S4) Menstrual Disorders Flashcards
Identify 7 common menstrual disorders
- Amenorrhoea
- Oligomenorrhoea
- Menorrhagia
- Dysmenorrhoea
- Intermenstrual bleeding (IMB)
- Dysfunctional uterine bleeding (DUB)
- Premenstrual syndrome (PMS)
What is amenorrhea ?
Amenorrhea is the absence of menstruation
Distinguish between primary and secondary amenorrhea
- Primary amenorrhoea: failure to establish menstruation by 16 years (rare)
- Secondary amenorrhoea: cessation of previously normal menstruation for ≥ 6 months
Identify some physiological causes of amenorrhea
- Prepubertal
- Pregnancy
- Menopause
How can pathology be determined in amenorrhea?
- Pathology occurs at the various levels of endocrine control
- Gonadotrophin levels indicate the level of the pathology
Identify the different types of pathology in amenorrhea
- Hypothalamic (stress)
- Pituitary (tumour or haemmorage)
- Ovarian (failure, genetic disorders)
- Uterine/endometrial
What is oligomenorrhea?
Oligomenorrhoea is infrequent menstruation >35 days i.e. 4-9x per year
due to prolonged follicular phase, to do with imbalance of hormones
cause:
PCOS
ovarian insufficieny
over active thyroid
eating disorders
What is menorrhagia/heavy menstrual bleeding?
Menorrhagia/HMB is a complaint of excessive menstrual blood loss over consecutive cycles or >80 mls per menstruation need ti change pads or tampons hourly
Identify 6 common causes for menorrhagia
- Leiomyoma (uterine fibroids)
- Uterine polyps
- Endometrial cancer
- Bleeding diathesis
- Copper from IUD coil
- Drugs e.g. warfarin
What is dysmenorrhea?
Dysmenorrhoea is pain during or before or both in menses, associated with ovulatory cycles
Distinguish between primary and secondary dysmenorrhea
- Primary dysmenorrhea is idiopathic, due to response of the uterus to local prostaglandins, hence painful contractions
- Secondary dysmenorrhea can be due to endometriosis or obstructed menses
What is dysfunctional uterine bleeding?
DUB is heavy and irregular menstrual bleeding that occurs secondary to an ovulation
What is premenstrual syndrome?
- PMS is a cyclical disorder, occurring in latter half of the menstrual cycle
- Symptoms could be physical or psychological and resolve with onset of menstruation
What is premenstrual dysphoric disorder?
Premenstrual dysphoric disorder is the severe end of the spectrum of PMS with extreme mood symptoms
Outline the Female HPO axis
Identify 7 possible causes of menstrual disorders
- Hormonal e.g. HPO axis
- Chromosomal anomalies
- Structural/Anatomical (uterine or vaginal)
- Bleeding diathesis
- Drugs
- Thyroid disease
- Chronic illness
Identify 4 chromosomal abnormalities which can cause menstrual disorders
- Turner’s syndrome
- Androgen insensitivity syndrome
- Swyer syndrome
- Congenital adrenal hyperplasia (CAH)
Identify 5 structural causes of menstrual disorders
- Agenesis/hypoplasia of the genital tract
- Leiomyoma
- Imperforate hymen & vaginal septae
- Asherman’s syndrome
- Cervical stenosis
Be able to identify an imperforate hymen
Be able to identify uterine fibroids
Oligomenorrhea is a feature of hormonal contraception but also has other causes.
Identify 4 of them
- Infection (STI/PID)
- Cervical ectopy or pathology
- Endometrial pathology (polyp or cancer)
- Ovarian cyst
Identify 7 components of a comprehensive history on a patient with a menstrual disorder
- Emphasis on age
- Onset of puberty
- Pain – cyclical or not
- Menstrual history – cycle, volume, change etc
- Sexual history
- Medical history
- Symptoms
What 4 types of examinations should one perform when examining a patient with a menstrual disorder?
- General
- Abdominal
- Speculum
- Bimanual
What 5 things should one look out for when performing an examination on a patient with a menstrual disorder?
- Presence or absence of secondary sexual characteristics
- Appearance of known chromosomal abnormalities
- Swellings/lumps/masses
- Discharge
- Pattern of hair growth
Identify and describe 4 types of investigations one can perform for a patient with a menstrual disorder
- Blood hormone profile – gonadotrophins, karyotype, thyroid function, FBC
- Imaging – USS, MRI
- Hysteroscopy – diagnostic and therapeutic
- Laparoscopy – diagnostic and therapeutic
Outline the pharmacological and surgical management of menstrual disorders
- Pharmacological – use of gonadotrophins, progesterone, combine oral contraceptive pill and hormone replacement therapy
- Surgical – depends on the condition
most common reasons for genitourinary malformations
causes for primary amenorrhea:
- imperforate hymen - obstructs the vagina and menstrual blood accumulates
- vaginal septum
- absent vagina or uterus
how can Turners syndrome be a cause for primary amenorrhea
- turners is failure of ovaries and genitals to properly develop including heart and other body defects
- they have no oestrogen so no pubertal changes
- some examples:
how can problems in the hypothalamus or pituitary gland cause primary amenorrhea and prevent secondary sexual characteristics
incongruous pubertal development can be a cause for primary amenorrhea
causes for secondary amenorrhea
effects on the uterus due to secondary ammenorreha
- scarring on the ovary and uterine (turn white)
- high FSH levels can cause loss if negative feedback
- PCOS
What is PCOS and its causes
- polycystic ovary syndrome
- can cause 20% of amenorrhea cases
- 50% cause behind olgiomenorrhea
- can cause high insulin levels (risk of type 2 diabetes)
how can PCOS present
- infrequent or no ovulation
- hypernadrogenism (acne, high testosterone)
- polycystic ovaries in ultrasound
management for PCOS
- lose weight
- screen for type 2 diabetes
- *metformin
- contraception to help with irregular periods
how can thyroid disease cause menstrual abnormalities
hyperthyroidism => weight loss, less leptin, amenorrhea
can lead to oligomenorrhoea
hyperthyroid => hyperprolactinemia
how can prolactinemia stop menstrual cycles
- raised prolactin
- can interfere with production of other hormones like oestrogen and progesterone
- can stop ovulation and lead to irregular or missed periods
- can be caused by pituitary tumours
name 3 abnormal uterine bleeding
- intermenstural bleeding - in between periods
- postcoital bleeding - after sex
- post menopausal bleeding - after menopause
causes of menorrhagia
uterine and ovarian pathologies:
- uterine fibroids
- PCOS
systemic diseases:
- hypothyroidism
- hyperprolactemia
Iatrogenic causes:
- anticoagulant (warfarin or heparin)
- contraceptives (copper coil)
what is a uterine fibroid
benign tumours caused by proliferation of a mixture of smooth muscle cells and fibroblasts causing hard round tumours in myometrium
risk factors for uterine fibroids
- age
- black and asian
- family history
red flags for ovarian cancer
- postmenopausal bleeding
- pelvic mass
- satiety
- ascites
what us endometriosis
growth of endometrium
second most common gynaecological condition
can cause chronic pain, bowel construction, and infertility
what hormone can be given to treat heavy periods
progesterone, think as if it is the opposite of oestrogen. Oestrogen makes the lining wall thicker so high progesterone will stop this and cause the lining to be thin so less blood shed
treatment for primary dysmenorrhea
- paracetamol
- oral contraceptives
