Repro 3.2 Menstrual Dysfunction Flashcards
What is primary amenorrhoea?
Absence of menses by age 14 with absence of secondary sexual characteristics or age 16 with normal ssc
What is secondary amenorrhoea?
Established menstruation has ceased:
for 3 months in a woman with a history of regular cyclic bleeding
for 9 months in a woman with a history of irregular periods
What are the potential origins of amenorrhoea?
Hypothalamic/pituitary
Ovarian
Outflow tract
If amenorrhoea is caused by obstruction of the outflow tract, what would the hormone levels be?
Normal - HPA axis is functional
What might disorders of the outflow tract might cause primary amenorrhea?
Uterine: Mullerian agenesis (15%)
Vaginal: Vaginal atresia, cryptomenorrhoea, imperforate hymen
What disorders of the outflow tract might cause secondary amenorrhoea?
Intrauterine adhesions (Asherman's syndrome) Scarring from trauma, childbirth etc
How might the ovary or gonads cause amenorrhoea?
If it does not respond to pituitary stimulation - ovulation does not occur
What are possible causes of gonadal/end-organ cause of amenorrhoea?
Primary:
Gonadal dysgenesis
Androgen insensitivity syndromeReceptor abnormalities for FSH and LH
Specific forms of congenital adrenal hyperplasia
Secondary: PREGNANCY Premature menopause Polycystic ovarian syndrome (PCO-S) Drug-induced
What are the hormone levels of women with gonadal/end-organ disorders causing amenorrhoea?
High FSH and LH (typically in the menopausal range)
Low oestrogen
What tests might be required for patients with hypergonanotrophic amenorrhoea?
Chromosome testing - Turner’s syndrome can cause this
What is hypogonadotropic amenorrhoea?
Inadequate levels of FSH lead to inadequately stimulated ovaries which then fail to produce enough oestrogen to stimulate the endometrium -> amenorrhoea
Pituitary/hypothalamic/central regulatory disorders
What is a hypogonadotropic cause of primary amenorrhoea?
Kallmann syndrome (genetic hypogonadotropic hypogonadism)
List some pituitary disorders causing of secondary amenorrhoea.
Sheehan syndrome (hypopituitarism)
Hyperprolactinaemia
Haemochromatosis (iron overload disorder)
List some hypothalamic disorders causing secondary amenorrhoea.
Exercise
Stress
Eating disorders - anorexia, bulimia, obesity
Weight loss
Hyper/hypothyroidism can also cause amenorrhoea
What features of a patients history are assessed to evaluate secondary amenorrhoea?
Menstrual history Contraception Pregnancy Surgery Medication Weight change Chronic diseases, stress, diet etc
What features of a patients family history need to be assessed to evaluate secondary amenorrhoea?
Age at menopause
Thyroid dysfunction
Diabetes
Cancer
What must be assessed in physical examination of a patient with secondary amenorrhoea?
BMI Hair distribution Thyroid Visual fields Breast-discharge? Abdomen-masses? Tenderness?
What investigations should be done to diagnose the cause of amenorrhoea?
Pregnancy test Blood - TSH, prolactin, FSH, LH If hirsuitism is present - testosterone levels, DHEAS, androstenedione, 17-OH progesterone LFT's - metastases? Look for growths via MRIs
Define menorrhagia.
Excessive (>80ml) uterine bleeding
Prolonged (>7 days) regular
What is DUB?
Dysfunctional uterine bleeding - Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease
Anovulatory
Usually occurs at extremes of reproductive life
Define oligomenorrhoea.
Uterine bleeding occurring at intervals between 35 days and 6 months
Define dysmenorrhoea.
Lower anterior abdominal pain associated with periods
What is mastalgia?
Pain of the breast
What is an anovulation?
A menstrual cycle in which an oocyte is not released
What causes DUB?
Disturbance of the HPO axis changes the length of the menstrual cycle
No progesterone withdrawal from an oestrogen primed endometrium
Endometrium builds up with erratic bleeding as it breaks down
What investigations might be done for DUB?
hCG
TSH
Smear if appropriate
When would a sample of endometrium need to be taken from a patient with DUB?
> 35
Ca risk factors
Tamoxifen use
How is DUB managed?
IV or IM conjugated oestrogen therapy if acute
Usually followed by OCP or progestogen
Cyclic progestogens fo 10-12 days each cycle
Consider mirena IUD
OCP
What is menorrhagia usually secondary to?
Distortion of the uterine cavity e.g. fibroids
What are some other causes of menorrhagia?
Uterus unable to contract down on open venous sinuses in the zone basal Organic Endocrinologic Haemostatic Iatrogenic
What aspects are assessed in a physical examination of a patient with menorrhagia?
Anaemia obesity Androgen excess eg hirsuitism, acne Thyroid Galactorrhoea Liver/spleen Pelvic-uterine Cervical Adnexal
What are the symptoms of fibroids?
Usually asymtomatic
Abnormal bleeding
Typical amenorrhagia
Usually what age are women suffering from fibroids?
40s
How are fibroids assessed?
Large fibroids may be palpable on bimanual examination (irregularly shaped uterus)
Examination by anaesthesia and curettage or by laparoscopy
Ultrasound may show presence of a mass but not distinguish from other tumours
How much menstrual blood loss is sufficiently great to have adverse effects?
> 80ml
How is the amount of menstrual blood loss assessed?
Pad and tampon counts
Measure haemoglobin/haematocrit levels
What are the options of treatment for heavy menstrual loss?
Non-surgical : GnRH agonist
Surgical: Endoscopic resection or abdominal myomectomy or hysterectomy
Peri-menopausal women often benefit from spontaneous shrinkage with age
What are the disadvantages of a strict hysterectomy?
(includes removal of ovaries)
sudden onset of menopause as ovary is removed and loss of ovarian androgens
