Menstrual disorders Flashcards
Abnormal uterine bleeding presentations?
- post coital bleeding
- heavy menstrual bleed
- Oligomenorrhoea/Amenorrhoea
- Intermenstrual bleeding
- Post-menopausal bleeding
- Dysmenorrhoea
- Menorrhagia
Post menopausal bleeding differntials
what is PMS
when do you get the symptoms and when do they regress?
describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle
resolves once menstruation begins
not present during preganacy and menopause
what r the causes of PMS?
- symptoms
- diagnosis
fluctuation in oestrogen and progesterone hormones during the menstrual cycle.
The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA
Dx
- A symptom DIARY spanning 2 menstrual cycles
- A definitive dx may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle & temporarily induce menopause, to see if the symptoms resolve.
Managment: PMS
moderate and severe
when to review?
Offer lifestyle advice :
- Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates.
- Regular exercise, sleep, redfuce stress, stop Smoking/alchol
If predominant symp is PAIN–> paracet or NSAID
►MODERATE: Consider prescribing a new-generation combined oral contraceptive (COC) (YASMIN)
►SEVERE: Consider prescribing a SSRI
- this may be taken continuously or just during the luteal phase*
- Review after 2 months to assess the effectiveness of the treatment.*
premenstrual dysphoric disorder.
When features are SEVERE and have a significant effect on quality of life
causes of heavy menstrual bleeding?
what defines menorrhagia?
more than an 80 ml loss.
hypothyroidism too
Ix & Ex: Menorrhagia
- Additional tests? (4)*
- when do u do Outpatient hysteroscopy?*
- when do u do Pelvic transvaginal USS?*
Incestigations:
FBC> iron deficiency Anemia
B-HCG
Additional tests:
- Swabs : if evidence if infection or discharge
- Coagulation screen: if FHx of bleeding disorders (von willebrand)
- Ferritin if are clinically anaemic
- TFT’s : features of hypothyroidism
- Hormone profile if concerns on premature ovarian insufficiency (POI)
Examination:
Pelvic exam + speculum and bimanual–>assess for fibroids, ascites and cancers.
Hysteroscopy?
- Suspected submucosal fibroids
- Suspected endometrial pathology, such as endometrial hyperplasia or cancer
- Persistent intermenstrual bleeding
Transvaginal USS?
- Possible large fibroids (palpable pelvic mass)
- Possible adenomyosis (assoc. pelvic pain or tenderness on exam)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
Mx: menorrhagia
when to refer to 2ndry care?
►►if don’t want Contraception
- Tranexamic acid–> no pain–>antifibrinolytic – reduces bleeding
- Mefenamic acid YES pain–> NSAID – reduces bleeding and pain
►►If want contraception
- Mirena coil IUS FIRST LINE
- COCP
- Cyclical oral progestogens (norethisterone 5mg ) x3 daily from day 5 – 26 (although this is assoc. w/ progestogenic SE & an increased risk of VTE)
why give COCP for heavy bleeding? tricks body into thinking its still in the luteal phase..
Referrels
- cancer pathway referral>>if suspect cancer
- 2ndry care>>women w/ fibroids of 3 cm for additional investigations.
Sx: menorrhagia (2)
what surgical options r available if regular treatment failed?
Endometrial ablation & Hysterectomy.
Endometrial ablation: removing the basal layer & functional layer (leaving myometrium)
Hysterectomy: partial & total (removal of cervix)
Complications of Hysterectomy
Short term
- Urinary retention
- ovary failure
- damage to nearby organs (ureters, bowel)
- infection
- bleeding and blood clots
- anesthetic problems
Long term
enterocoele and vaginal vault prolapse.
Cx of primary vs secondry Amenorrhoea
definition of both
Primary(divide it alaa as w/ normal or absent 2ndry sexual charactersitics ok?)
Normal
- Physiological causes
- Genito-urinary malformations–Imperforate hymen, Transverse septum, Absent vagina or uterus.
- Endocrine disorders
Absent
- Chromosomal irregularities–>Turners, gonadal agenesis
- Hypothalamic dysfunction–>stress, excessive excersize,
- Causes of ambiguous genitalia–> 5a-reductase deficiency, Androgen-secreting tumours, CA
Secondary:
- Physiological causes–>pregnancy, latation, menopause, medication
- Hypothalamic dysfunction–>stress, excessive exercise, and/or weight loss, Chronic systemic illness
- Pituitary causes–>TB, prolactinoma, sheehans, sarcoidosis
- ovarian insufficiency–>PCOS, chemo, radio, autoimmune D.
- Uterine causes–>ashermans, cervical stenosis
- thyroid–>hypo or hyper
- Surgery–>hysterectomy
Examination for 1* Amenorrhoea
- measure BMI-->low BMI is bad
- Features of Turner’s syndrome (short stature, web neck, shield chest with widely spaced nipples, wide carrying angle, and scoliosis).
- Features of Cushing’s syndrome
- Features of PCOS-->hirsuitism, Acne, fatso
- Features of androgen insensitivity (absence of axillary and pubic hair with normal breast development; testes may be palpable in the inguinal canal or labia).
Examination for 2* Amenorrhoea
- Measure BMI
- examine for thyroid D, cushings,
- hyperprolactinoma–>galactorrhoea
- Decreased endogenous estrogen–> reddened or thin vaginal mucosa).
- Access visual Fields–>pituitary tumor
Investigations 1* (4 approach)
initial investigations for underlying medical conditio
- FBC and ferritin = anaemia
- U&E = CKD
- Anti-TTG or anti-EMA antibodies = coeliac disease
- TFT’s
Hormonal blood tests assess for hormonal abnormalities:
- FSH and LH = low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
IL-Gf I is used as a screening test for GH deficiency
Prolactin = hyperprolactinaemia
Testosterone = high PCOS , AIS, CAH
Genetic testing with a microarray test to assess for underlying genetic conditions:
- Turner’s syndrome (XO)
Imaging can be useful:
- Xray of the wrist = assess bone age and inform a diagnosis of constitutional delay
- Pelvic USS= to assess the ovaries and other pelvic organs
- MRI of the brain = pituitary pathology and assess the olfactory bulbs in possible Kallman S.
investigation 2* Amenorrhoea
Urine or serum PREGNANCY TEST MUST BE DONE
then u order FSH: with estrogen and Gonadotropins
- if E low: POF (w/ high FSH) or supressed hypothalamic function (if low fsh)
Then check other shit……..
- Serum Prolactin–> in pituitary adenoma, if persistant–> must do neuroimaging
- serum Androgens–> high in PCOS, VERY HIGH in androgen-producing tumors
- TSH–>rule out primary hypoth or hyperthyroidism
Mx: 1* Amenorrhoea
Weight-related=
- encourage weight gain = refer to a dietician.
- eating disorder = consider referral to a psychiatrist
Exercise-related
- advise reducing exercise, increase calorie intake
- Consider referral to, or liaison = sports physician
Stress-related
- consider measures to manage stress and improve coping strategies ex CBT
Mx: 2* Amenorrhoea
Treat the Cause:
PCOS-manage accordingly
Hypothyroidism–>Thyroxine
Menopause–> possible HRT
Hyperprolactinaemia–> refer endo (bromocriptine, cabergoline)
Menopause
define: perimenopause, Post menopause,
* which age is considered premature menopause? why do they get it?*
woman has had no periods for 12 months.
Menopause is the point at which menstruation stops.
Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
Premature menopause is menopause b4 the age of 40 years. It is the result of premature ovarian insufficiency.
Postmenopause: describes the period from 12 months after the final menstrual period onwards.
Menopause physiology behind it?
Menopause is caused by a lack of ovarian follicular function, which produce estrogen and progesterone
- Oestrogen and progesterone levels are low
- LH and FSH levels are HIGH bc theres NO negative feedback from oestrogen on hypothalamus and pit so GnRH is HIGH
- The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles.
- W/OUT oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea).
- Lower levels of oestrogen also cause the perimenopausal symptoms.
Perimenopausal Symptoms
H–> Hot flushes
O–> Osteoporosis
A–> atrophy of vagina
C–> Coronory A disease
S–>Sleep disturbances
Complications of menopause (5)
& why they happen
- CVS disease and stroke–> increased LDL
- Osteoporosis–> E inhibits oseteoclasts
- Pelvic organ prolapse–> weakness of muscles
- Urinary incontinence–> tissues r thin, dry & less elastic
- diabetes type 2 –> increased IR
Diagnosis menopause
A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.
- 1st line: pregnancy testing
- other: FSH and serum estrogen
FSH blood test to help with the diagnosis in:
- Women under 40 years with suspected PREMATURE menopause
- Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
Management of Perimenopausal Symptoms
(non-HRT)
split into 3 categories:
- Lifestyle modifications
- Hormone replacement therapy (HRT)
- Non-hormone replacement therapy
For Vasomotor symptoms:
- regular exercise, weight loss, lighter clothing, turn down heating, sleep in cooler room, use fans, reduce stress.
- SSRI—Clonidine—Gabapentin
- CBT
For mood disorders
- Self-help resources and a trial of CBT for low mood and/or anxiety.
- Antidepressant if confirmed depression/anxiety
- Ginseng
For urogenital symptoms
- Vaginal moisturizers ex: Replens MD
- Vaginal lubricants if insufficient vaginal secretions for comfortable sexual activity
Arrange to review the woman after 3 months, then at least Yearly afterwards
HRT and contraception in menopause
- women should use effective contraception until the following time ?(name 2)*
- which HRT does not increase the risk of VTE?*
- 1 YEAR after the LMP in women more than 50
- 2 YEARS after the LMP in women LESS than 50
TRANSMDERMAL
What types of HRT regimes are available?
- contraindications? (5)
- what r 3 steps to consider when choosing the HRT formulation?
HRT
- Less than 12 months sequential combined HRT
- Post menopausal –> continuous combined HRT
continous HRT B4 postmenopause can lead to irregular breakthrough bleeding
- Do they have local or systemic symptoms?
- Does the woman have a uterus?
- Have they had a period in the past 12 months?
contraindications to taking HRT (4)
- Current or past BC
- Any E-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- VTE
- pregnancy
- Acute liver disease
- thrombophillic disorder
Side effects of HRT
Oestrogen: breast tenderness, leg cramps, bloating, nausea and headaches.
Progestogen: PMS-like symptoms, breast tenderness, backache, depression and pelvic pain.
Bleeding: Breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens.
Advice on stoppping HRT
When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term and Not long term ok?
She should be referred to secondary care if treatment is ineffective, if there are ongoing side effects or if there is unexplained bleeding.
Stop HRT 4 WEEKSSS before major surgery
Premature ovarian insufficiency
(premature ovarian failure)
define, pathophys
menopause before the age of 40
characterised by hypergonadotropic hypogonadism.
Under-activity of the gonads (hypogonadism) means there is a LACK of neg feedback on the pituitary gland= excess of the gonadotropins (hypergonadotropism).
premature ovarian insufficiency
- diagnosis
- feautres/symptoms
- treatment
- how is it different from menopause?
TWOO blood tests for FSH (done 4–6 weeks apart ) bc ur FSH levels change at different times during your menstrual cycle)
feautres:
- irregular menstrual periods, lack of menstrual periods
- symptoms of low oestrogen, ex: hot flushes, night sweats and vaginal dryness.
- INFERTILITY
blood tests will show :
- Raised LH** and **FSH levels
- LOW oestradiol levels
Treatment:
HRT or a COC
to reduce the CVS, osteoporosis, cognitive and psychological risks associated with premature menopause
- It’s different from menaopause in that women can still spontaneously get PREGNANT, bc they have intermittent ovarian function!*
- .*
causes of Premature ovarian insufficiency (5)
- Idiopathic
- Iatrogenic, chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
- Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
- Genetic, with a FHx or Turner’s syndrome
- Infections ex: mumps, TB or CMV
what is Mittelschmerz?
due to the small amount of fluid released during ovulation
Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
What is the most common identifiable cause of postcoital bleeding?
cervical ectropion
more common in women who take COCP
