (uterine artery embolization)
- Myomectomy
- Hysterectomy (no more kids)
