Lecture 9: Introduction to menstrual disorders

Question 1

What is amenorrhoea?

Answer 1

Absence of menstruation, so can be normal (childhood, pregnancy, menopause), but can be pathological

Question 2

What are the different types of amenorrhoea?

Answer 2

Both are quite rare
Primary: when menstruation has not yet started by the age of 16 in the presence of normal secondary characteristics (RARE)
Secondary: absent periods for 6 months who previously had regular periods, or 12 months if she has oligomenorrhoea (bleeds less frequently than 6 weekly) (MORE COMMONLY SEEN)

Question 3

What is the main difference in causes between primary and seconary amenorrhoea?

Answer 3

Secondary usually to do with the HPG axis and you have had your period before
Primary could also involve problems with the genitalia

Question 4

What are the causes of primary amenorrhoea?

-can just be due to a constitutional delay of puberty

Answer 4

-most common causes are genitourinary malformations (anatomical causes) if there are secondary characteristics
e.g. imperforate hymen, vaginal septum (longitudinal or transverse), absent vagina, absent uterus
If there are no secondary sexual characteristics it is usually due to a chromosomal/hormonal cause
e.g. turners syndrome, CAIS, hypothalamic-pituitary dysfunction

Question 5

What is an imperforate hymen?

Answer 5

Congenital disorder where a hymen without an opening obstructs the vagina. Caused by failure of hymen to perforate during fetal development.
-most often diagnosis is in adolescent girls when menstrual blood accumulates in the vagina and sometimes the uterus

Question 6

What is turners syndrome?

Answer 6

45 XO (loss of one of the X chromosomes)

• ovary does not complete its development (dysgenesis)
• no oestrogen produced so no pubertal changes
• high FSH and LH

Question 7

What is complete androgen insensitivity syndrome (CAIS)?

Answer 7

• X linked recessive
• resistance to testosterone due to defect in the androgen receptor
• 46 XY but normal female phenotype (external)
• absence of upper vagina, uterus, and fallopian tubes
• testes should be surgically excised after puberty

Question 8

What are the causes of secondary amenorrhoea?

Answer 8

• scarring
• ashermans syndrome (intrauterine adhesions)
• primary ovarian insufficiency (premature menopause) where there is depletion of oocytes before 40 yo, there is no oestrogen or inhibin=high FSH due to loss of negative feedback
• PCOS (polycystic ovarian syndrome): elevated LH, raised insulin resistance, may be asymptomatic, multiple small follicles on the ovaries
• thyroid disease
• hyperprolactinemia

Question 9

What is the PCOS triad?

Answer 9

• mesntrual irregularlity
• androgen excess (can cause acne/hirsutism)
• obesity (diabetes and cardiovascular risk)

Question 10

How does thyroid disease cause secondary amenorrhoea?

Answer 10

In both hypothyroidism and hyperthyroidism but predominantly hyperthyroidism
-may be due to the fact that the changes in the thyroid hormones have an impact on the HPG axis

Question 11

How does hyperprolactinemia cause secondary amenorrhoea?

Answer 11

-raised prolactin levels
-high prolactin levels intefere with normal production of oestrogen and progesterone which can stop ovulation
Causes
-pituitary tumours (prolactinomas)
-hypothyroidism
-some medicines for depression, psychosis and high BP

Question 12

What are some examples of hypothalamic and pituitary diseases that cause secondary amenorrhoea?

Answer 12

• prolactinoma (treated with dopamine, as it inhibits prolactin)
• pituitary necrosis
• weight loss
• emotional stress/stress caused by illness

Question 13

What are some diseases in the hypothalamus/pituitary that cause primary amenorrhea?

Answer 13

Isolated GnRH deficiency (idiopathic hypogonadotrophic hypogonadism)
-no secondary sexual characteristics (this can be associated with loss of smell (anosmia) which is Kallman syndrome)

Question 14

What are some examples of physiological amenorrhoea?

Answer 14

• pregnancy

- menopause

Question 15

What is meant by abnormal uterine bleeding?

Answer 15

Uterine bleeding that is:

• duration greater that 8 days
• flow greater than 80ml/cycle or heavier than normal flow
• occur more frequently than every 24 days or less frequently than every 38 days
• intermesntrual bleeding/postcoital spotting
• absence of menses

Question 16

What do these terms mean?

amenorrhea/oligomenorrhea/metrorrhagia/menorrhagia

Answer 16

Amenorrhea: absent menses
Oligomenorrhea: infrequent menses
Metorrhagia: irregular menses
Menorrhagia: heavy menses

Question 17

What are the duration classifications of abnormal uterine bleeding?

Answer 17

Acute
-epsiode of heavy bleeding that is of sufficient quantity to require immediate clinical intervention to stop further blood loss

Chronic
-bleeding of abnormal volume, duration, regularity, or frequency that has been present for most of the 6 previous months

Question 18

What are some underlying causes of abnormal menstrual bleeding? (PALM-COEIN)

Answer 18

Structural

• polyps
• adenomyosis
• leiomyoma (fibroid)
• malignancy/hyperplasia

Non-structural

• coagulopathy
• ovulatory dysfunction (includes thyroid)
• endometrial
• iatrogenic
• not yet classified (DUB)

Question 19

What is the most common cause of abnormal uterine bleeding?

Answer 19

Fibroids

• benign tumour of uterine smooth muscle (leiomyoma)
• oestrogen dependent
• 40% prevalence

Question 20

What are some complications of fibroids?

Answer 20

• heavy menstrual bleeding
• intermenstrual bleeding
• subfertility
• bulk pressure effects
• rare malignant change to leiomyosarcoma
• worse in pregnancy due to the increase in oestrogen, but they do shrink in menopause
• a pedunculated fibroid can twist and cause pain

Question 21

What is DUB?

Answer 21

Dysfunctional uterine bleeding 
-bleeding of an endometrial origin
-unknown cause
-common at extremes of reproductive life
Sudivided into:
ANOVULATORY: related to ovarian cycle
IDIOPATHIC: unknown cause

It is a diagnosis of exclusion (not yet classified)

Question 22

What is dysmenorrhea?

Answer 22

Painful menstruation: crampy, intermittently intense or a continuous dull ache
45-95% of women in reproductive age
-presented 1-2 days before or during menses
-usually in lower abdomen/suprapubic area

Question 23

What are the types of dysmenorrhea?

Answer 23

Primary: since menarche (since they started their period), unlikely to have an underlying cause
Secondary: developed over time, more likely to have an underlying cause

Question 24

What is a common cause of dysmenorrhea?

Answer 24

Endometriosis

• endometrial glands and stroma that occur outside the uterine cavity
• 5-10% prevalence
• oestrogen dependant, benign, inflammatory disease

Question 25

What are the risk factors for endometriosis?

Answer 25

• early menarche
• short cycles
• heavy bleeding
• low BMI
• nulliparity (never given birth)

Question 26

Where are the most common sites for endometriosis?

Answer 26

-ovaries (most common): endometrioma (chocolate cyst)
-bladder
-rectum
-peritoneal lining
Causes accumulation of blood, and this can cause pain in that area

Question 27

How do you manage dysmenorrhea?

Answer 27

• NSAIDS
• hormonal contraceptives (pill or interuterine device)
• GnRH analogues
• surgery (maybe hysterectomy)
• heat