Dysmenorrhea

Question 1

DDX of secondary amenorrhea

Answer 1

With hyperandrogegism
- PCOS
- antonomus hyperandrogegism (androgen secretion independent of HPO axis) can be ovarian tour, hyperthecosis, adrenal androgen-secreting tumour.
- late onset or mild cognital adrenal hyperplasia
Without hyperandrogegism
- increase gonadotrophin(↑ FSH) and decrease gonodism (↓E). 3 types Idiopathic, autoimmune (T1DM, Addison’s or thyroid), Iatrogenic (radiation or cyclophosphamide)
- Hyperprolactinemia
- Endocrinopathies - most common ↑or↓ thyroid
- Hypogonadotrophic hypogonadism
- Functional hypothalamic - most common - amenorrhea often related to stress, excessive exercise +/or anorexia

Question 2

Causes of hypogonadotrophic hypogonadism

Answer 2

Pituitary compression or destruction
Pituitary adenoma, craniopharoma?
Lymphocytic hypophysitis, infiltration
Head injury
Sheehan's syndrome

Question 3

Types of amenorrhea

Answer 3

Primary amenorrhea
Secondary amenorrhoea
Oligomenorrhea

Question 4

Define primary amenorrhea

Answer 4

No menses by age 13 in the absence of 2° sexual characteristics or no menses by age 15 with 2° sexual characteristics or no menses 2 yrs after thelarche

Question 5

Define secondary amenorrhea

Answer 5

No menses for >6 m or 3 cycle after documented menarche.

Question 6

Define oligomenorrhea

Answer 6

episodic vaginal bleeding occurring at internals >35 days

Question 7

DDX of primary amenorrhea and 2° sexual development

Answer 7

Normal breast and pelvic development
- Hypothyroidism
- hyperprolactinemia
- PCOS
- Hypothalamic dysfunction 
Normal breast and abnormal uterine development
- Androgen insensitivity
- Anatomic abnormality eg mullerian genesis, uterovaginal septum, Imperforate hymen.

Question 8

DDX of primary amenorrhea and without 2° sexual development

Answer 8

↑FSH (hypergonadotrophic/ ↓gonadism
- Gonada dysgenesis - abnormal sex chromosome eg Turner’s, Noral sex chromosome
↓FSH (↓gonadtrophic, ↓gonadis)
- constitutional delay - most common. Can be due to Congenital abnormality such as isolated GnRH deficiency, pituitary failure e.g. Kallman syndrome, Head injury, pituitary adenoma. Can also be acquired such as endocrine disorders e.g. T1DM, Pituitary tumour, systemic disorder e.g. IBD, JRA, Chronic infection

Question 9

What work up for a patient with amenorrhoea

Answer 9

BhcG
Hormonal work up - TSH, Prolactin, FSH, LH, Androgens, Estradiol
Progesterone challenge to assess E status
if withdrawal bleed = adequate E. If no withdrawal bleed = inadequate E or excessive androgens or progesterone
Karyotype if premature ovarian failure or absent puberty
USS to confirm normal anatomy and ID PCOS.

Question 10

Mx of primary amenorrhea caused by androgen insensitivity syndrome

Answer 10

Gonadal resection after puberty,
Psychological counselling
creation of neo vagina

Question 11

Mx of primary amenorrhea caused by Anatomical abnormalities e.g. imperforate yen, cervical agenesis, transverse vaginal septum

Answer 11

Surgical management

Question 12

Mx of primary amenorrhea caused by mullein dysgenesis

Answer 12

Psychological counselling
creation of neovagina with dilation
diagnosis study to confirm normal urinary system and spine.

Question 13

Mx of secondary amenorrhea caused by uterine defect e.g. Asherman’s syndrome

Answer 13

Evolution with hypersalpingography or sonohysterography.

Hysteroscopy excision of synechiae

Question 14

Mx of secondary amenorrhea caused by HP acts dysfunction

Answer 14

ID modifiable underlying cause

COCP to ↓ risk osteoporosis, maintain normal vaginal and breast development (not proven)

Question 15

Mx of secondary amenorrhea caused by premature ovarian failure

Answer 15

Screen for DM, ↓thyroid, ↓PTH, ↓corticolism.

Hormonal therapy with E and P to reduce risk of osteoporosis - OCP

Question 16

Mx of secondary amenorrhea caused by hyperprolactinemia

Answer 16

MRI/CT if neg Bromocriptine, cabergolin if fertility wanted += surgery

Question 17

Mx of secondary amenorrhea caused by PCOS

Answer 17

Cycle control
Infertility
Hirsutism.

Question 18

Prolactinoma Symptoms

Answer 18

Galactorrhea
visual changes
headache

Question 19

Ix for 1° amenorrhea with secondary sex characteristics

Answer 19

Karyotypes
XX = imperforate hymen, transverse vagina spectrum, cervical agenesis, mullein ageneses
XY = androgen insensitivity syndrome

Question 20

Ix for 1° amenorrhea without secondary sex characteristics

Answer 20

FSH/LH
If high = hypergonadotrophic gondola agenesie/dysgenesis
If low = hypogonadotrophic with constitutional delay or HP axis abnormalities.

Question 21

Ix for 2° amenorrhoea

Answer 21

Start with B-hcG

Question 22

Ix for 2° amenorrhoea with -ve B-hcG

Answer 22

Prolactin first

• Normal = Progestin challenge.
• Abnormal >100 then CT head. test TSH for hypothyroidism

Question 23

What to do after progestin challenge

Answer 23

Withdrawal bleed - test FSH/LH
if high = premature ovarian failure or PCOS due to increase androgen
If normal or low = HPA axis dysfunction need MRI. Measure progesterone. may be caused by wt los, increase exercise and systemic disease.
No withdrawal bleeding = uterine defect, washerman’s syndrome or HPA axis dysfunction.

Question 24

Define abnormal uterine bleeding

Answer 24

Change in frequency, duration or amount of menstrual flow

Question 25

What are the different types of abnormal uterine bleeding

Answer 25

amenorrhea - absence of periods Hypomenorrhea - decrease amount of blood Oligomenorrhea - cycle intervals >35 days polymenorrhea - cycle intervals 7 days or excessive amount >80cc/cycle Metrorrhagia - irregular intervals particularly between period Menometrorrhagia - excessive blood at period and in-between Post menopausal - any bleeding after >1yr after menopause. Must rule out endometrial cancer.

Question 26

Compare anovulatory and ovulatory forms of abnormal uterine bleeding

Answer 26

Anovulatory is more common, unpredictable endometrial bleeding of various flow and duration where ovulatory is of typical cyclic but heavy or prolonged.

Question 27

Causes of anovulatory causes of abnormal uterine bleeding

Answer 27

``` PCOS thread dysfunction elevated prolactin E producing tumors Stress Wt loss exercise liver and kidney function structural disease Drug AE ```

Question 28

Causes of ovulatory abnormal uterine bleeding

Answer 28

anatomic eg polyps, fibroid, adenomyosis, neoplasm, Foreign body Homeostatic defect infection trauma local disturbances in prostaglandin eg ↑endomyometrial vasodilatory prostaglandin, ↓vasoconstrictive PG.

Question 29

Pathogenesis of anovulatory abnormal uterine bleeding

Answer 29

oestrogen dependent breakthrough bleeding. Increase E chronically with not enough P -> ↑ proliferation -> ↑ ET that out grows blood supply = focal necrosis = partial shedding = irregular prolonged/heavy bleeding.

Question 30

DDX of abnormal uterine bleeding by age

Answer 30

Pre menarchal - trauma, sexual abuse Pre menopausal - ovulary, anovulatory, pregnancy related Post - menopausal - genital tract disease - atrophy, neoplasms, or systemic disease or Drugs e.g. HRT, anticoagulants

Question 31

work up for abnormal uterine bleeding

Answer 31

Vital +/- orthostatic vitals FBC, serum ferritin BhcG TSH, free T4 Coagulation profile esp in adolescent to rule out vWD Prolactin if amenorrheic RSH, LH Serum androgens esp testeren Day 21 progesterone to confirm ovulation pap smear Pelvis USS - polyps, fibroids, easier ET (Post menopause) TVUSS - polyps and fibroids Endometrial biopsy if >40 yr to exclude endometrial Ca D+ C to diagnosis not to tx

Question 32

Tx of abnormal uterine bleeding

Answer 32

resus if needed Tx underlying disorders- if all causes are ruled out = DUB Medical DUB Stop constant bleeding = continuous progestogen: medroxy-P4 acetate 30mg daily Non-hormonal = NSAIDs or tranexamic acid Hormonal = COCP, Mirena, or cyclical progestogens day 5 - 25 If abnormal endometrium - pipette, repeat USS in early follicular stage or Hysteroscopy Clomiphene - if fertility is desired Fibroids - refer Surgical - Endometrial ablation, hysterectomy or myomectomy.

Question 33

Define Dysmenorrhea

Answer 33

Painful menstruation

Question 34

Types of Dysmenorrhoea

Answer 34

``` Primary - Idiopathic - begin 6m-2yr after menarche Secondary - Endometriosis - Adenomyosis -Uterine polyps - Uterine anomalies eg non-communicaating uterine hormones - Leiomyoma - Intrauterine synechiae - Ovarian cysts - Cervical stenosis - Imperforate Hymene, Transverse vaginal septum - PID - IUD - Copper - Foreign body. ```

Question 35

Symptoms of Primary Dysmenorrhea

Answer 35

Low midline abdo pain radiates to back or thighs Varies from dull dragging to a severe cramping pain Maximun pain at beginning of period May commence up to 12hrs before menses Usually last 24hr-2-3days. +/- Nausea and vomiting Headache, syncope or flushing

Question 36

Signs of Primary dysmenorrhea

Answer 36

No abnormal findings

Question 37

Tx of Primary dysmenorrhea

Answer 37

Rule out underlying pathology and dyspareunia, abnormal bleeding or infertility. Full explain and reassurence Promote healthy lifestyle eg reg exercise and stop smoking and reduce alcohol

Question 38

Define premenstrual syndrome

Answer 38

Physiological and emotional distrubances 1-2 wk prior to mensus

Question 39

Cause of premenstrual syndrome

Answer 39

Multifactoral, Genetic, Hormone effect and NT = Serotonin dysfunction

Question 40

Symptoms and diagnostic criteria

Answer 40

1 - At least 1 affective+1somatic symptom in 5 d before menses for 3 cycles. - Affective = depression, angry, outbursts, irritability, anxiety, confusion, social withdrawal - Somatic = Breast tenderness, abdo bloating, headache, swelling or peripheral 2 - Symptoms relieved 4d post onset of menses, 3 - symptoms present in absence of drugs or alcohol 4 - reproducible in 2 cycle 5 - ID dysfunction in social or economic performance

Question 41

Tx of premenstrual syndrome

Answer 41

Goal is symptom relief Psycholical support Diet/supplements - avoid Sodium, caffeine + alcohol, Ca, Mg, VE, VBG Med - NSAIDs if pain/discomfort - SSRI - either for the 14 days of luteal phase or continuous - Spironolactone - in luteal phase to reduce fluid retention - COCP - Danazol - androgen -ve to block the POAxis. Mind/body approach - exercise, CBT, Relaxation, if therapy Herbal remedies - evening primrose oil, black cohosh, St John Wart Surgery - BSO if severe.