Menstrual Disorders (Irregular, absent, painful or excessive menstruation))

Question 1

What is dysmenorrhoea?
How do we categorise it?

Answer 1

excessive pain during the menstrual period.

divided into primary and secondary dysmenorrhoea.

Question 2

What is primary dysmenorrhoea ?

Answer 2

• no underlyig pelvic pathology
• 50% menstruating women get it
• present in 1-2 years of menarche
• ++ endometrial prostaglandins thought to be part of cause

Question 3

What are the features of primary dysmenorrhoea?

Answer 3

• pain typically starts just before or within a few hours of the period starting
• suprapubic cramping pains which may radiate to the back or down the thigh

Question 4

What is the management of primary dysmenorrhoea?

Answer 4

1st line :
* mefenamic acid and ibuprofen (NSAIDS) effective in up to 80% of women. ( inhibit prostaglandin production)

2nd line:
* combined oral contraceptive pills

Question 5

What is secondary dysmenorrhoea?

Answer 5

• develops many years after the menarche
• the result of an underlying pathology.

**Contrast to primary dysmenorrhoea **
* the pain usually starts 3-4 days before the onset of the period.

Question 6

What are some causes of secondary dysmenorrhoea?

Answer 6

• endometriosis
• adenomyosis
• pelvic inflammatory disease
• IUD (IUS mirena may help)
• fibroids

Question 7

How do you classify amenorrhoea?

Answer 7

Primary

Secondary

Question 8

Define primary amenorrhoea?

Answer 8

1. failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (e.g. breast development)

OR

2. by 13 in girls with no secondary sexual characteristics

Question 9

Define secondary amenorrhoea

Answer 9

1. cessation of menstruation for 3-6 months in women with previously normal and regular menses,

OR

2. 6-12 months in women with previous oligomenorrhoea

Question 9

What are some causes of primary amenorrhoea?

Answer 9

• Gonadal dysgenesis (e..g Turners syndrome)
• Testicular feminisation
• congenital malformations of the genital tract
• functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
• congenital adrenal hyperplasia
• imperforate hymen

Question 10

What are some secondary causes of amenorrhoea (excluding pregnancy!)

Answer 10

• hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
• polycystic ovarian syndrome (PCOS)
• hyperprolactinaemia
• premature ovarian failure
• thyrotoxicosis
• Sheehan’s syndrome
• Asherman’s syndrome (intrauterine adhesions)

Question 11

How would you investigate amenorrhoea?

Answer 11

Bedside:
* exclude pregnancy with urinary or serum bHCG

Lab:
* FBC, U&E, coeliac screen, thyroid function
* Gonadotrophin levels
-Low : hypothalmic cause
-High: ovarian problem (e..g Premature ovarian failure)
Note: raised in gonadal dysgenesis (Turners)
* Prolactin levels
* Androgen levels (high in PCOS)
* Oestradiol

Question 12

How do you manage primary amenorrhoea?

Answer 12

• investigate and treat any underlying cause
• e.g. primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) treat with HRT to prevent osteoporosis

Question 13

How do you treat secondary amemorrheoa?

Answer 13

• exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
• treat the underlying cause

Question 14

What is oligomenorrhea?

Answer 14

infrequent menstrual periods (fewer than six to eight periods per year)

Question 15

What causes oligomenorrhoea?

Answer 15

• The same causes of primary or secondary amenorrhoea can cause oligomenorrhoea
• PCOS - the most common cause of irregular periods in women

Question 16

When evaluating a pt with oligomenorhoea / amenorrhoea what should you remember to include in history?

Answer 16

Looking for clues about cause so ask about:

• health problems in infancy or childhood
• when first period started / if one did
• how frequent subsequent periods have been
• FHx of irregular periods
• Discharge from breasts
• hot flashes
• adult acne
• facial / chest hair
• headaches / impaired vision (prolactinoma)
• stress
• medications / supplements used
• recent gynaecological procedures
• changes in weight
• diet
• exercise patterns
• illnessess e.g. coeliac can appparently cause amenorrhoea or oligomenorrhea