Menstrual Disorders Flashcards
What is dysmenorrhoea?
Primary = menstrual pain occurring with no underlying pelvic pathology Secondary = menstrual pain occurring with associated pelvic pathology
What causes period pains and what causes primary dysmenorrhoea?
As steroidal hormones drop at the end of a cycle the endometrial cells respond by releasing prostaglandins. These prostaglandins cause spiral artery vasospasm leading to shedding and bleeding and increased myometrial contractions. Primary dysmenorrhoea is due to excessive prostaglandins.
What are the risk factors for dysmenorrhoea?
Early menarche Long menstrual phase Heavy periods Smoking Nulliparity
What sort of symptoms do patients suffering with dysmenorrhoea get?
Crampy pelvic pain lasting 2-3days around the time of the period.
Malaise
Nausea
Vomiting
Diarrhoea
Dizziness
Abdominal and pelvic examination are usually unremarkable bar uterine tenderness
What causes of secondary dysmenorrhoea should be ruled out before a diagnosis of primary dysmenorrhoea?
Endometriosis Adenomyosis PID Adhesions Fibroids IUD only
Check for abdominal masses, dyspareunia, history of STDs and surgery
How should dysmenorrhoea be investigated?
Speculum
Bi manual examination
Swabs both high vaginal and endocervical
If pelvic mass, then TVUSS
How should dysmenorrhoea be managed?
Treat cause
Stop Smoking
NSAIDs – mefenamic acid or ibuprofen
COCP or other hormone contraceptives
What is the premestrual syndrome?
Definition – psychological, physical or behaviour symptom in the luteal phase of the menstrual cycle that regress at onset of menses.
How is a diagnosis of premestrual syndrome made?
Diagnosis – most women self-diagnose but for a official diagnosis a diary will need to be filled out. Moderate/severe PMS includes interruption to daily life
What are the diagnostic criteria for pre menstrual syndrome?
5 symptoms present for most of the late luteal phase with remission a few days after onset of menses and absence of symptoms post menses. At least one symptoms must be from the following list: • Depression, hopelessness • Anxiety • Affective lability – suddenly sad or tearful • Persistent anger/irritability • Decreased interest in usual activities • Change in appetite • Difficulty concentrating • Lethargy • Hypersomnia or insomnia • Feeling of being overwhelmed • Breast tenderness, swelling, headaches, joint or muscle pain, bloating and weight gain
How can you help manage pre menstrual syndrome?
- Hormonal Ovulation suppression – COCP but may worsen side effects so monitor. GnRH analogues also a possibility
- Non-hormonal – SSRI, tricyclics
- Surgery – removal of ovaries and uterus but must first test that symptoms resolve with a GnRH test.
- Self Help – Healthy diet, Vitamins, exercise, stress reduction and CBT
What is menorrhagia
Definition – heavy menstrual bleeding – heavy being defined by the woman
What are the risk factors for menorrhagia?
Age – approaching menopause
Obesity
C-section and adenomyosis
What causes menorrhagia?
Dysfunctional uterine bleeding (formerly known as dysfunctional uterine bleeding) – Diagnosis of exclusion but the most common reason.
Fibroids – (benign neoplasm that increases SA and painful due to muscle contractions Adenomyosis Endometriosis Hypothyroidism Endometrial Cancer Endometrial Polys – adenomas of the endometrium Chronic infection Coagulation disorders – VWM
What are the signs and symptoms of menorrhagia?
Fatigue
Shortness of breath
Anaemia
Bleeding that effects daily living
Tender uterus or cervical excitation point to adenomyosis or endometriosis
What questions should be asked in a full menstrual history?
Age at menarche Frequency Duration Volume Clots? Date of last menstrual period
How should you investigate a woman presenting with menorrhagia?
FBC and TFT
Enquire about smear history and contraception
Abdominal palpation, speculum and bimanual examination – looking for masses
Important to rule out ectopic pregnancy
Endocervical and High vaginal swab
Coagulation screen
BMI
If <45 then only need thyroid function and FBC
If over 45 then:
USS followed by hysteroscopy and biopsy if endometrial thickness > 4mm
How/when is menorrhagia managed medically?
Medical – no explanation or fibroids < 3cm. Consider whether they require contraception
• IUS Mirena Coil – side effects: irregular bleeding 4-6m and insertional issues.
• NSAIDS – Mefanamic acid – Gi upset and ulceration. Caution asthmatics, renal disease, and peptic ulcer. If cause is fibroids, then skip this step.
• Antifibrinolytic - Tranexamic acid – side effects: N and V
• COCP or Progestogen only pill (later likely to supress menstruation which may or may not be beneficial to the patient)
If necessary, GnRH analogues
How/when is menorrhagia managed surgically?
Surgical – fibroids > 3cm
• Endometrial embolisation - least invasive via interventional radiology and 90% of women have significant or complete resolution.
• Endometrial Ablation (microwave, balloon or electrical) – suitable if family complete (although will still need contraception). Can cause, pain, bleeding or infection, damage to nearby organs including uterine puncture. 80% success rate at reducing painful periods.
• Hysterectomy either with or without the cervix. Ovaries are kept unless abnormal
What is the definition of amenorrhoea?
Definition – the absence of menstrual periods
Primary – failure to commence menses. Either: girls aged 16+ in the presence of secondary sexual characteristics such as pubic hair/breast development or girls aged 14+ in the absence of secondary sexual characteristics.
Secondary – cessation of period for more than six months after the menarche
Which hormonal organs can the problem be located to in amenorrhoea?
Hypothalamus
Pituitary
Ovaries
Adrenal glands
Genintal
What hypothalamic causes of amenorrhoea are there?
- Functional disorders – low eating/high exercise causes suppression of GnRH via Ghrelin and leptin
- Severe chronic disorders – psychiatric disorders or both thyroid diseases (TRH stimulates prolactin and sex hormone binding hormone in hyper- binds oestrogen) and sarcoidosis
- Kallmann syndrome – X-linked recessive disorder characterised by migration of GnRH cells and lack of sense of small.
What pituitary causes are there for amenorrhoea?
- Prolactinomas – prolactin supresses GnRH will also cause galactorrhoea
- Other pituitary tumours e.g. Acromegaly or Cushing’s
- Sheehan’s syndrome – post partum pituitary necrosis secondary to massive obstetric haemorrhage
- Destruction of pituitary gland
- Post contraception amenorrhoea – most commonly seen with depo
What ovarian causes are there for amenorrhoea?
- PCOS – more commonly causes oligomenorrhea
- Turner’s syndrome – also short, webbed neck and aortic coarctation
- Premature ovarian failure (POF) – primary ovarian insufficiency before the age of 40 resulting in early menopause – low oestrogen and high FSH
What adrenal causes are there for amenorrhoea?
• Congenital adrenal hyperplasia (CAH) – at this age usually late onset or mild
What genital causes are there for amenorrhoea?
Genital abnormalities – concealed bleeding and also pain
• Ashermann’s syndrome – intrauterine adhesions following instrumentation of the uterus, usually following surgical management of miscarriage
• Imperforate hymen/Transverse vaginal septum/cervical stenosis – obstruction
• Agenesis of the Mullerian-duct and so absence of the uterus and upper vagina
What should be explored in the history of a patient with secondary amenorrhoea?
Focus on sexual history and pregnancy risk Galactorrhoea or androgenic symptoms Menopausal symptoms Previous gynae surgery Drug use (dopamine) and eating/exercise
How should amenorrhoea be investigated?
Detailed menstrual history
Pregnancy test
Bloods: Thyroid, Prolactin, FSH, LH, Progesterone, Oestrogen, Testosterone and SHBG
17 hydroxyprogesterone – CAH
USS to visualise ovaries
Karyotyping
Progesterone challenge to elicit a withdrawal bleed
• If they bleed there is adequate oestrogen and so likely anovulation and PCOS
• No bleed indicates low oestrogen or outflow obstruction
How should amenorrhoea be managed?
Attempt to treat cause
Regulate periods using a hormonal contraceptive
Premature ovarian failure – HRT, Calcium and Vitamin D replacement
Symptoms control – hair growth (COCP) and acne (antibiotics)
Lifestyle advice – for causes related to weight encourage weight gain.
For PCOS encourage weight loss and maybe statins
Clomiphene and metformin – stimulate ovulation and regulate blood sugar in PCOS
Surgical intervention for pituitary tumours and genital tract abnormalities
What is oligomenorrhoea?
Definition – irregular periods with intervals between menstrual cycles of more than 35 days and/or less than 9 periods a year. Usually this is due to anovulation.
What are the common causes of oligomenorrhoea?
- PCOS
- Contraceptive/Hormonal treatments
- Perimenopause
- Thyroid disease/Diabetes
- Eating Disorders – both high and low BMI and excessive exercise
- Ovarian resistance, incipient POF – rare.
- Medications such as antipsychotics/epileptics – dopamine and prolactin
What investigations should be considered in a women presenting with oligomenorrhoea?
Detailed menstrual history
Pregnancy test
Bloods: Thyroid, Prolactin, FSH, LH, Progesterone, Oestrogen, Testosterone and SHBG
17 hydroxyprogesterone – CAH
USS to visualise ovaries
Karyotyping
Progesterone challenge to elicit a withdrawal bleed
• If they bleed there is adequate oestrogen and so likely anovulation and PCOS
• No bleed indicates low oestrogen or outflow obstruction
How should oligomenorrhoea be managed?
What are patients aims – regular periods or fertility
Treat underlying causes if any are found
Attain normal BMI
For regular cycles:
COCP or cyclical progestogens
For PCOS a minimum of 3 periods a year to reduce risk of endometrial hyperplasia
Full fertility screen if ovulation induction is required
What is the most common cause of pelvic pain presentations in women?
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz).
What is an endometrial polyp?
Endometrial Polyp – benign growth of endometrial tissue – Adenoma malignant 1%. More common in women over age of 40.
What is the most common cause of abnormal uterine bleeding?
Endometrial polyp is the most common cause of abnormal uterine bleeding
