WH: Menstrual Disorders Flashcards
What is amenorrhoea
Lack of menstrual periods
what is primary amenorrhoea ? what age?
patient has never developed menstural periods
( not starting menstruation by 15 when there are other sings of puberty)
what could cause primary amenorrhoea ? (5)
- Abnormal function of hypothalamus (hypogonadotorphic hypogonadism)
- Abnormal function of gonads (hypergonadotrophic hypogonadism)
- congenital structural abnormalities (imperforate hymen)
- Congenital Adrenal hyperplasia
- Androgen insensitivity syndrome
what is secondary amenorrhoea ?
patient has piously had periods that they stop
Causes of secondary amenorrhoea ? (7) most common ?
- Pregnancy (most common)
- menopause
- Physiological stress
- PCOS
- Medications (hormonal)
- Thyroid hormone abnormailites
- Cushings
what physiological stress could cause secondary amenorrhoea ?
- high exercise
- low BMI
- chronic disease
- Physcosocial factors
What is irregular mesntruation
abrnomal uterine bleeding: abnormal
- Frequency
- Duration
- Volume of menses
- Regularity
What does irregular menstruation indicate? (2)
- annovulation (lack of ovulation)
- Irregular ovulation
what pathophysiology could cause irregular menstruation?
- disruption of normal hormone levels
- ovarian pathology
(think HPG axis)
causes of irregular menstruation ? (6)
- Extremes of reproductive age
- PCOS
- Psychosocial stress
- eating disorder/chronic disease
- Hormonal imbalance
- thyroid disorder
What is intermenstural bleeding (IMB)
any bleeding that occurs between menstural periods
what is intermenstrual bleeding a red flag for?
red flag for cervical cancer but has more common causes
common causes of IMB?
intermenstrual bleeding
- hormone contraception
- Cervical ectropion/polyps
- STI
- pregnancy
What is dysmenorrhoea
Painful periods
What could cause dysmenorrhoea ?
- Primary dysmenorrhoea (no underling pathology)
- Endometriosis
- Fibroids
- PID
- Copper coil
- Cervical/endo cancer
- PCOS
what is menorrhagia ?
heavy menstrual periods
What could cause menorrhagia ? (9)
- Dysfunctional uterine bleeding
- Extremes of reproductive age
- fibroids
- Endo
- PID
- Contraceptive (copper coil)
- anticoags
- Bleeding disorders
- PCOS
What is post-coital bleeding a red flag for?
red flag for cervical cancer but other reasons more common
post coital bleeding causes? (4)
- trauma
- Atrophic vaginitis
- cervical ectropion/polyps
- endo/vaginal/cervical cancer
what could cause pelvic pain? (12)
- UTI
- Dysmenorrhoea
- IBS
- ovarian cysts
- endo
- PID
- Ectopic pregnancy
- Appendicitis
- Mittelschmerz
- Pelvic adhesions
- Ovarian torsion
- IBD
what vaginal discharge is concerning?
excessive
discoloured
foul smelling
what could cause abnormal vaginal discharge? (6)
- BV
- STI
- foreign body
- Pregnancy
- Ovulation
- Cervical ectropion
what is kallman syndrome ? what type of amenorrhoea does it cause?
Kallman syndrome
- genetic condition causing hypogonadotrophic hypogonadism with failure to start puberty (primary amenorrhoea)
Briefly describe hypogonadotrophic hypogonadism: defieicy in what ? due to abnormal functioning of what?
abnormal function of hypo/AP => deficiency in LH + FSH
- causes low oestrogen
Briefly describe hypergonadotrophic hypogonadism: defieicy in what ? due to abnormal functioning of what?
abnormal function of gonads
ovaries fil to respond to gonadotrophin (LH + FSH) => no oestrogen => high LH + FSH, low sex hormones
hypothalamic causes of amenorrhoea? (3)
(hypogonadotrophic hypogonadism)
- Functional disorders (eating disorders, exercise)
- Severe chronic conditions (psychiatric, thyroid disease)
- Kallmann syndrome
what type of inheritance is Kallmann syndrome ?
x-linked recessive disorder
Kallmann syndrome pathophysiology
underdevelopment of specific neurones in brain => filature of migration of GnRH cells => hypogonadotrophic hypogonadism => primary amenorrhoea
Pituitary causes of amenorrhoea ?
(hypogonadotrophic hypogonadism)
- Prolactinomas
- Other pituitary tumours
- Sheehans syndrome (post-partum)
Ovarian causes of amenorrhoea/oligomenorrhoa ? (3)
- PCOS
- Turners syndrome
- Premature ovarian failure (early menopause - before 40)
Adrenal causes of amenorrhoea ?
congenital adrenal hyperplasia
physiological causes of amonorhoea ?
(secondary)
- Pregnancy
- lactation
- Menopause
What is congenital adrenal hyperplasia ?
congenital deficiency 21-hydroxylase enzyme => underproduction of cortisol + aldosterone + overproduction of androgens
(cause of primary amenorrhoea)
What type of inheritance is congenital adrenal hyperplasia ?
autosomal recessive
what is androgen insensitive syndrome ?
genetically males are unable to reopen to androgen hormones (testosterone) and excess converted to oestrogen => male genotype and female phenotype (female secondary characteristics)
Genetic abnormilaites causing primary amenorrhoea ?
- Turnerss syndrome
- Kallmanns syndrome
- androgen insensitivity syndrome
definition of secondary amenorrhoea ?
no mesntruation for more than 3 months after previous regular menstrual periods
How does hyperprolactinaemia cause secondary amenorrhoea ? what type of amenorhhoea is this?
raised prolactin supresses GnRH release from hypothalamus (hypogonadotrophic hypogonadism)
Hyperprolactinaemia treatment ?
dopamine agonist: cabergoline
what investigations would you do for amenorrhoea ?
- pregnancy test
- LH + FSH
- prolactin
- TFT
what are patient with amenorrhoea associated with low oestrogen at higher risk of?
osteoporosis risk
What is PMS? during which phase?
premenstrual syndrome
- psychological, emotional +physical symptoms that occur during the luteal phase (days prior to menstruation)
what is PMS caused by?
fluctuation of oestrogen + progesterone (not fully understood)
PMS presentation
- Low mood, anxiety, mood swings, irritability
- bloating, fatigue, breast pain
- Reduced confidence, cognitive difficulties, reduced libido
what is severe PMS that affects QOL ?
premenstrual dysphoric disorder
how is PMS diagnosed? when do symptoms improve ?
symptom diary shows cyclical changes
- symptoms improve after menstruation
PMS management
- general healthy lifestyle (diet, exercise, alcohol, stress, sleep)
- COCP
- SSRI
- CBT
What is menorrhagia?
heavy menstrual bleeding
average blood loss during menstruation ?
40ml
what counts as excessive blood loss? vol? symptom complaint?
> 80ml
- changing pad every 1-2 hours
- bleeding lasting >7days
- passing large clots
Causes of menorrhagia ? (9)
- dysfunctional uterine bleeding (no identifiable cause)
- extremes of reproductive age
- fibroids
- PCOS
- PID
- Endo
- Bleeding disorder
- Anticoagulants
- Copper coil
what investigations might you to for menorrhagia ?
- Pelvic exam + speculum + bimanual
- consider hysteroscoy, TVUS
menorrhagia management categories ? (3)
- contraceptive
- non-contraceptive
- definitive
what contraceptive management is there for menorrhagia ? (3)
1) mirena coil
2) COCP
3) cyclical oral progestogens
what non-contraceptive managmetn is there for menorrhagia ?
- Tranexamic acid
what is a definitive management option for menorrhagia ? (2)
- endometrial ablation
- hysterectomy
What is primary dysmenorrhoea ? secondary ?
primary: menstural pain occurring with no underlying pelvis pathology
secondary: menstrual pain that occurs with an oassocaietd pelvic pathology
examples of secondary dysmenorrhoea causes ?
- endometriosis
- adenomyosis
- PID
- Adhesions
- non gynae (IBD, IBS)
what is the pathophysiology of parity dysmenorrhoea ? what chemical involved ?
thought to be due to excessive prostaglandin release by endometrial cells
- prosaglandins => serial artery vasospasm (=> ischaemic necrosis) + increase myometrial contractions
features of primary dysmenorrhoea ? associated with ?
lower abdo or pelvic pain
- crampy, lasts 48-72 hrs
- associated with malaise/N+V/diarhoea/dizziness
primary dysmorrhoea Mx ?
lifestyle: stop smoking
- pharmacological NSIADs (inhibits the production of prostaglandins)
- 2nd line: COCP, mirena coil
What is HRT ? in who is it used ?
used I perimenopausal + PM women to alleviate symptoms of menopause
what brings on the sx of the menopause ? associated with what ?
sx associate with decline in oestrogen
(so HRT: exogenous oestrogen)
what hormones are in HRT ?
oestrogen
- plus progesterone given to women that have a uterus (to prevent endometrial hyperplasia/thicken of endo => endo cancer secondary to unopposed oestrogen)
what is unopposed oestrogen ?
oestrogen without protection of progesterone
Generally, what HRT recommended for: women that have periods ?
cyclical HRT with cyclical progesterone + regular breakthrough bleeds
Generally, What HRT recommended for: PM women with uterus + more than 12 months without periods?
continuous HRT
no hormonal Tc for menopause Sx ?
- lifestyle change (diet, stop smoking, increase exercise, reduce alcohol, reduce caffein, reduce stress)
- CBT
- SSRI, venlafaxine
- gabapentin
- clonidine
what is clonidine used for ?
redue BP + reduce HR => reduce hot flushes (vasomotor sx of menopause)
indications for HRT ? (6)
- replaying hormones in premature ovarian insufficiency (even without sx)
- hot flushes, night sweats (sx of reduced vasomotor)
- improve low mod
- low libido
- poor sleep
- reduce osteoporosis risk
benefits of HRT ? (3)
- improved sx
- improved QOL
- reduce osteoporosis risk
HRT risks ? (4)
- increase breast cancer risk (combined HRT)
- increase endo cancer risk (so add progestogen if have uterus)
- increase VTE risk (so use patches rather than pill)
- stroke
HRT contraindications ? (7)
- undiagnosed abnormal bleeding
- endometrial hyperplasia/cancer
- breast cancer
- uncontrolled hypertension
- VTE
- liver disease
- pregnancy
does cyclical or continuous HRT have better endo protection ?
continuous HRT has better endo protection than cyclical HRT
what different options for oestrogen are there for HRT ?
oral, transdermal (gel/patches)
-transdermal: better for poor oral Mx, increase VTE risk, CVD, headaches
why is progesterone used in HRT ?
reduce risk of end-hyperplasia + cancer in women with uterus
(helpful for reduced libido, depression)
what different types of progestogen are used in HRT ?
oral, transdermal, IUS (mirena)
- C19: derived from testosterone (helpful in low libido)
- C21: derived from progesterone (helpful in depression/acne)
what can mirena be used for ? (3)
- HRT
- contracpetion
- Menorrhagia
are patches or pills typically better for HRT ?
patches tend to be better due to reduced VTE risk
what HRT regime for woman with no uterus ?
oestrogen only pill or patch
what HRT regime for premenopausal woman with periods ?
cyclical combined tablet/patch/mirena coil
PLUS oestrogen only pills/patches
example regime for PM women with uterus?
continuous combine tablet/patch, mirena coil PLUS oestrogen only pills/patches
additional HRT mx ? when check up ?
follow up 3 months after starting HRT
- SE usually settle with time, takes 3-6 months to get full effects
is HRT contraception ?
nope
- but mirena or POP (in addition to HRT) is
HRT SE ?
oestrogen: nausea, bloating, breast swelling, breast tenderness, headaches
- progesterone: mood swings, bloating, fluid retention, weight gain, acnei
If you are getting HRT SE, what should you consider ?
changing pill => patch
different progestogen
how to stop HRT ?
rescued gradually or stopped abruptly
What is premature ovarian insufficiency ? due to what ?
It is menopause <40 yrs
- due to decline invariant activity => early menopause sx
what are the hormone levels like in premature ovarian insufficiency ? what hyper/hypogonadotorphin things is this ?
hypergonadoprophic hypogonadism (under activity of ognads)
- high LH + high FSH
- Low estradiol
causes of premature ovarian insufficiency ? (5) most common ?
- idiopathic (50%)
- iatrogenic (chemo, radiotherapy, oophorectomy)
- autoimmune
- genetic
- infection (mumps, cytomegalovirus)
premature ovarian insufficiency px ? (3)
oligomenorrhoea or secondary amenorrhea
- sx of low oestrogen (hot flushes, night seats, vaginal dryness)
premature ovarian insufficiency dx ?
typical monpasual sx PLUS elevated FSH
(in a women <40 yrs)
what conditions are associated with the reduced oestrogen in premature ovarian insufficiency ? (5)
- CVD
- Stroke
- Osteoporosis
- Cognitive impairment
- Dementia
premature ovarian insufficiency Mx ?
HRT
- traditional HRT
- or COCP
