Week 6: Womens' health (2) (menstrual problems) Flashcards
menarche
first period
menopasue
end of periods
amenorrhoea
absence of periods
- primary
- secondary
dysmenorrhoea
painful menstruation
menorrhagia
heavy/prolonged menstrual bleeding
oligomenorrhoea
infrequent periods
inter-menstrual bleeding
- Post coital (after sex)
- Breakthrough (irregular bleeding on hormonal contraception)
abnormal uterine bleeding (AUB) covers
- Menorrhagia
- Intermenstrual
- Post coital
- Break through
does not cover amenorrhea
AUB: types of symptoms
- Heavy
- Irregular
- Infrequently
- Frequent
- Shortened
- Postcoital
- Intermenstrual
causes of AUB
- (PALM- COEIN (FIGO))
- Structural
- Polyp
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy/hyperplasia
- Non-structural
- Coagulopathy
- Ovulatory dysfunction (includes thyroid)
- Endometrial
- Iatrogenic
- Not yet classified (DUB)
- Structural
with abdominal pain or heavy bleeding always
THINK: DO A PREGNANCY TEST
- DO A URINE PREGNANCY TEST IF IN ANY DOUBT!
Consider the following scenarios, which could all be related to pregnancy but might be interpreted as a new onset ‘period problem’
- Missed period Pregnancy is the most likely cause
- “Painful period” Could she be pregnant and having a miscarriage or ectopic pregnancy?
- “Heavy period” Could she be pregnant and having a miscarriage?
menorrhagia
- Abnormal menstrual bleeding (heavy or prolonged)
- Interferes with woman’s physical, emotional and social QoL
- Refers to abnormal uterine bleeding outside of parameters noted below
- duration greater than 8 days
- glow greater than 80mL/cycle or subjective impression of heavier-than-normal flow
- occurs more frequently than every 24 days or less frequently than 38 days
- intermenstrual bleeding or postcoital spotting
clinical diagnosis of menorrhagia
>80 mL/cycle
causes of menorrhagia
- Hypothyroidism
- PID
- Endometriosis
- Idiopathic
- Fibroids (non cancerous growths)
- Blood clotting disorders/ warfarin
- Contraceptive pill
presentation of menorrhagia
- FBC- anaemia
- Endocrine tests
- Bleeding disorders
- US
management of menorrhagia
- First line: Mirena (often not first line in practice due to what women wants)
- Second line: tranexamic acid, NSAIDS such as mefenamic acid or COCP/POP
dysmenorrhoea
- Low anterior pelvic pain which occurs in association with periods
- Primary- period pains since start of period
- Secondary- occurring later, with previously normal periods
causes of dysmenorrhoea
- Excess or imbalance of prostaglandins in menstrual fluid, which causes vasoconstriction in the uterine vessels, causing uttering contractions which produce pain
- Prostaglandins may explain: diarrhoea, nausea, headache etc
- Endometriosis
- PID
- Fibroids
- Copper IUDà may hurt for a few months after fitting
- Childbirth reduces dysmenorrhoea
investigation of dysmenorrhoea
- Good history
- Speculum exam of cervix
- High vaginal swap
- Pelvic/ transvaginal US
resentation of dysmenorrhoea
- 1-2 days before or with onset of menses
- Improves 12-72 h
- Crampy and intermittently intense, or continuous dull ache
- Lower abdomen and suprapubic area
management of dysmenorrhoea
- Lifestyle- stop smoking, exercise
- NSAIDs
- Hormonal treatment
- COCP
- Dep-povera
- Coil
- Surgery
- Laparoscopic uterine nerve ablation
- hysterectomy in rare cases
endometriosis
- Endometrial glands and stroma that occur outside uterine cavity
- 5-10% prevalence
RF for endometriosis
- Nulliparity (a woman has never given birth to a child, or has never carried a pregnancy)
- Early menarche
- Short cycles
- Heavy bleeding
- Low BMI
causes of endometriosis
- Not really sure
- Oestrogen dependent, benign inflammatory disease
- Responds to cyclical hormonal changes
- Can cause dysmenorrhea, dyspareunia (recurring pain in genital area), chronic pain and infertility
- Multifactorial pathogenesis- retrograde menstruation??
Most common sites of endometriosis
Adenomyosis: endometrial tissue found deep within myometrium
- Ovaries
- Endometrioma= chocolate cyst
- Bladder
- Rectum
- Peritoneal lining and pelvic side walls
oligomenorrhoea
- Infrequent menstrual periods (fewer than 6 to eight periods per year)
amenorrhoea: primary
- refers to absence of menstrual periods
- Primary (when menstrual periods have not started by age 15)
amenorrhoea: secondary
absence for more than 3 to 6 months in a women who has previously had periods
causes of amenorrhoea: primary
- Genitourinary malformation (imperforate hymen, vaginal septum, absent vagina, absent uterus)
- Chromosomal disorder (turners syndrome 45XO)
- Endocrine disorder (hypothalamic pituitary dysfunction)
- Complete androgen insensitivity disorder
- Isolated GnRH deficiency
causes of amenorrhoea: secondary
- PCOS (usually oligomenorrhea)
- hypothalamic amenorrhea (e.g. body weight too low)
- prolactinoma
- pituitary necrosis – Sheehan’s syndrome- when women loses a lot of blood during birth
- hyper/hypothyroidism
- scarring e.g. cervical stenosis, intrauterine adhesion
- primary ovarian deficiency
management of amenorrhoea: PCOS
- Lifestyle- weigh loss (orlistat)
- COCP
- Metformin
management of amenorrhoea: hypothalamic amenorrhoea
- Nutrition and counselling, reducing exercise
management of amenorrhoea: ovarian insufficiency
- Counselling
- HRT for symptoms
management of amenorrhoea (high prolactin)
dopamine agonists (bromocriptine and cabergoline)
management of amenorrhoea : endometrial adhesions and anatomical problems
surgery
physiological amenorrhea
- Pregnancy
- Menopause
- Towards end of women’s repro timespan periods may become irregular before stopping completely
- Still possible to get pregnant in transition
compelte androgen insensitivity disorder
Isolated GnRH deficiency
Gynaecological cancers
- Ovarian
- Endometrial
- Cervical
- Vulval
FIGO staging used
red flags of gynaecological cancer
- Post coital bleeding
- Haematuria
- Fatigue
- Weight loss
- Early satiety
endometrial cancer
There are two main types of endometrial cancer, corresponding to
- oestrogen-dependent endometrioid (type 1)
- oestrogen-independent non-endometrioid carcinomas (type 2)
RF for endometrial cancer
- >50
- Hormone replacement therapy: prolonged periods of unopposed oestrogen (e.g. when oestrogen is not modified by effect of progesterone)
- Being nulliparous
- Menopause
- Obesity
- PCOS
- Tamoxifen
rotective factors against endometrial cancer
COCP
presentation of endometrial cancer
- Post-menopausal bleeding
- Irregularities in menstrual cycle
- Constitutional symptoms
investigations of endometrial cancer
- Endometrial biopsy
- Hysterscopy
- TVUS
management of endometrial cancer
- Depends on stage
- Hysterectomy
- Radiation
- Chemotherapy
ovarian cancer types
- Epithelial ovarian tumours
- Most common
- Some subtypes
- Germ cell tumours
- Primitive germ cells of embryonic gonad
- Younger women
- High survival rates
- Different types including teratoma
- Sex cord-stromal tumours
- Derived from connective tissue cells
- E.g. fibroma
- Germ cell tumours
- Metastasise: breast, GI, haemopoietic system, uterus or cervix
RF for ovarian cancer
- Increasing age
- Lifestyle (smoking, obesity, talcum powder use)
- Early menarche and late menopause
- HRT
- Genetic factors BRCA1 and BRCA2
- History of ovarian, breast or bowel cancer
protective factors against ovarian cancer
childbearing, breastfeeding, oral contraceptive
presentation of ovarian cancer
- Insidious early symptoms vague e.g. abdom discomfort, distention or bloating
- Weight loss, anorexia and depression
- Pelvic or abdominal mass later on
- Uterine bleeding
- Ascites
- FIGO staging
management of ovarian cancer
- Chemotherapy
- Surgery (staging and debulking)
- Palliative care – often presents late
cevrical cancer
- Cancer of the cervix
- Mostly detected through cervical screening
classification of cervical cancer
Then can become invasive where it breaches the epithelial basement membrane
causes of cervical cancer
- Causes by persistent infection with HPV (99%)
- High risk types are HPV 16 and 18
- Risk factors
- Heterosexual women
- Multiple sexual partners
- Smoking
- Lower income
- Immunosuppression
resentation of cervical cancer
- Abnormal vaginal bleeding
- Vaginal discharge
- Vaginal discomfort/urinary symptoms
- Late symptoms
- Painless haematuria
- Painless fresh rectal bleeding
- Altered bowel habit
- Leg oedema
- Signs on exam
- White or red patches on cervix
- Rectal exam may reveal a mass or bleeding
management of cervical cancer
- Often affects women of childbearing ageà fertility-sparing surgery
- Primary treatment: surgery, radiotherapy , chemotherapy
vulval cancer
- Very rare
- Usually squamous
RF vulval cancer
- Vulval intraepithelial neoplasia
- Premalignant state
- HPV infection
- Age
- Premalignant state
presentation of vulval cancer
- Vulval lump, bleeding, pruritus or pain
- Delayed onset
- Differential : lichen planus
Management of vulval cancer
- Surgery
- Radiotherapy with or without chemo
- Sentinel lymph node biopsy
Perimenopause
- Period of change leading up to the last period
- Can only be defined after twelve months spontaneous amenorrhoea
As women move towards the menopause menstruation becomes erratic and eventually stops.
when does menopause occur
- Occurs in all women when their finite number of ovarian follicles becomes depletes
- Usually starts in mid to late 40s – final menstrual periods occur between he ages of 45- 55
what happens to womens hormones during menopause
- Causes oestrogen and progesterone levels to falls
- LH and FSH increase in response
Presentation of menopause
Symptoms are attributed to tissue sensitivity for lower oestrogen levels. Experiences varies widely
- Menstrual irregularity
- Hot flushes and sweats
- Urinary and vaginal symptoms
- Sleep disturbance
- Mood changes
- Loss of libido
- Other changes
- Brittle nails
- Thinning of har
- Hair loss
- Generalised aches and pains
hot flushes and swats
- Hallmark symptoms
- Affect face, head, neck and chest and last for a few minutes
- Loss of homeostasis by central thermoregulatory centre
urinary and vaginal symptoms after menopause
- Due to loss of trophic effect of oestrogen
- May include: dyspareunia (pain during sex), vaginal discomfort and dryness, recurrent lower UTI and UI
- vaginal atrophy
*
loss of libido
- Causes by a number of factors: oestrogen, progesterone and testosterone all implicated
- Vaginal dryness, loss of self -image and other psychosocial factors play a part
Premature ovarian insufficiency (POI)
- Menopause <40 years
- Triad of
- Amenorrhoea
- Elevated gonadotropins
- Oestrogen deficiency
RF for premature ovarian insufficiency
- Smoking
- Low socio-economic factors
- Menarche
- Parity
- Oral contraceptive
- BMI
- Ethnicity
- Fx
investigations for menopause
Diagnosis is usually clinical and investigations are not recommended
- High FSH may suggest menopause but could be to do with follicles needing more stimulation
- Unhelpful tests
- LH
- Oestrogen
- Progesterone
associated diseases with menopause
- Cardiovascular disease
- Osteo porosis – due to oestrogen deficiency
- Urogenital atrophy
- Redistribution of body fat (CVD and diabetes)
- Alzheimer’s disease – related to oestrogen levels
blood tests for osteoporosis
usually normal
Blood calcium levels are usually normal in osteoporosis. Alkaline phosphatase (ALP), an enzyme from liver and bone, usually shows normal activity in osteoporosis.
managament of menopause
- healthy lifestyle: stop smoking, weight loss, limit alcohol, adequate calcium
- HRT
- antidepressants for mood
HRT
- Most effective treatment to relieve symptoms i.e. hot flushes and night sweats, mood swings, vaginal and bladder symptoms
- Vaginal symptoms slower to respond to treatment and reoccur if stopped
- can prevent bone loss
contraindication for HRT
- Pregnancy
- Untreated hypertension
- Recent arterial thromboembolic disease and previous
- Undiagnosed vaginal bleeding
adverse events with HRT
- Blood clots
- Risk of cancer
- Breast cancer
Can use ……………….. to improve vaginal atrophy
topical HRT Use vaginal lube
