Menstruation and Menstrual Disorders Flashcards
Causes of primary amenorrhoea
Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology
Causes of secondary amenorrhoea
Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hyper or hypothyroid)
Excessive prolactin, from a prolactinoma
Cushing’s syndrome
Causes of irregular periods
Extremes of reproductive age (early periods or perimenopause)
Polycystic ovarian syndrome
Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
Causes of intermenstrual bleeding
Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants
Intermenstrual bleeding is a red flag for…
Cervical cancer
Causes of dysmenorrhoea
Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer
Causes of menorrhagia
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
What are the two phases of the menstrual cycle?
Follicular phase
Luteal phase
When is the follicular phase?
Start of menstruation to the moment of ovulation
first 14 days in a 28-day cycle
When is the luteal phase?
The moment of ovulation to the start of menstruation
final 14 days of the cycle
What stages do the follicles go through in the follicular phase?
Primordial follicles
Primary follicles
Secondary follicles
Antral follicles (also known as Graafian follicles)
Outline the follicular phase
Primary follicles grow into secondary follicles
Secondary follicles have FSH receptor
FSH stimulates further development and begin secreting oestrogen
Oestrogen has negative effect on pituitary gland so less FHS and LH produced
One follicle will develop furthest and become dominant follicle
LH spikes just before ovulation, causing dominant follicle to release ovum
Outline the luteal phase
After ovulation, the follicle that released the ovum becomes the corpus lutem
Corpus lutem secretes high levels of progesterone which maintains endometrial lining
No fertilisation -> corpus lutem degenerates and stops producing oestrogen and progesterone
This causes endometrium to break down and menstruation occurs
Negative feedback from oestrogen and progesterone on hypothalamus and pituitary ceases, allowing LH and FSH levels to rise and cycle to restart
What is menstruation?
Superficial and middle layers of endometrium separating from basal layer
Definition of primary amenorrhoea
Not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development
What is hypogonadism?
Lack of the sex hormones (oestrogen and testosterone) that normally rise before and during puberty
Causes a delay in puberty
What is hypogonadotropic hypogonadism?
Deficiency of LH and FSH, leading to deficiency of sex hormones (oestrogen)
LH and FSH are gonadotrophins produced by anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus
No gonadotrophins simulating the ovaries -> ovaries do not produce sex hormones (oestrogen)
Therefore, “hypogonadotropism” causes “hypogonadism”
What is hypergondaotropic hypogonadism?
Gonads fail to respond to stimulation from the gonadotrophins (LH and FSH)
Without negative feedback from the sex hormones (oestrogen), anterior pituitary produces increasing amounts of LH and FSH
Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”)
What is Kallman syndrome?
What is it associated with?
Genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty
Associated with anosmia
What is congenital adrenal hyperplasia?
Congenital deficiency of the 21-hydroxylase enzyme
Causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth
Autosomal recessive
Presentation of congenital adrenal hyperplasia
Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
What is androgen insensitivity syndrome?
Condition where tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop
Results in a female phenotype, other than the internal pelvic organs
Normal female external genitalia and breast tissue
Internally there are testes in the abdomen or inguinal canal
Absent uterus, upper vagina, fallopian tubes and ovaries
Structural pathology causing primary amenorrhoea
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation
Initial investigations in primary amenorrhoea
FBC and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal blood tests in primary amenorrhoea
FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
TFTs
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia
Management of primary amenorrhoea
Treat underlying cause
Replacement hormones can induce menstruation and improve symptoms
What conditions can pulsatile GnRH treat?
Hypogonadotrophic hypogonadism e.g.
Hypopituitarism
Kallman syndrome
Define ‘secondary amenorrhoea’
No menstruation for more than three months after previous regular menstrual periods
Causes of secondary amenorrhoea
Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
Pituitary causes of secondary amenorrhoea
Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
Assessment of secondary amenorrhoea
Detailed history and examination to assess for potential causes
Hormonal blood tests
Ultrasound of the pelvis to diagnose polycystic ovarian syndrome
Hormone tests in secondary amenorrhoea
bHCG urine or blood tests to diagnose or rule out pregnancy
High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests PCOS
Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour
TSH can screen for thyroid pathology
T3 and T4 when the TSH is abnormal
Raised TSH and low T3 and T4 indicate hypothyroidism
Low TSH and raised T3 and T4 indicate hyperthyroidism
Raised testosterone indicates PCOS, androgen insensitivity syndrome or congenital adrenal hyperplasia
Osteoporosis and secondary amenorrhoea
Low oestrogen = risk of osteoporosis
Amenorrhoea >12 months requires risk mitigation
Ensure adequate vitamin D and calcium intake
HRT or COCP
What is premenstrual syndrome?
Psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation
Management of PMS
General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
COCP
SSRI antidepressants
CBT
Define menorrhagia
Blood loss >80mls
How do we quantify blood loss in practice?
Based on symptoms
Changing pads every 1- 2 hours
Bleeding lasting more than seven days
Passing large clots
Causes of menorrhagia
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
PID (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
PCOS
Investigations in menorrhagia
Speculum + bimanual
FBC - iron deficiency anaemia
Hysteroscopy if suspected fibroids/endometriosis
Swabs (infection)
Coagulation screen (Fix clotting disorders)
Ferritin if clinically anaemic
TFTs
Management of menorrhagia
Treat underlying cause
Mirena coil (first line)
COCP
Cyclical oral progestogens, such as norethisterone
If woman does not want contraception:
Tranexamic acid when no associated pain (antifibrinolytic - reduces bleeding)
Mefenamic acid when there is associated pain (NSAID - reduces bleeding and pain)
Outline the Rotterdam criteria for PCOS
Must have TWO of:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
