Menstrual problems Flashcards
Fibroids.
a) What are they?
b) Classification
c) Risk factors
d) Presentation
e) Examination and investigations
f) Management (trying to conceive vs. not trying)
g) Indications for surgery (surgery to preserve fertility?)
h) Complications
a) Benign, oestrogen-dependent tumours of uterine smooth muscle (uterine leiomyomas)
b) - Intramural: within myometrium
- Submucosal: grow into uterine cavity; may be pedunculated (stalked); associated with infertility
- Subserosal: growing outwards from the uterus into abdomen; may be pedunculated
c) - Increased oestrogen (early menarche, nulliparous, obesity)
- Family history, African-American
d) - Often asymptomatic; incidental
- Age 30 - 50
- Menorrhagia (may also have IMB)
- Pressure effects: urinary frequency, constipation, abdominal discomfort
- Infertility (submucosal - improves on excision), or in pregnancy - miscarriage, other complications
e) - Abdominal/bimanual exam: Enlarged, often irregular, firm, non-tender uterus
- Bedside: pregnancy test
- Bloods: FBC, iron studies (anaemia), ?CA-125
- Imaging: TVUS
- Special tests: Pipelle biopsy/ hysterscopy + biopsy (if PMB - ?endometrial Ca)
f) - Asymptomatic: no treatment required
- Conservative: NSAIDs, TxA
- Mirena (1st line) / COCP (not if trying to conceive)
g) - Surgery indications: pressure symptoms, failure of medical management, submucosal fibroids causing infertility, very large uterus
- Myomectomy to preserve fertility
- Other options: hysterectomy, UAE
h) - Menorrhagia + IDA, torsion, mass effects, infertility
- In pregnancy: miscarriage, red degeneration (fever, pain, vomiting), malpresentation, IUGR, prem labour
Menopause.
a) Premature and late
b) LH and FSH - released from…?
c) Symptoms
d) Laboratory confirmation of menopause
e) Treatments
a) 45-50 = early; < 40 = premature ovarian failure
>55 = late
b) Anterior pituitary
c) Hot flushes, insomnia, mood changes, dyspareunia (urogenital atrophy), osteoporosis, loss of libido
d) Elevated FSH on 2 separate occasions
e) Hormone replacement (note - if they have a uterus, must give combined oestrogen and progesterone due to risk of unopposed oestrogen - cancer)
Postmenopausal bleeding (PMB)
a) PMHx
b) Differentials
c) Symptoms to ask about
d) Menstrual hx
e) Management
a) PCOS - risk for endometrial; lichen sclerosis - risk of vulval cancer
b) Endometrial cancer, endometrial hyperplasia, vaginal atrophy, endometrial / cervical polyps
- Other differentials: cervical, vulval and ovarian Ca
c) Weight loss, loss of appetite, discharge, dyspareunia, pelvic pain, bladder/bowel symptoms
d) Age of menarche and menopause; parity, breastfeeding, contraception/HRT
e) - 2 week wait
- TVUS (>3mm), hysteroscopy + endometrial biopsy
Management of endometrial cancer
a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4
a) Confined within uterus: TAH + BSO
b) Includes cervix: … + LN clearance + RT/chemo
c) Includes ovary, vagina or LNs
d) Includes bladder/bowel or distant metastases
Primary amenorrhoea.
a) Define
b) Causes - present secondary sexual characteristics (CHAP)
c) Causes - absent secondary sexual characteristics (CHOP)
d) Investigations
e) Management
a) The failure to menstruate by age:
- 16 years in the presence of normal secondary sexual development, or
- 14 years in the absence of secondary sexual characteristics
b) CHAP.
- Constitutional delay (ask FHx - age of menarche)
- Hyperprolactinaemia (eg. secondary to hypothyroid)
- Androgen resistance syndrome (testicular feminisation)
- Pregnancy
- Plus… GU malformations (eg. imperforate hymen)
c) CHOP.
- CAH
- Hypothalamic failure: anorexia, stress, chronic illness, excessive exercise, Kallman’s (hyposmia)
- Ovarian failure: Turner’s, chemoradiotherapy,
- Pituitary failure: tumour, head injury
d) - Bedside: pregnancy test
- Bloods: FSH and LH, androgens (testosterone/ SHBG), prolactin, TFTs, ?cortisol, ?day-21 progesterone (assessment of ovulation), 7-hydroxyprogesterone (raised in CAH)
- Imaging: TVUS
- Special tests: ?karyotyping (Turner’s), ?hysteroscopy
e) 1. Treat underlying cause:
- Prem ovarian failure: HRT until age 50
- Structural - may be amenable to surgery
- Turner’s - growth hormone, contraception
2. Fertility/contraception support
3. Bone protection (increase OP risk in low oestrogen)
Secondary amenorrhoea.
a) Define
b) Causes - normal androgens (2 main ones + others)
c) Causes - androgen excess (mnemonic: PCOS)
d) Possible examination findings
e) Investigations and findings
f) Management
a) Cessation of menses for > 6 months in a woman previously menstruating
b) 2 main ones:
- Pregnancy, menopause, breastfeeding, contraception (IUS, depot, implant, sometimes POP)
- Premature ovarian failure (< 40)
Others:
- Iatrogenic (hysterectomy, prolactin-raising drugs)
- Hypothalamic failure (stress, exercise, anorexia, chronic disease)
- Pituitary disease /hyperprolactinaemia (eg. Sheehan’s)
- Thyroid dysfunction
- Addison’s
c) - PCOS
- CAH (late-onset)
- Ovarian / adrenal cancer
- Steroids (Cushing’s)
d) - BMI low (?anorexia), high (?PCOS)
- Androgen excess: hirsutism, acne, balding
- Stigmata of disease (thyroid, Cushing, etc.)
- Gynae: enlarged uterus (?pregnancy)
e) - Bedside: pregnancy test
- Bloods: FSH and LH, androgens (testosterone/ SHBG), prolactin, TFTs, ?cortisol, ?day-21 progesterone, 17-hydroxyprogesterone (raised in CAH)
- Imaging: TVUS
- Special tests: ?karyotyping (Turner’s), ?hysteroscopy
f) 1. Treat underlying cause:
- Prem ovarian failure: HRT until age 50
- Structural - may be amenable to surgery
2. Fertility/contraception support
3. Bone protection (increase OP risk in low oestrogen)
Precocious puberty.
< 8 in girls
< 9 in boys
Delayed puberty.
Hypogonadotrophic hypogonadism
PCOS.
a) Pathophysiology
b) Rotterdam diagnostic criteria
c) Presenting features
d) Biochemical findings
e) Other blood tests (eg. to exclude DDx)
f) Management (if not trying to conceive)
g) Management (if trying to conceive)
h) Complications
a) - Increased androgen production (probably due to elevated LH)
- Increased insulin resistance probably due to obesity (causes hyperinsulinaemia)
b) 2/3 of:
- Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
- Clinical and/or biochemical signs of hyperandrogenism
- Oligo-ovulation or anovulation
c) - Menstrual: oligomenorrhoea, infertility
- Androgen excess: acne, hirsutism, male-pattern baldness/ alopecia, deep voice
- Obesity or difficulty losing weight and OSA
- Acanthosis nigricans (due to hyperinsulinaemia)
- Psychological - mood swings, depression, anxiety
d) Elevated LH, (LH:FSH ratio > 2)
- Normal/raised testosterone
- Normal/low SHBG*
* SHBG binds to testosterone; hence a low SHBG means higher free (active) testosterone
e) - Lipids and glucose + OGTT (insulin resistance)
- TFTs, cortisol, prolactin, 17-hydroxyprogesterone
f) - Conservative: weight loss, exercise, low GI diet, manage DM/HTN, etc.
- IUS, COCP or POP (for menstrual irregularity and endometrial protection)
- Co-cyprindrol (for hirsutism and acne)
g) - Conservative (as above)
- Clomifene (induces ovulation: anti-oestrogen, stimulates GnRH release by occupying oestrogen receptors in the hypothalamus)
- Metformin (alternative to improve fertility)
h) - Endometrial hyperplasia/ Cancer (with prolonged amenorrhoea/ oligomenorrhoea)
- Infertility, miscarriage, menstrual irregularity
- Weight gain, T2DM, CVD, sleep apnoea, psychological
A 16 year-old girl was brought to clinic because she had not yet started menstruating. She is 1.5 metres tall and 57kg. She had normal development of pubic and axillary hair. Initial breast development had been normal, but no further development had occurred over the last year. Her sisters started menstruating at the ages of 13 and 14 years respectively.
a) What investigations would you request and how would these inform your management?
b) Enumerate the possible diagnoses in this situation and discuss the characteristic and distinguishing features of each one of them.
c) Discuss initial and future management options
a) Primary amenorrhoea, secondary sexual characteristics present (causes: CHAP)
- Bedside: pregnancy test, ?PV exam (GU malformation)
- Bloods: FSH/LH, prolactin, TFTs
- Imaging: ?TVUS
b) CHAP: Constitutional, Hyperprolactinaemia (eg. hypothyroid, prolactinoma, dopamine-lowering drugs), Androgen resistance, Pregnancy
c) - Reassurance and watchful waiting
- Healthy lifestyle (healthy weight, avoid excessive exercise)
Pre-menstrual syndrome.
a) What is it?
b) Symptoms
c) Possible examination/investigations
d) Management
a) Symptoms occuring during luteal phase of each menstrual (ovarian) cycle and which regresses by the end of menstruation; symptom-free interval between menses and ovulation
b) - Psychological symptoms: irritability, labile affect, low mood, anxiety and lassitude
- Physical symptoms: breast tenderness, bloating, clumsiness and fluid retention.
c) - BP, HR
- Thyroid, breast exam
- ?TVUS, internal examination
d) - Conservative: healthy diet, limit salt intake (fluid retention), no smoking, low alcohol, increase exercise and weight loss; wear supportive bra and stockings
- Psychological: family support, counselling, CBT, stress management
- Medical: vitamin B6, SSRIs, ovarian suppression (COCP, IUS, GnRH)
Hormone profile: spot diagnosis.
a) 35 year old woman, secondary amenorrhoea: FSH and LH are raised
b) 16 year old girl, primary amenorrhoea: no secondary sexual characteristics; normal stature, FSH and LH low
c) 32 year old woman, secondary amenorrhoea: LH raised, FSH normal (ratio > 2:1), androgens slightly raised
d) 14 year old girl, amenorrhoea, no secondary sexual characteristics, raised serum 17-hydroxyprogesterone
a) Premature ovarian failure
b) Constitutional delay, or hypothalamic failure (stress, exercise, anorexia, chronic illness)
c) PCOS
d) CAH (21-hydroxylase deficiency)
Menorrhagia.
a) Define
b) Structural causes
c) Non-structural causes
d) Investigations in primary care
e) Management in primary care (trying to conceive or not)
f) Who to refer to secondary care?
g) Investigations in secondary care
h) Surgical management if required
a) Menstrual blood loss interfering with QoL (> 80ml per month)
b) Structural causes: Polyps Adenomyosis Leiomyoma Malignancy
c) Non-structural causes: Coagulopathy Ovulatory dysfunction Endometriosis Iatrogenic/ inflammatory (PID) Not specified
d) - Bedside: ?swabs
- Bloods: FBC (anaemia), ?TFTs, ?clotting
e) Not trying to conceive:
- 1st line: IUS (Mirena coil) - leave in situ for 12 months
- 2nd line: TxA, NSAIDs (eg. mefenamic acid), COCP
- 3rd line: progestogens (POP, Depo injection)
Trying to conceive:
- TxA, NSAIDs
Also:
- Ferrous sulphate for anyone who is IDA
f) - Persistent IMB / PMB
- Symptoms / IDA with no improvement on medication
- Age > 45 with heavy menstrual bleeding.
- Suspicion of endometrial pathology
- Abnormality suspected (apart from fibroids <3 cm)
- Risk factors for endometrial cancer or hyperplasia
g) - TVUS: gold standard for structural abnormality
- Hysteroscopy + biopsy
h) - Endometrial ablation
- UAE
- Hysterectomy
Clomifene: indication
Female infertility due to ovulatory dysfunction (eg. PCOS)
32 years old lady with infrequent periods. No previous pregnancies, but would like to become pregnant. Her periods started at 13 and have never been very regular. She started COCP at 17 to regulate her cycle, but stopped 2 years ago. Has had 2 or 3 periods each year with a very irregular pattern. She is generally healthy but has had problems with anorexia in the past, and finds it difficult to maintain weight. She also has problems with facial hirsutism.
a) Enumerate the possible diagnoses in this situation
b) What investigations would be helpful in this case?
c) Discuss possible management options
a) Secondary amenorrhoea:
- Androgen excess (likely due to hirsutism): PCOS, Cushings; rare: CAH, ovarian/adrenal Ca
- Non-androgen excess: anorexia, hypothyroid, hyperprolactinaemia
b) - Bedside: pregnancy,
- Bloods: LH and FSH, testosterone and SHBG, prolactin, TFTs, cortisol, day-21 progesterone
- Imaging: ?TVUS
c) PCOS
- General: conservative measures (weight loss, low GI diet, etc.)
- Wanting to conceive: clomifene or metformin
- Not wanting to conceive: ovarian suppression (IUS, COCP, POP)
- Co-cyprindiol for hirsutism
