Session 5 Flashcards
Define amenorrhoea
This is classed as an absence of menstruation. It can be further divided into primary and secondary amenorrhoea.
Define primary amenorrhoea. Why might this happen?
This is classed as a condition where a patient has never had a period by the age of 16 years old.
Causes:
Turners syndrome - most common cause of amenorroea
Lacking a sex chromosome - 45XO
- 1:2500 live female births
- Ovary does not complete its normal development (dysgenesis)- Only stroma is present at birth = “streak” ovaries/gonads
- Lab values:
- Low estradiol • High FSH and LH due lack of negative feedback
- No estrogen= no pubertal changes
Complete Androgen Insensitivity Syndrome
- X-linked recessive disorder
- Resistant to testosterone due to a defect in the androgen receptor
- 46XY but normal female phenotype (external)
- Testes may be palpable in the labia or inguinal area
- Absence of the upper vagina, uterus, and fallopian tubes
- The testes should be surgically excised after puberty at roughly 25 due to cancer risk
You have a Y chromosome you will have testicular formation so testosterone and AMH will be produced. AMH will cause regression of the female structures but body will not be able to respond to testosterone so no fusion of external genitalia and male secondary sexual characteristics. Instead this excess testosterone will be convereted to oestrogen (aromatisation). This will give female secondary characteristics instead so female phenotype but male insides.
Hypothalamic and pituitary disease
- Isolated GnRH deficiency
- “Idiopathic hypogonadotrophichypogonadism”
- Autosomal dominant or x-linked autosomal recessive
- Poor development of secondary sexual characteristics
- With anosmia (loss of sense of smell) = Kallmansyndrome
Constitutional delay of puberty
More common in boys than girls
Diagnosis of exclusion
All aspects of puberty delayed
Anatomical Causes:
- 20% of cases of primary amenorrhea
- E.g Imperforate hymen
- Transverse vaginal septum (Rare! 1:30 000 -80 000)
- Mullerian agenesis (Mayer Rokitansky Kuster Hauser Syndrome) - Congenital absence of vagina with variable uterine development
Define secondary amenorrhoea. What would cause this?
Started having periods, but then subsequently menstruation has stopped. Secondary amenorrhoea after 6 months of not having a period.
Most common physiological cause is pregnancy. Also consider menopause in older women and weight loss.
Anatomical causes
• Scarring
- Cervical stenosis
- Ashermansyndrome (intrauterine adhesions)
• Ovarian disorders
- Primary ovarian insufficiency (POI) –“Premature menopause” - Depletion of oocytes before age 40 so no oestrogen, no inhibin so High FSH (loss of negative feedback)
Poly cystic ovarian syndrome (grouped symptoms)
- 20% of amenorrhea (up to 50% of oligomenorrhea)
- Elevated LH
- Raised insulin resistance so diabetes risk
- May be asymptomatic although signs of hyperandrogenism (acne, excessive growth (hirtuism)), obesity and anovulatory symptoms are the common triad of symptoms.
- Polycystic ovaries on ultrasound - Multiple small follicles (forms diagnosis with hormone blood profile)
- Treatment –Combined oral contraceptive pill, lifestyle advice
Endocrine:
Thyroid disease:
- Menstrual abnormalities common in both hyper and hypothyroidism
- Severe hyperthyroidism classically associated with amenorrhea
- May be proceeded by oligomenorrhea
- Complex interplay between thyroid hormones and HPG axis
Hyperprolactinemia:
Too much prolactin will supress GnRH
Can be physiological e.g from pregnancy or breast feedingwhich will raise prolactin
dopamin inhibits prolactin so any drugs that affect dopamine release can have side effects alike to hyperprolactinemia. Prolactinoma or other tumours can also cause it. Side effect of hypothyroidism, as TSH also acts on the pituitary to release prolactin. Hypothyroidism will see increased TSH.
Hypothalamic and pituitary disease:
- Prolactinoma (Adenoma of pituitary gland)
- High prolactin level (>800)
- CT head to diagnose along with FBC to check serum prolactin
Can be treated with dopamine or dopamine like drugs instead of surgery because dopamine inhibits prolactin.
- Pituitary necrosis –“Sheehan syndrome” - caused by obstetric haemhorrage during childbirth and hypotension.
- Functional hypothalamic amenorrhea:
Caused by weight loss and excessive exercise, emotional stress and stress induced by illness
Often seen in gymnasts/athletes, anorexia
Abnormal GnRH secretion so absent LH surge leading to anovulation and low oestrogen
Risk of bone loss due to hypoestrogenemia
Define oligomenorrhoea
This is classed as menstruation that has reduced in frequency, leading to a cycle length of greater than 38 days, resulting in 4-9 periods a year.
Define menorrhagia
This is defined as heavy menstrual bleeding, either by objective volume and/or the subjective opinion that periods have become heavier or that she is passing clots. Could be caused by benign or malignant growths in the endometrium, as well as clotting disorders or anticoagulation therapy. It is important to look for anaemia in these patients.
Define dysmenorrhea
This is defined as painful periods, i.e. cyclical pain associated with menstruation, to the point where it is interfering with quality of life. It often leads to chronic pelvic pain, and can be as a result of obstructive structural causes.
- 45-95% of women of reproductive age
- Presentation • 1-2 days before or with onset of menses • Improves after 12-72h • Lower abdomen and suprapubic area
- Primary –since menarche • Secondary –developed over time
Common cause is endometriosis but can also be inflammatory bowel disease, recurrent cyctitis.
How do you form a differential diagnosis when looking at menstrual disorders?
Hormonal
Firstly, it is important to look at the HPG axis. Is there a problem with the release of GnRH? If so, all subsequent values will be low. Is there a problem with the pituitary’s ability to release FSH and LH? Is there a problem with the ovary’s response to FSH and LH?
Structural
If there are no identifiable disorders with the HPG axis, then consider a structural problem of the uterus or vagina as a cause of menstrual disorders. This can be investigated by USS, MRI or more intensive imaging e.g. hysteroscopy, hysterosalpingography or laparoscopy.
System review
Thyroid disorders can cause patients to have menorrhagia or oligomenorrhoea so it is important to consider thyroid function tests.
What is menopause? Incidence of menopause?
- Menopause is the permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity
- Menopause is defined as the time when there has been no menstrual periods for 12 consecutive months and no other biological or physiological cause can be identified.
When the ovaries are no longer able to produce follicles, oestrogen levels start to decline.
INCIDENCE OF MENOPAUSE
• Physiologic menopause: – The normal decline in ovarian function due to ageing begins in most women between ages 45 and 55 on average 50 – result in infrequent ovulation, – decreased menstrual function and eventually cessation of menstruation.
• Pathologic menopause : – The gradual or abrupt cessation of menstruation before 40 years. Can occur idiopathically.
What is the menopausal phase?
End of reproductive life. age ranges between 45-55 years with average being 50
The menopause phase is usually broken down into four categories:
Pre-menopause (may be slight changes to FSH/LH levels but cycle will be relatively normal)
Peri-menopause (transition menopause things start to happen to the cycle)
Menopause
Post-menopause
What happens during pre-menopause?
The broad definition of pre-menopause is the time prior to menopause.
– Typically from age circa 40+ yrs – Slightly less oestrogen secreted – LH & FSH levels may rise, FSH more (due to reduced inhibin) • May be reduced negative feedback – Could result in some reduced fertility – But cycles may be relatively unchanged
What happens during peri-menopause?
Transition phase
– characterized by the physiological changes associated with the end of reproduction capacity
- Follicular phase shortens
- Ovulation early or absent
– terminating with the completion of menopause – also called climacteric
Mood swings and hot flushes may also occur
What happens during the “menopause” phase of menopause
This is when there has been a complete cessation of menstrual periods for 12 months.
– Permeant cessation of menstruation caused by ovarian follicular development failure
What happens during the post menopause phase of menopause?
Women who have gone through the other three stages of menopause are now considered menopausal. They are no longer able to conceive or have periods
– It is defined formally as the time after which a women has experienced 12 consecutive month of amenorrhea
How do we classify symptoms of menopause?
Most symptoms relate to oestrogen deficiency. They can be classified by early, intermediate and late stages of menopause
What are the symptoms of the early stages of menopause?
Typically hot flushes and sweating (‘vasomotor’) occur early on in the peri-menopausal patient. This can be accompanied by insomnia and mood swings or depression. As mentioned, irregular menstruation can occur, anything from heavier periods to longer, shorter or fluctuating lengths of the menstrual cycle.
What are the symptoms of intermediate stage menopause?
These symptoms relate to further decreasing levels of oestrogen, such as tissues that are reliant on oestrogen; vaginal atrophy leading to dyspareunia, and the urinary system such as tissues lining the urethra and bladder, which can lead to increased frequency of UTIs and stress incontinence.
There are also changes to the genitals in that the ovaries will atrophy, and there will be thinning of the uterus and loss of vaginal rugae.
There are also changes in the external genitalia, reduction of pubic hair due to It also causes changes to testosterone decline later in menopause.
Breast tissue can also change on structure and reduce in size.
There can be other changes with regards to general appearances such as skin elasticity, fat storage, changes to hair and voice. Other common symptoms include bloating, related to reduced motor activity of the GI system and can also cause constipation due to reduced progesterone. Progesterone activates smooth muscle.
Vaginal atrophy, dsypareunia, skin atrophy, urge-stress incontinence
