Menstrual problems Flashcards
Management of premenstrual syndrome
Mild
- lifestyle- exercise, small meals 2-3 hours apart, stop smoking alcohol
Moderate
- COCP
Severe
- SSRI for luteal phase or continuous
Presentation of premenstrual syndrome
Physical
- bloating
- breast pain
Emotional
- anxiety
- mood changes
- fatigue
What causes mittelschmerz
In ovulation a small amount of fluid is released
What is a cervical ectropion
Increased oestrogen levels can cause the transformation zone to move down into the ectocervix
Symptoms of cervical ectropion
Post coital bleeding from trauma to cervix (columnar cells more fragile than squamous)
Dyspareunia
Increase in discharge
How does cervical ectropion appear
Reddening around the cervical OS
This is the shifting of transformation zone where columnar cells are visible which are red
Management of cervical ectropion
Ablation if very troublesome symptoms
Management of menorrhagia
Do they want contraception?
Yes
1st line- LNG-IUS
2nd line- COCP
3rd line- injection or implantable progestogen
NO
Do they have painful periods?
YES
Mefanemic acid
NO
Tranexamic acid
When suspect PCOS
Amenorrhoea, oligomenorrhoea, infertility
Signs of acne, hirsutism
Acanthosis nigricans
FHx
What is acanthosis nigricans
Dry rough skin with pigmented appearance
How is PCOS diagnosed in adults versus adolescents
Adults- rotterdam criteria
2 of
- amenorrhoea/infertility
- signs of hyperandrogenism (including just elevated testosterone)
- presence of cysts (over 12 measuring over 2mm or ovary size of over 10ml)
Adolescents
- hyperandrogenism and amenorrhoea required
If do not meet criteria then described as “at risk”
Most common cause of dysmenorrhoea
Primary dysmenorrhoea
Pathophysiology of PCOS
Production of LH greatly increased causing excess androstenedione which enters the blood and is converted to oestrone which inhibits LH surge. As such ovulation does not occur meaning that dominant follicle either degenerates or becomes a cyst
What is thought to cause anterior production of LH production in PCOS
Presence of hyperinsulinaemia causes proliferation of theca cells as they have insulin receptors. LH production increases
Consequences of high androstenedione
Hrisutism
Male pattern baldness
Acne
Where does acanthosis nigricans develop
Folds of neck, groin and underarms
What bloods tests do you do in PCOS
Sex hormone binding globulin
Free androgen index
Total testosterone
LH
FSH
Prolactin and thyroid
What can happen to prolactin in PCOS
Slightly raised
What is sex hormone binding globulin
Protein in the blood which binds to testosterone primarily
What is sex hormone binding globulin in PCOS
Low
What is the free androgen index
(100x testosterone)/ SHBG
This is a measure of total free testosterone essentially
What happens to free androgen index PCOS
Raised
Important things to screen for in PCOS
Wellbeing
Sleep apnoea
CVD risk
Who with PCOS should be offered OGTT
BMI over 25
Not overweight but other risk factors like fhx
Non white
Who gets an annual OGTT with PCOS
Impaired fasting glucose
Impaired glucose tolerance
What should PCOS people have annually
Weight monitoring
BP checks
How to manage amenorrhoea in PCOS
If prolonged amenorrhoea (1 in 3 months) then prescribe cyclical progestogen for 14 days to induce a withdrawal bleed and then refer for TVUSS
If over 10mm get sampling
If normal then offer either low dose COC, cyclical progestogen or LNG-IUS depending on whether wants withdrawal bleeds or has acne etc
If does not wish to have any of these then refer to specialist where will be offered USS every 6-12 months
Weight loss also useful
Management of acne in PCOS
First line is COCP- co-cyprindiol
If needed follow acne pathway
Healthy lifestyle
Management of hirsutism in PCOS
Healthy lifestyle
Discuss methods of hair reduction- waxing and removal
Management of infertility in PCOS
Healthy lifestyle- stop smoking and lose weight especially when overweight
Refer to specialist where can prescribe 1st line clomifene and then add metformin or use first line when overweight
Second line includes- gonadotrophins, Pulsatile GNRH and ovarian drilling
MOA of clomifene
Occupies oestrogen receptors in brain without activating them which stimulates GNRH release and ultimately FSH
Inheritance of androgen insensitivty syndrome
X-linked
Investigations for androgen insensitivty syndrome
Karyotyping- 46 XY
Testosterone levels very high
When suspect androgen insensitivty syndrome
Amenorrhoea
Breast development as can get conversion of testosterone to oestrogen
No pubic hair anywhere
Groin swellings which are undescended testicles
Management of androgen insensitivity syndrome
Counselling that should raise as a girl
Bilateral orchidectomy
Oestrogen therapy
Causes of secondary dysmenorrhoea
Endometriosis
Adenomyosis
PID
Fibroids
Cu IUD
Difference in pain for secondary dysmenorrhoea
Can start a few days before
Pain in dysmenorrhoea
Starts within a few hours of period and can radiate to back or down thighs
Management of pain in primary dysmenorrhoea
Mefanemic acid and paracetamol
2nd line COCP
3rd line can use POP or Mirena
Complications of PCOS
Endometrial cancer
Stroke
CVD
Infertility
OSA
How many periods aim in PCOS for per year
3 to reduce Ca risk
What happens to PCOS patients when do IVF
OHSS
What happens to the majority of secondary oocytes in ovaries
Undergo atresia not from ovulation
When is prime time to assess levels of hormones
Day 2-5 of menstrual cycle
Why do you want to lose weight in PCOS
Adipose tissue synthesises oestrogen which can adds to oestrogen levels in blood
How does PCOS appear on USS
Pearl sign
Sagging of ovaries
What are signs of extremely high testosterone in women
Deep voice
Virilisation
Cliterol hypertrophy
Rapidly progressing hirsutism
Problem of using accutane in PCOS treatment
It is teratogenic so must be on contraception
Why give COCP in PCOS
Increases SHBG
If presenting with menorrhagia what are first line investigations
Clotting screen
FBC
What type of drugs are tranexamic
Antifibrinolytic
How is primary amenorrhoea defined
Failure to menstruate by 15 with secondary sexual characteristics
Failure to menstruate by 13 without secondary sexual characteristics
What are spiral arteries
What supply the endometrium
Proliferate in the luteal phase
What is most common cause of primary amenorrhoea
Turners
What is second most common cause of primary amenorrhoea
Mullerian agenesis
What is included in mullerian duct system
Uterus, cervix and upper 2/3 of vagina
What is virilisation
When females develop male sexual characteristics
What does cause of primary amenorrhoea depend on
Development of secondary sexual characteristics such as breasts
Causes of priary amenorrhoea where development of secondary sexual characteristics
Endocrine
- CAH
- high prolactin
- thyroid dysfunction
- cushings
Androgen insensitivty (testosterone produced which can be converted to oestrogen)
Genitourinary dysfunction
- imperforate hymen
- mullerian agenesis
- transverse septum
What is imperforate hymen
The hymen is memebrane which is partially closed in the vagina
If imperforate then completely occludes the vagina
How does imperforate hymen present
Amenorrhoea with regular painful periods- eventually get abdo distention and discomfort from where uterus and cervix fill with blood. Can also get urinary retention
What is investigation for imperforate hymen
Abdo USS
- shows haematocolpos and haematometra
What is management of imperforate hymen
Incision under anaesthesia
Then evacuation of uterus and cervix
Causes of haematocolpos and haematometra
Imperforate hymen
Transverse septum
What is a transverse septum
When have tissue sitting across whole of vaginal canal
Amenorrhoea with impaired sense of smell
Kallman
Causes of primary amenorrhoea without secondary sexual characterstics
Constituional
Turners
Hypothalamic-pituitary dysfunction
- stress (mental and physical)
- weight loss
- kallmans
What causes functional hypothalamic amenorrhoea
Excess exercise
What defines secondary amenorrhoea
Absence of menstruation for 3-6 months after regular menses
Absence of menstruation for 6-12 months after oligomenhorrhoea
How does mullerian agenesis present
Dyspareunia
Agenesis
What does amenorhhoea with very little pubic har suggest
Androgen insensitivity
Signs on examination of haematocolpos
Parting of labia may reveal blue bulging membrane
Abdominal mass
If have examinaed the breasts when can next measure prolactin
48 hours
Examinations for amenorrhoea
BMI
Inspection of whole body
- hirsutism
- acne
- striae
- buffalo hump
- galactorrhoea
- lack of pubic hair
- abdominal mass
Test visual fields
Investigations for primary amenorrhoea
TSH
FSH/LH
Prolactin
Testosterone
TVUSS
What looking for in TVUSS for primary amenorrhoea
Streak ovaries
Lack of uterus/ovaries
What do if prolactin 500-1000
Primary amenorrhoea investigation
Repeat
What can cause mild hyperprolactinaemia
Drugs
- anti-psychotics
- SSRI
- anti-emetics metoclopramide
Stress
PCOS
Renal impairment (can go as high as 2000)
Thyroid dysfunction
How to interpret testosterone levels in primary amenorrhoea investigation
Normal- less than 2.5
2.5-5- PCOS
Over 5- CAH, Cushings, testosterone tumour, AIS
What level of prolactin warrants an MRI
Over 1000
Most common cause of hyperprolactinaemia in primary care
Stress or drugs
When does normal referral for primary amenorrhoea get changed
If present younger than 13 or 15 but
- growth retardation
- 5 years post thelarche and no menses
- thyroid cause suggested
- androgen excess
- galactorrhoea
Who to refer to for amenorrhoea
Gynaecologist most of time
Endocrinologist if hyperandrogenism, hyperprolactinaemia or thyroid causes suggested
How to manage amenorrhoea caused by excess exercise, weight loss or stress
Refer all to endocrinologist to rule out pituitary tumour
If ruled out
Excess exercise- reduce exercise and refer to sports physician if possible
Stress- manage stress
Weight loss- dietician or relevant services if ED
When do you consider osteoporosis prophylaxis for amenorrhoea
Over 12 months
When refer to gynae for secondary amenorrhoea
POI in under 40
Recent uterine or cervical surgery suggesting asherman or endometritis
Infertility
What is asherman syndrome
Amenorrhoea caused by recent uterine procedure or severe uterine infection which may have lead to adhesions meaning no functional endometrium
Causes of endometritis
Recent rupture of membranes
IUD insertion
Hysteroscopy and biopsy
Cervical curettage
PID
C-section
When manage osteoporosis risk in amenorrhoea
POI under 40
Hypothalamic hypogonadism
High prolactin
How manage osteoporosis risk in amenorrhoea
Lifestyle- stop smoking and lose weight
Vit d levels
HRT considered if amenorrhoea over 12 months
- if functional hypothalamic give for 12 months and then stop for 6 months to see if menses return
How manage osteoporosis risk in secondary amenorrhoea if caused by functional hypothalamic amenorrhoea
Give for 12 months and then stop for 6 months to see if menses return
How to daignose asherman syndrome
Hysteroscopy
What is seen on vaginal examination of imperforate hymen
Bulging membrane
What are gonadotorphin levels in prolactinaemia
Low FSH and LH
If present with galactorrhoea and amenorrhoea what do
Exclude thyroid causes and renal dysfunction
Then MRI
What is vulvodynia
Presence of pain in vaginal/vulvar region for 3 months with no identifiable cause
Difference between unprovoked and provoked vulvodynia
Unprovoked- present most of time without identifiable trigger
Provoked- has identifiable trigger like speculum or sex
What is most common cause of discharge in a prepubescent girl
Vulvovaginitis
What causes vulvovaginitis in a prepubescent girl
Due to low oestrogen the vaginal mucosa is very thin meaning susceptible to infections
Management of vulvovaginitis
Good hygiene
Wear cotton undergarments
If have hyperprolactinaemia causing amenorrhoea what are first investigations
Rule out other causes
Hypothyroidism
CKD
What is it called if somenoe has AIS
Male intersex
Management plan if unprovoked vulvodynia
First line- amitryptylline
Second line- gabapentin or pregabalin
What is premenstrual dysmorphic syndrome
A severe form of premenstrual syndrome whereby exhibit only the psychological symptoms of PMS without the physical
Investigation for pre menstrual syndrome
Symptom diary for 2 cycles
What is average size of dominant follicle
2cm
What produces the oestrogen near ovulation
Dominant follicle
What determines a cycle length
How long it takes to produce a dominant follicle
Luteal phase is fixed 14 days in everyone
If a fundus at umbilicus is 20 weeks what is it coming out of pelvis
12 weeks
What type of drug is mefanemic acid
Prostaglandin inhibitors
How to treat asherman syndrome
Hysteroscopy with adhesiolysis
Postoperative systemic oestrogen
What defines primary dysmenorrhoea
It occurs within 1 year of menache
In PMS, how give the COCP
Omit pill free period
What is best drug for dysmenorrhoea if dont want to take a pill every day
Mefanemic acid as can be given as a short course
Cause of menopause with liver problems, joint pain and diabetes
Haemochromatosis
What must do before TVUSS in PCOS amenorrhoea assessment
Give progesterone for 14 days to induce bleed
What is given to reduce endometrial cancer risk in PCOS
Low dose COCP
Cyclical progesterone every 14 days in 3 months
How does a post hysterectomy bladder injury present
Anuria
Pain
Blood in urine
