Session 5: Menstrual Disorders Flashcards
Define amenorrhoea
Absence of menstruation
What can amenorrhoea be divided into?
Primary amenorrhoea
Secondary amenorrhoea
Define primary amenorrhoea
When a patient never had a period by 16 years old.
Common causes of primary amenorrhoea?
(Not specific just broadly)
Congenital
Hormonal
Structural
Define secondary amenorrhoea.
Patient started having periods but for some reason they have stopped.
Defined as being without one’s period for 6 months.
Common causes of physiological secondary amenorrhoea
Pregnancy
Menopause
Define oligomenorrhoea
Menstruation that has reduced in frequency. Leading to a cycle length >35 days.
Define menorrhagia.
Heavy menstrual bleeding.
Objective volume >80 ml.
Subjective volume - Opinion of patient that period have become heavier or that she is passing clots.
Most common cause of primary amenorrhoea.
Turner’s syndrome
Explain Turner’s syndrome
45 XO meaning that you lack an X chromosome.
Ovary does not complete its normal develpoment (dysgenesis)
This leads to low levels of oestradiol (oestrogen) and high FSH and LH due to the lack of negative feedback.
No oestrogen = no puberty = no menses
Other causes of primary amenorrhoea
Anatomical causes
Complete androgen insensitivity syndrome
Hypothalamic and pituitary disease
Give some anatomical causes of primary amenorrhoea.
Imperforate hymen
Transverse vaginal septum
Mullerian agenesis (Mayer Rokitansky Kuster Hauser Syndrome)
Explain imperforate hymen.
When the hymen (opening of the vagina to the vaginal canal) is not actually not an opening but shut.
Explain transverse vaginal septum.
Failure of fusion of the paramesonephric duct and urogenital sinus.
Explain mullerian agenesis (MRKH)
When the paramesonephric duct degenerates leading to congenital absence of the proximal vagina and agenesis of the cervix.
This can also vary in degree of how developed the uterine will be. From fully developed to non-developed.
Explain Complete Androgen Insensitivity Syndrome
X-linked recessive disorder.
In this condition the patient is resistant to testosterone due to a defect in the androgen receptor.
Patients with this are genotypically male (XY) but have normal external genitalia female phenotype.
The testes may be palpable in the labia or inguinal area and there is an absence of the upper vagina, uterus and fallopian tubes.
Explain hypothalamic and pituitary diseases leading to primary amenorrhoea.
Isolated GnRH deficiency:
Idiopathic hypogonadotrophic hypogonadism which is a autosomal dominant or x-linked autosomal recessive disease. Poor development of secondary sexual characteristics.
This condition with anosmia is called Kallman syndrome.
Constitutional delay of puberty
Causes of secondary amenorrhoea
(No specifics only broad)
Anatomical/Structural
Endocrine
Hypothalamic and pituitary disease
Give examples of anatomical causes of secondary amenorrhoea
Scarring (most common) like cervical stenosis or Asherman syndrome which is intrauterine adhesions.
Ovarian disorders like Primary ovarian insufficiency (POI) leading to premature menopause.
Explain POI
Depletion of oocytes before age 40
No oestrogen and no inhibin leads to high FSH and no menstruation.
Explain polycystic ovarian syndrome. (PCOS)
An idiopathic condition which is a consulation of symptoms.
Elevated LH and raised insulin resistance.
Can be asymptomatic.
Triad of symptoms in PCOS.
Menstrual irregularity or amenorrhoea
Androgen excess
Obesity
Give examples of endocrine conditions that can lead to secondary amenorrhoea.
Hypothyroidism
Severe hyperthyroidism (thyrotoxicosis)
Hyperprolactinaemia (e.g. Prolactinoma)
Explain how hyperprolactinaemia can lead to secondary amenorrhoea.
E.g. a prolactinoma will cause an increase in prolactin. Prolactin causes negative feedback on GnRH and inhibits it.
No GnRH means no FSH and LH. This means no Oestrogen and no ovulation -> Amenorrhoea
Explain how hypothyroidism can lead to secondary amenorrhoea.
Low levels of T3 & T4 leads to an increase in production and secretion of TRH. TRH stimulates TSH to produce more T3 and T4.
However TRH also stimulates production of prolactin. Prolactin will inhibit GnRH.
Explain how severe hyperthyrodism can lead to secondary amenorrhoea.
T3 & T4 stimulates the liver to bind produce SHBG (sex hormone binding globulin). SHBG binds to oestrogen and androgen in the blood. Oestrogen bound to SHBG is biologically inactive. This is physiologically normal.
However if SHBG is especially high then more oestrogen will bind and the free active oestrogen will decrease. This leads to negative feedback of on GnRH and LH as the oestrogen levels don’t rise enough to cause a surge.
Leading to amenorrhoea.
Give examples of hypothalamic and pituitary diseases that can lead to secondary amenorrhoea.
Prolactinoma
Pituitary necrosis also known as Sheehan Syndrome
Functional hypothalamic amenorrhoea.
What does functional hypothalamic amenorrhoea include?
Weight loss and excessive exercise.
Emotional stress and stress induced by illness.
Physiological causes of amenorrhoea.
Pregnancy
Menopause
Define metrorrhagia.
Irregular menstruation.
This means that the shortest cycle is much shorter than the longest cycle. >7-9 days.
This is different from oligomenorrhoea where oligo is infrequent but still regular.
This is just irregular and not necessarily infrequent.
Different classifications of abnormal uterine bleeding.
Duration of symptoms
Underlying cause
Type of symptoms
Explain what acute AUB means.
Episode of heavy bleeding that is of sufficient quantity to require immediate clinical intervention to stop further blood loss.
Explain chronic AUB.
Bleeding of abnormal volume, duration, regularity or frequency that has been present for most of the previous 6 months.
Give the underlying cuases of AUB.
PALM-COEIN
(Structural)
Polyps
Adenomyosis
Leiomyoma
Malignancy
(Non-structural)
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
Type of symptoms of AUB.
Heavy
Irregular
Infrequent
Frequent
Prolonged
Shortened
Postcoital
Intermenstrual
Explain fibroids.
Benign tumours of uterine smooth muscle.
They are also called leiomyoma.
These fibroids are oestrogen dependent meaning they will grow with pregnancy, and they will shrink with menopause.
There can be rare malignant change to leiomyosarcoma.
Usually painless but can become painful if the twist (torsion) but generall the idea is that if it is painful, it is probably not fibroid.
Complications of fibroids.
Heavy menstrual bleeding or irregular menstrual bleeding.
Subfertility and recurrent pregnancy loss
Bulk pressure effects (mass effect)
Explain dysfunctional uterine bleeding. (DUB)
A bleeding of endometrial origin where there is heavy menstrual bleeding without any sign of pathology.
This is common at the extremes of reproductive life.
It can be subdivided into anovulatory or ovulatory (also called idiopathic).
Define dysmenorrhea.
Painful menstruation
Explain the pain of dysmenorrhoea.
Usually in lower abdomen and suprapubic area.
Can even go as far down as lower thighs.
Usually one ore 2 days before or with onset of menses.
Last 12-72hrs.
Difference between primary and secondary dysmenorrhoea.
Primary - since menarche
Secondary - developed over time
What is endometriosis?
Ectopic growths of endometrial glands and stroma.
Oestrogen dependent, benign and inflammatory disease. This means it responds to cyclical hormonal changes.
Risk factors of endometriosis.
Nulliparity
Early menarche
Short cycles
Heavy bleeding
Low BMI
Retrograde menstruation
Complications of endometriosis.
Dysmenorrhoea
Dyspareunia
Chronic pain
Infertility
What are common sites for endometriosis ectopic growths?
Ovaries is the most common site called endometrioma.
But can also be found in bladder, rectum and peritoneal lining and pelvic side walls.
What is adenomyosis?
Endometrial tissue found deep within myometrium.
Dysmenorrhoea management
NSAIDs
Hormonal contraceptives like COCP and intrauterine device.
GnRH analogues to desensitise GnRH receptors and shut down the HPG axis.
Surgery
Heat, ginger, acupuncture, TENS
Explain PCOS in a bit more detail.
Hypderandrogenism and chronic anovulation.
Triad of symptoms - amenorrhagia, androgen excess and obesity.
Related to a lack of pulsatile GnRH release where many follicles begin to develop but a dominant follicle is not selected to mature.
Anovulation is thought to occur because of inappropriate feedback signal from the ovary.
The abnormal oestrogen secretion puts the patient at increased risk of endometrial malignancy as well.
