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Repro > Menstrual disorders > Flashcards

Menstrual disorders Flashcards

1
Q

What is amenorrhoea?

A

Absence or cessation of menstruation

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2
Q

What is oligomenorrhoea?

A

Infrequent menstruation defined by a cycle length between 6 weeks and 6 months

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3
Q

What is menorrhagia?

A

Excessive (heavy) menstrual blood loss

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4
Q

What is dysmenorrhoea?

A

Painful cramping, usually in lower abdomen, which occurs shortly before or during menstruation

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5
Q

Two types of amenorrhoea with explanation

A

Primary - failure to establish menstruation by 15 years old or 13 (if have no secondary sexual characteristics eg breast buds)

Secondary - cessation of menstruation for 3-6 months for women with normal regular periods before or 6-12 for women with previous oligomenorrhoea

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6
Q

Is primary and secondary amenorrhoea rare?

A

Primary - relatively rare (0.3% of women)

Secondary - more common but only 4% of population

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7
Q

Problem with diagnosing secondary and primary amenorrhoea

A

Overlap as secondary menorrhea can present as primary if the cause presents early enough in life (when they would usually start menstruating)

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8
Q

Questions to ask in amenorrhoea

A

Is there any pubertal development?
If not investigate as delayed puberty

If there is, exclude genital tract anatomy anomaly and look at secondary amenorrhoea

If development is ambigious - exclude chromosomal cause and hyperandrogenism

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9
Q

Causes of primary amenorrhoea with normal secondary sexual characteristics

A

Genitourinary malformations (anatomical cause - MOST COMMON)

Imperforate hymen - blood cannot escape

Vaginal septum (fusion problem)

Absent vagina or uterus

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10
Q

Imperforate hymen explained

A

Hymen without an opening completely obstructs the vagina

Failure of hymen to perforate during fetal development

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11
Q

When is imperforate hymen diagnosed usually?

A

When menstrual blood accumulates in vagina and sometimes also uterus (can cause swelling)

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12
Q

Causes of primary amenorrhoea with no secondary sexual characteristics

A

Chromosomal or hormonal cause eg Turner syndrome or HPG axis dysfunction

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13
Q

What is turner syndrome genotype?

A

45 XO - missing X chromosome

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14
Q

What is the phenotype of turners syndrome?

A

Ovary does not complete its normal development - streak ovaries

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15
Q

Lab results of Turner syndrome

A

Low oestradiol (form of oestrogen)
High FSH and LH

No oestrogen = no puberty changes

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16
Q

Physical features turners syndrome

A

Short stature
Low hairline
Shield shaped thorax
Widely spaced nipples
Shortened IV metacarpal
Small nails
Constriction of aorta
Elbow deformity
Streak ovaries
No menstruation

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17
Q

Disease affecting HPG axis causing primary amenorrhoea with no secondary sexual characteristics

A

Isolated GnRH deficiency

Constitutional delay of puberty

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18
Q

Cause of isolated GnRH deficiency

A

Idiopathic hypogonadotropic hypogonadism

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19
Q

What is Idiopathic hypogonadotropic hypogonadism?

A

Autosomal dominant or X linked autosomal recessive

Causes poor development of secondary characteristics due to GnRH deficiency

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20
Q

What is Idiopathic hypogonadotropic hypogonadism with anosmia (no sense of smell)?

A

Kallman syndrome - GnrH deficiency resulting in lack of sense of smell and no pubertal development

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21
Q

Pathway with what happens in GnRH deficiency

A

No GnRH
No FSH and LH
No oestrogen
= no secondary sexual development

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22
Q

Causes of primary amenorrhoea with ambiguous (incongruous) pubertal development

A

Androgen insensitivity (testicular feminisation pt is XY but appears female)

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23
Q

Explain androgen insensitivity

A

X linked recessive
Resistant to testosterone due to defect in androgen receptor
46XY but female phenotype

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24
Q

Examination findings for androgen insensitivity

A

Testes may be palpable in labia or inguinal area
Absence of upper vagina, uterus and fallopian tubes

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25
Q

Outcome for androgen insensitivity

A

Testes should be surgically excised after puberty

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26
Q

Secondary amenorrhoea causes - physiological

A

Pregnancy
Breastfeeding
Menopause

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27
Q

Secondary amennorhoea causes hypothalamus and pituitary

A

Chronic illness
Eating disorder
Excessive exercise
Stress
Tumours - prolactinoma, hypothalamus or pituitary tumours

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28
Q

Thyroid causes of secondary amenorrhoea

A

Hyper or hypothyroidism (mostly hyper)

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29
Q

Adrenal gland causes of secondary amenorrhoea

A

Cushing syndrome
Addisons disease
Congenitial adrenal hyperplasia
Adrenal tumours

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30
Q

Uterus and ovary causes of secondary amenorrhoea

A

PCOS (polycystic) - 20%
Premature ovarian insufficiency
Ovarian tumours

Asherman syndrome
Cervical stenosis

31
Q

What is primary ovarian deficiency which causes secondary amenorrhoea?

A

Premature menopause - depletion of oocytes before 40
No oestrogen and inhibin = high FSH

32
Q

What is asherman’s syndrome causing secondary amenorrhoea?

A

Intrauterine adhesions - pale adhesions inside uterus
Scarring

33
Q

What is the polycystic ovary syndrome triad?

A

Menstrual irregularity
Androgen excess
Obesity

34
Q

What does PCOS increase the risk of?

A

Type 2 diabetes due to raised insulin resistance

35
Q

Diagnosis of PCOS

A

Infrequent/no ovulation (mainfested as infrequent or no menstruation

Hyperandrogenism clinical or biomedical signs (eg acne, hirsutism (hairy) or high testosterone)

Polycystic ovaries on ultrasound

36
Q

Management for PCOS

A

Lifestyle advice
Screening for type 2 diabetes
Combined oral contraceptive pill or cyclical progesterone

37
Q

What is hyperprolactinaemia?

A

Raised prolactin levels - anterior pituitary hormone which initiates and maintains lactation

38
Q

Problem with high levels of prolactin

A

Interfere with production of progesterone and oestrogen - can stop ovualtion and lead to irregular/missed periods

39
Q

Causes for hyperprolactinaemia

A

Prolactinoma (pituitary tumour)
Hypothyroidism
Medicines for depression, psychosis and high BP

40
Q

What test result shows liklihood of prolactinoma?

A

Prolactin >800
CT head showing pituitary macroadenoma (>1cm)

41
Q

What is the syndrome involving pituitary necrosis which can cause secondary amenorrhoea?

A

Sheehan syndrome

42
Q

Causes of functional hypothalamic anenorrhoea

A

Weight loss/excessive exercise
Emotional stress and stress induced by illness
(eg gymnasts and athletes)

43
Q

Problem with functional hyppothalamic amenorrhoea

A

Risk of bone loss due to low oestrogen (esp occurs in athletes etc so is more of a problem)

44
Q

What is oligomenorrhoea usually due to?

A

Prolonged follicular phase
Constitutional maybe but most are direct or indirect hormonal imbalances

45
Q

Causes of oligomenorrhoea

A

PCOS
Ovarian insufficiency
Perimenopause (before)
Thyroid dysfunction
Excessive exercise/eating disorders
Hormonal contraception

46
Q

Consequence of menorrhagia

A

Interferes with a woman’s physical, emotional social and material quality of life

47
Q

Values for menorrhagia

A

Blood loss of 80ml or more
or
Duration of 7 days or more
or
Change of products 1-2 hourly
Passage of clots or very heavy as reported by woman

48
Q

Most common cause of menorrhagia

A

50% - no cause is found
AKA Dysfunctional uterine bleeding

49
Q

3 types of abnormal uterine bleeding

A

Intermenstrual bleeding (between periods)

Postcoital bleeding (after sex)

Post menopause bleeding

50
Q

Uterine/ovarian pathologies causing menorrhagia

A

Uterine fibroids
Endometriosis
PID or pelvic infection
Endometrial polyps
Endometrial hyperplasia or carcinoma
PCOS

51
Q

Systemic diseases causing menorrhagia

A

Coagulation disorders (eg von willebrand disease)
Hypothyroidism
Diabetes mellitus
Hyperprolactinaemia
Liver/renal disease

52
Q

Iatrogenic treatment causing menorrhagia

A

Anticoagulants
Intrauterine contraceptive device (copper coil and not hormonal)

53
Q

What are uterine fibroids?

A

Leiomyomas - benign tumours caused by proliferation of smooth muscle cells and fibroblasts which from round hard tumours in MYOMETRIUM

54
Q

When do leiomyomas (uterine fibroids) develop?

A

Women of reproductive age and regress after menopause

55
Q

Risk factors for leiomyomas (uterine fibroids)

A

Increasing age (until menopause)
Early menarche
Older age at first pregnancy
Black/asian ethnicity
Family history

56
Q

Menorrhagia management for dysfunctional uterine bleeding (no cause found)

A

Levonorgestrel intrauterine system (aka Mirena coil that has progesterone on it)

Tranexamic acid or NSAID

Combined pill or progesterone only pill

57
Q

When to refer fibroids?

A

If >3cm - REFER

58
Q

Red flags alongside menorrhagia

A

Post menopausal bleeding
Intermenstrual bleeding
Postcoital bleeding
Pelvic mass/bloating/early satiety
Ascites

= REFER

59
Q

What should all women have if coming to GP with menorrhagia before treatment?

A

Full blood count

60
Q

Two types of dysmenorrhoea

A

Primary - absence of any underlying pathology

Secondary - underlying pathology is causing

61
Q

When do primary and secondary dysmenorrhoea start?

A

Primary - usually 6-12 months after menarche. May be caused by uterine prostaglandins during menstruation

Secondary - after several years of painless periods

62
Q

Causes of secondary dysmenorrhoea

A

Endometriosis
Fibroids
Endometrial polyps
PID
IUD insertion

63
Q

What is endometriosis?

A

Growth of endometrium-like tissue outside the uterus - commonly in pelvis but can be extra-pelvic in bowel (rarer)

64
Q

Common deposits of endometrial tissue in endometriosis

A

Ovaries
Uterosacral ligaments
Pouch of douglas (rectouterine)
rectum
Sigmoid colon
Bladder
Distal ureter

65
Q

Extra pelvic (rare) deposits of endometrial tissue

A

Diaphragm
Bowel
Umbillicus
Pleural cavity

66
Q

Why does endometriosis cause problem?

A

Tissue responds to hormones associated with menstruation
Bleeding, chronic inflammation, scar tissue formation

67
Q

Endometriosis - is it common?

A

1/10 women have it
Second most common gynae condition (after fibroids)

68
Q

Diagnosis of endometriosus

A

Laparoscopy
Takes 7.5 years on average to get diagnosis

69
Q

Risk factors for endometriosis

A

Early menarche
Late menopause
Delayed childbearing
Family history
Vaginal outflow obstruction
White ethnicity
Low BMI
Autoimmune disease
Late first sexual encounter
Smoking

70
Q

Complications of of endomentriosis

A

Endometriomas (ovarian cysts containing blood and endometrial tissue)
Adhesions
Chronic pain
Bowel obstruction
Infertility
Reduced QOL

71
Q

Association between endometriosis and cancer?

A

Suggested by studies to be linked to ovarian cancer

72
Q

Primary dysmenorrhoea management

A

NSAID or paracetamol
Oral contraceptive trial (3-6 months - COCP or POP)

73
Q

Secondary dysmenorrhoea management

A

Referral if red flags
Management of symptoms - NSAIDs, hormonal contraception
Surgery if fertility is priority

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