Menstruation disorders Flashcards
Amenorrhea
Amenorrhoea is the absence or cessation of menstruation.
Primary amenorrhoea= the failure to establish menstruation by 15/16 yrs in girls with normal secondary sexual development or by 13/14 yrs in girls with no secondary sexual development.
Secondary amenorrhoea= the absence of menses for 3 cycles or for 6 months in previously menstruating woman.
Causes:
- exclude pregnancy
- 2NDRY - hypothalamic suppression, chronic anovulation, ovarian failure, hyperprolactinaemia, uterine disorders.
Diagnosis
- Take history (family/sexual Hx, contraception, stress, weight loss, level of exercise), Examine person (BMI, height etc), optional pelvic ultrasound, TSH/T/LH/FSH levels, serum prolactin
TEST MAINLY DONE BY SPECIALIST
Treatment
REFER primary and in 2ndry if investigation needed.
- Amenorrhea from anorexia responds to weight gain, Excessive exercise = reduce exercise quantity and intensity.
- Hyperprolactinemia = bromocriptine
- Anovulation 2ndry to PCOS = if planning pregnancy clomiphene citrate +/- insulin sensitizing agent. If not = Insulin s agent =/- OC with progesterone.
- Other/unknown cause = progestin - induce withdrawal bleeding followed by oestrogen/progestin therapy
Amenorrhoea >1 yr consider osteoporosis prophylaxis.
Premenstrual syndrome (PMS) & Premenstrual dysphoric disorder (PMDD)
PMDD = severe form of PMS - DSM5 = 5/11 inc. mood
Symptoms normally relived within 4 days of menses.
Symptoms:
1. Emotional symptoms
* Irritability, anxiety and nervous tension.
* Lower coping ability and difficulty concentrating.
* Wanting to be alone.
* Lower libido.
* Reduced interest in work and social life.
* Mood swings, depression or aggression.
2. Physical symptoms:
* Fluid retention & abdomen bloating.
* Breast swelling and tenderness.
* Skin problems such as acne.
* Headaches, poor co-ordination or clumsiness.
* Tiredness, lethargy, insomnia, aches and pains.
* Food cravings and weight gain
* Constipation.
Diagnosis:
- Take history find out symptoms
- SOCRATES
- Physical exam rule out other causes
- Record daily symptoms diary for 2-3 cycles - Symptoms shown then diagnose
Treatment
Based on severity
- Lifestyle advise (diet, alcohol, stress, exercise, sleep, smoking cessation)
- Moderate PMS - COC +/- CBT
- Severe PMS Moderate + SSRi
SSRi = intermittent dosing 14 days B4 luteal phase
Review after 2 months see effectiveness
Dysmenorrhoea
Means painful period. (painful cramping occur shortly B4 and/or during menstruation)
Primary - normal painful menstruation
Secondary - caused by an underlying pelvic pathology (endometriosis, fibroids, or PID) or by IUD insertion.
Common condition. - affects day to day activities.
Risk factors for primary: Early age 1st period, Heavy flow, Family Hx, nulliparity (never been pregnant)
Diagnosis: Exclude 2ndry causes, Take history (socrates, menstrual/ medical/ obstetric/ Drug Hx), Examine women - Can do investigations (swabs, Ultrasound, pregnancy test exclude ectopic)
Primary most likely started 6-12 months after menarche
2ndry most likely after several years painless
Treatment
Primary: Non-pharmacological (TENS, Hot water bottle), NSAIDs +/-Paracetamol, If dont want to conceive OC.
Severe symptoms and no response within 3-6 months or doubt of diagnosis refer to gynaecologist
Secondary: REFER to secondary care
Menorrhagia
Is excessive menstrual bleeding (80ml or +) or bleeding between periods lasting >7 days.
Causes: polyps, fibroids, endometriosis, infection, some contraceptives, Uterine cancer, Meds (anticoagulants)
Diagnosis: Detailed clinical Hx, Asses if physical exam needed, FBC (rule out Fe deficiency),
Treatment
No found pathology, Fibroids <3cm diameter, sus/found adenomyosis:
- 1st line Levongestrel IUD
ALT - Tranexamic acid, NSAIDs or COC/ Oral progestogens. Sill fail then REFER.
- Fibroids >3cm REFER treat whilst waiting Tranexamic and/or NSAIDs. Specialist: As normal + ulipristal acetate, uterine artery embolisation surgery.
Endometriosis
Is growth of the lining of uterus (endometrium) at extra-uterine sites.
Cause unknown theories = retrograde menstruation, personal genetics, metaplasia, and environmental factors
Commonly occurs in pelvis, or within ovaries, and on the peritoneum or beneath pelvic viscera.
Extra pelvic - bowel, rectum, appendix, umbilicus, kidney and lungs
- Associated with menstruation hormonal changes induce bleeding, chronic inflammation, and scar tissue formation.
Symptoms: pelvic pain, painful periods and subfertility.
Condition can occur without symptoms.
Diagnosis: Suspect if show symptoms:
- Chronic pelvic pain,
- Period pain,
- Deep pain during/after sex
- Period related/ cyclical GI symptoms (bowel movements)
- Period related/ cyclical Urinary symptoms (Blood/pain in urine)
- Infertility with 1 or above.
If SUS: Take detailed history, pain and symptom diary, examine women (abdominal & pelvic)
Definite by laparoscopic visualization of pelvis
Visual: Classical- Bluish-black pigments, Non classical- Red, tan, or white lesions and vesicles
Treatments
Options meds and surgery
- 1st line Short trial (3 months) Paracetamol or NSAID or combo.
- AND/OR Hormonal treatment COC, Progestogen, POP, Implant, Injectable, L-IUD.
Surgery:
Excision then ablation
B4 surgery for deep endometriosis given 3 months B4 surgery GnRH agonists. Post surgery Hormonal treatment.
Hysterectomy can be indicated.
Review after 3-6 months or earlier if symptoms play up.
