Menstrual Disorders Flashcards
What is the definition of menorrhagia?
Prolonged and increased (>80ml per period) menstrual flow (heavy bleeding)
What is metrorrhagia?
Regular intermenstrual bleeding
What is polymenorrhoea?
Menses occurring at < 21 days intervals
What is amenorrhoea?
Absence of menstruation for > 6 months
What is oligomenorrhoea?
Menses at intervals of > 35 days OR 5 or less menstrual cycles per year
What are the local causes of menorrhagia?
Fibroids Adenomyosis Endocervical or endometrial polyp Endometrial hyperplasia IUD PID Endometriosis Malignancy Hormone producing ovarian tumours Arteriovenous malformation
What are the systemic causes of menorrhagia?
Endocrine: - thyroid, DM, adrenal disease, prolactin Haematological: - vWD, ITP, clotting factor deficiency Liver cirrhosis Renal disease Anticoagulants
What is dysfunctional uterine bleeding (DUB)?
Menorrhagia in the absence of pathology –> diagnosis of exclusion
What are the 2 types of DUB and their features?
Anovulatory (80%):
- irregular cycle at extremes of reproductive age
Ovulatory:
- regular heavy periods
- due to inadequate progesterone production by corpus luteum
What are the options for medical management of DUB?
- IUS (mirena coil) - first line
- COCP
- Tranexamic acid (antifibrinolytic)
- NSAIDs e.g. mefenamic acid
- Oral progestogens e.g. norethisterone + medroxyprogesterone acetate
- GnRH analogues/agonists
When are tranexamic acid and NSAIDs taken for menorrhagia?
Taken during menstruation only
Good for women who want to conceive
Give an example of GnRH analogues/agonists?
Goserelin
Buserelin
What are the side effects of GnRH analogues/agonists?
Long term use causes osteoporosis unless combined with HRT
–> only use short term (< 6 months)
When might surgical management be offered to women with menorrhagia?
Failure of medical management
not recommended if wanting to preserve fertility
What are the options for surgical management of menorrhagia?
Endometrial resection/ablation
Hysterectomy
What are the risks associated with endometrial ablation?
If becomes pregnant, risk of prematurity or morbidly adherent placenta –> must take COCP/HRT
What are the causes of intermenstrual bleeding?
Cervical ectropion PID and STIs Endometrial or cervical polyps Cervical cancer Endometrial cancer Undiagnosed pregnancy/pregnancy complications Hydatiform molar disease
What are the features of premenstrual syndrome?
Bloating, cyclical weight gain Mastalgia Abdominal cramps Fatigue Headache Depression Changes in appetite + cravings Irritability
How can premenstrual syndrome be treated if impacting quality of life?
SSRIs/SNRIs + CBT
Lifestyle changes for mild symptoms
COCP, transdermal oestrogen, short term GnRH analogues
Hysterectomy + bilateral salpingo-oophorectomy (last resort)
What are the causes of post-coital bleeding?
Cervical ectropion Cervical cancer Trauma Atrophic vaginitis Cervicitis secondary to STI Polyps Idiopathic
What is cervical ectropion usually caused by?
Hormonal changes:
- high oestrogenic states in pregnancy
- use of COCP
What are the causes of post-menopausal bleeding?
Atrophic vaginitis (most common) Endometrial polyps Endometrial hyperplasia Endometrial cancer Cervical cancer Ovarian cancer (oestrogen-secreting theca cell tumours) Vaginal cancer - rare
How is post-menopausal bleeding investigated?
Transvaginal USS first line to assess endometrial thickness
- if < 3mm - reassure
- if > 4mm –> biopsy
- (if taking HRT, cut off is 5mm or less)
Women on Tamoxifen –> hysteroscopy + biopsy if first line (USS not helpful as endometrium will always be thick)
How is atrophic vaginitis managed?
Topical oestrogen + vaginal lubricants
Consider HRT
How is endometrial hyperplasia managed?
Dilatation and curettage
Progesterone treatment:
- IUS first line
- oral progestogens e.g. norethisterone
What is the most common cause of menstrual irregularity?
PCOS
Which criteria is used to diagnose PCOS and what are the criteria?
Rotterdam criteria - 2 of the following:
- clinical or biochemical evidence of hyperandrogenism
- polycystic ovaries on USS
- oligo/amenorrhoea
What are the signs of hyperandrogenism?
Hirsutism Acne High free testosterone Low sex hormone binding globulin High free androgen index
What are the clinical features of PCOS?
Obesity
Hypertension
Acanthosis nigricans (thickening + pigmentation of the neck, axillae + intertriginous areas)
Acne + hirsutism
Alopecia
Insulin resistance, DM, lipids –> increased CV risk
Irregular periods - infertility
Increased risk of endometrial hyperplasia + cancer
What is the management for infertility in PCOS?
Weight loss of 5-10% if BMI >30 First line: Clomifene Can add metaformin Ovarian drilling if clomifene unsuccessful Gonadotrophin injections IVF last resort
How is acne managed in PCOS?
Dianette
COCP
How amenorrhoea managed in PCOS?
COCP
Cyclical medroxyprogesterone or IUS
–> to manage risk of endometrial hyperplasia/cancer
What is dysmenorrhoea and how is it classified?
Excessive pain during the menstrual period
- primary –> onset within 2 years of menarche, no underlying pathology
- secondary –> develops years after menarche, result of underlying pathology
What are the main causes of secondary dysmenorrhea?
Endometriosis Adenomyosis PID IUD (copper coil) Fibroids
How is dysmenorrhoea managed?
Stop smoking
NSAIDs first line e.g. mefenamic acid and ibuprofen (inhibit prostaglandin production)
COCP second line
Levonogestrel IUS - if also menorrhagia
GnRH analogues - best of symptomatic relief, esp when due to fibroids, when awaiting hysterectomy
How is amenorrhoea categorised?
Primary (absence of menarche):
- age 16+ in the presence of secondary sexual characteristics
- age 14+ in absence of secondary sexual characteristics
Secondary:
- cessation of periods for > 6 months, after menarche
How can causes of amenorrhoea be categorised?
Hypothalamic Pituitary Ovarian Adrenal gland Genital tract
What are the hypothalamic causes of amenorrhoea?
Functional disorders e.g. eating disorders, exercise
Severe chronic conditions e.g. thyroid, sarcoidosis
Kallmann syndrome
What is Kallmann syndrome?
X linked recessive condition
–> failure of migration of GnRH cells
What are the pituitary causes of amenorrhoea?
Prolactinomas
Other pituitary tumours e.g. acromegaly or Cushing’s (mass effect)
Sheehan’s syndrome
Destruction of pituitary gland e.g. radiation, AI disease
Post contraception amenorrhoea e.g. Depo-Provera
What is Sheehan’s syndrome?
Post-partum pituitary necrosis secondary to massive obstetric haemorrhage
What are the ovarian causes of amenorrhoea?
PCOS
Turner’s syndrome (45 XO)
Premature ovarian failure
What is Turner’s syndrome?
Genetic condition –> amenorrhoea, lack of secondary sexual characteristics + infertility
- short stature
- webbed neck
- aortic coarctation
What is premature ovarian failure defined?
Primary ovarian insufficiency before age of 40 associated with menopausal symptoms
- low oestrogen + high FSH
What are the adrenal causes of amenorrhoea?
Late onset/mild congenital adrenal hyperplasia
- high levels of 17-hydroxyprogesterone in the blood
What are the genital tract causes of amenorrhoea?
Ashermann’s syndrome
Imperforated hymen/transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser syndrome (congenital absence of uterus)
What is Ashermann’s syndrome?
Secondary to instrumentation of the uterus following surgical management of a miscarriage –> intrauterine adhesions
