Menstruation and Menstrual Disorders Flashcards by Ellie C

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

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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

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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

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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

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Intermenstrual bleeding is a red flag for…

Cervical cancer

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Causes of dysmenorrhoea

Primary dysmenorrhoea (no underlying pathology)

Endometriosis or adenomyosis

Fibroids

Pelvic inflammatory disease

Copper coil

Cervical or ovarian cancer

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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

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What are the two phases of the menstrual cycle?

Follicular phase

Luteal phase

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When is the follicular phase?

Start of menstruation to the moment of ovulation

first 14 days in a 28-day cycle

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When is the luteal phase?

The moment of ovulation to the start of menstruation

final 14 days of the cycle

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What stages do the follicles go through in the follicular phase?

Primordial follicles

Primary follicles

Secondary follicles

Antral follicles (also known as Graafian follicles)

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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

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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

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What is menstruation?

Superficial and middle layers of endometrium separating from basal layer

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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

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What is hypogonadism?

Lack of the sex hormones (oestrogen and testosterone) that normally rise before and during puberty

Causes a delay in puberty

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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)