Menstrual Dysfunction Flashcards
Define amenorrhoea
It is the absence of periods for at least 6 months
Define menorrhagia
Excessive (>80ml) uterine bleeding
Prolonged (>7days) regular
Define DUB
Dysfunctional Uterine Bleeding
Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease.
Define Oligomenorrhea
Uterine bleeding occurring at intervals between 35 days and 6 months
What is primary amenorrhoea?
Absence of menses by age 14 with absence of Secondary Sexual Characteristics (SSC) e.g. breast development or absence by age 16 with normal SSC
What is secondary amenorrhoea?
Where an established menstruation has ceased - for three months in a women with a history of regular cyclic bleeding, or nine months in a woman with a history of irregular periods. Usually happens to women aged 40-55
What are the origins of amenorrhoea?
Hypothalamic/pituitary
Ovarian/Gonadal
Outflow tract i.e. uterus, vagina, cervix
Describe how amenorrhoea can be caused by an outflow tract problem.
In an outflow tract problem, the hypothalamic-pituitary-ovarian axis is functional
The FSH level is therefore normal
Primary
Uterine: Müllerian agenesis (Second most common cause)
Vaginal: Vaginal atresia, cryptomenorrhoea (hidden periods), imperforate hymen
Secondary Intrauterine adhesions (Asherman's syndrome)
Describe how Gonadal/end-organ disorders can cause amenorrhoea.
If the ovary or gonad does not respond to pituitary stimulation. Gonadal dysgenesis or premature menopause are possible causes. Low oestrogen levels are seen in these patients.
Gonadal, usually ovarian, abnormalities tend to be linked to elevated FSH levels or hypergonadotropic amenorrhoea
Primary:
Gonadal dysgenesis, including Turner syndrome
Androgen insensitivity syndrome
Receptor abnormalities for hormones FSH and LH
Specific forms of congenital adrenal hyperplasia.
Secondary: Pregnancy Anovulation Menopause Premature menopause Polycystic ovarian syndrome (PCO-S) Drug-induced
Describe how hypothalamic/pituitary disorders can cause amenorrhoea.
Generally inadequate levels of FSH lead to inadequately stimulated ovaries which then fail to produce enough oestrogen to stimulate the endometrium, hence amenorrhoea.
In general, women with hypogonadotropic amenorrhoea are potentially fertile.
Primary:
Hypothalamic - Kallmann syndrome
Secondary:
Hypothalamic - Exercise amenorrhoea, related to physical exercise, stress amenorrhoea, eating disorders and weight loss (obesity, anorexia nervosa, or bulimia)
Pituitary - Sheehan syndrome (vascular necrosis of pituitary), Hyperprolactinaemia, Haemochromatosis.
Other central regulatory: hypo or hyperthyroidism
How do you evaluate secondary amenorrhoea?
Menstrual history Contraception Pregnancy Surgery Medication Weight change Chronic diseases, stress, diet etc... Family history: - Age at menopause - Thyroid dysfunction - Diabetes - Cancer
Physical examination: BMI Hair distribution - PCO-S Thyroid Visual fields - pituitary Breast-discharge? Lactinomas Abdomen masses? Tenderness?
How do you manage amenorrhoea? (in terms of investigations)
History.
Remember to always rule out pregnancy
History and examination suggests:
- Ovarian-axis problem - TSH, prolactin, FSH, LH
- Hirsuitism (excessive hair growth) - Testosterone,
DHEAS, androstenedione and 17-OH
progesterone
- Chronic disease - ESR, LFT’s
- CNS - MRI
Tell me a little about DUB
Dysfunctional Uterine Bleeding
Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease.
Diagnosis of exclusion
Anovulatory
Usually extremes of reproductive life and in patients with PCOS
What is the pathophysiology of DUB?
Disturbance in the HPO axis thus changes in length of menstrual cycle
No progesterone withdrawal from an oestrogen-primed endometrium
Endometrium builds up with erratic bleeding as it breaks down
What are some DUB investigations?
HCG, TSH Coagulation workup? Ensure smear if appropriate >35 or Ca risk factors, tamoxifen use? Sample endometrium
