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Reproductive systems > Menstrual disorders > Flashcards

Menstrual disorders Flashcards

1
Q

What is amenorrhoea?

A
  • The absence or cessation of menstruation
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2
Q

What is primary amenorrhoea?

A
  • Failure to establish menstruation
  • by 15 years of age in girls with normal secondary sexual characteristics
  • Or by 13 years of age in girls with no secondary sexual characteristics
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3
Q

What is secondary amenorrhoea?

A
  • Cessation of menstruation
  • for 3-6 months in women with previously normal and regular meses
  • or for 6-12 months in women with previous oligomenorrhoea
  • primary amenorrhoea is rarer
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4
Q

Why is there an overlap in presentation of primary and secondary amenorrhoea?

A
  • Secondary causes may present as primary if they happen early enough in life
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5
Q

Outline how you would investigate primary amenorrhoea

A
  • If no pubertal development, investigate as for delayed puberty
  • If normal pubertal development, exclude genital tract abnormalities and investigate as for secondary amenorrhoea
  • If incongruous pubertal development, exclude chromosomal abnormalities and causes of hyperandrogenism
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6
Q

What is the most common cause of primary amenorrhoea?

A
  • Genitourinary malformations:
  • imperforate hymen
  • a vaginal septum
  • absent vagina (logitudinal or transverse absent uterus)
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7
Q

What is an imperforate hymen?

A
  • Hymen without an opening completely obsrtucts vagina
  • Caused by failure of hymen to perforate during fetal development
  • Menstrual blood accumulates in vagina and uterus
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8
Q

What are the possible causes of primary amenorrhoea with no secondary sexual characteristics?

A
  • An underlying chromosomal or hormonal cause
  • E.g. Turner syndrome or hypothalamic-pituitary dysfunction
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9
Q

Outline Turners syndrome

A
  • 45XO (missing an X chromosome)
  • 1/2500 live female births
  • Ovary doesn’t complete normal development - streak ovaries
  • Low estradiol
  • High FSH and LH
  • No oestrogen = no pubertal changes
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10
Q

What happens if there’s no GnRH produced by the hypothalamus?

A
  • No pituitary stimulation
  • No LH/FSH
  • No ovarian or uterine function
  • No oestrogen
  • No secondary sexual development
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11
Q

Which diseases in the hypothalamus and pituitary prevent secondary sexual characteristics from developing?

A
  1. Isolated GnRH deficiency
    - Idiopathic hypogonadotropic hypogonadism
    - Autosomal dominant or X-linked autosomal recessive
    - Poor development of secondary sexual characteristics
    - With anosmia = Kallman syndrome
  2. Constitutional delay of puberty
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12
Q

What is androgen insensitivity syndrome?

A
  • X-linked recessive disorder
  • Normal female external genitalia but 46XY
  • Have testes but these are undescended (excised after puberty)
  • Absence of upper vagina, uterus, and fallopian tubes
  • Androgen receptor fails so resistant to testosterone
  • Testosterone converted to oestrogen
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13
Q

How does androgen insensitivity syndrome lead to a female phenotype in spite of the XY chromosome?

A
  • XY causes testes to grow
  • Anti-mullerian hormone and testosterone produced
  • Mullerian structures regress
  • Androgen receptor fails
  • Absence of virilization
  • Testosterone converts to oestrogen
  • Female phenotype
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14
Q

What physiological conditions can cause secondary amenorrhoea?

A
  • Pregnancy
  • Breastfeeding
  • Menopause
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15
Q

What are some ovarian and uterine causes of secondary amenorrhoea?

A
  • Scarring due to cervical stenosis or Asherman syndrome (intrauterine adhesions)
  • Primary ovarian insufficiency (premature menopause) - depletion of oocytes before age 40. No oestrogen, no inhibin = high FSH
  • PCOS
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16
Q

What is the most common cause of oligomenorrhoea?

A
  • PCOS (causes up to 50% of oligomenorrhoea)
  • Also causes 20% of amenorrhoea
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17
Q

What is the triad of PCOS?

A
  • Menstrual irregularity
  • Androgen excess
  • Obesity
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18
Q

How is PCOS diagnosed?

A
  • Infrequent or no ovulation
  • Clinical and/or biochemical signs of hyperandrogenism (hirsutism, acne, elevated levels of testosterone)
  • Polycystic ovaries on ultrasound
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19
Q

How is PCOS managed?

A
  • Lifestyle advice e.g. weight loss
  • Screening for type 2 diabetes mellitus
  • Combined pill or cyclical progesterone
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20
Q

Other than oligomenorrhoea, what else can PCOS lead to?

A
  • Raised insulin resistance
  • This combined with obesity can result in type 2 diabetes
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21
Q

What are the signs and symptoms of PCOS?

A
  • Hair loss
  • Hirsutism
  • Pelvic pain
  • Overweight
  • Acne
  • Irregular periods
  • Infertility
  • High testosterone levels
22
Q

What are the endocrine causes of secondary amenorrhoea?

A
  • Thyroid disease (both hyper and hypothyroidism)
  • Hyperprolactinaemia
23
Q

How do thyroid diseases lead to amenorrhoea?

A
  • Severe hyperthyroidism classically associated
  • May be proceeded by oligomenorrhoea
  • Complex interplay between thyroid hormones and HPG axis
24
Q

How does hyperprolactinaemia cause amenorrhoea?

A
  • Raised prolactin levels
  • Interferes with normal production of hormones such as oestrogen and progesterone
  • Can change or stop ovulation
  • Leads to irregular or missed periods
25
Q

What are some of the causes of hyperprolactinaemia?

A
  • Pituitary tumours (prolactinomas)
  • Hypothyroidism
  • Medicines given for depression, psychosis, high blood pressure
26
Q

What hypothalamic and pituitary diseases can lead to amenorrhoea?

A
  • Prolactinoma
  • Pituitary necrosis - Sheehan syndrome
  • Functional hypothalamic amenorrhoea
27
Q

How do hypothalamic and pituitary diseases lead to amenorrhoea?

A
  • Lead to abnormal GnRH secretion
  • LH surge absent
  • Anovulation
  • Low estradiol
28
Q

What are some causes of functional hypothalamic amenorrhoea?

A
  • Weight loss and excessive exercise e.g. gymnasts/athletes, anorexia
  • Emotional stress and stress induced by illness
  • Risk of bone loss due to low oestrogen
29
Q

What is oligomenorrhoea?

A
  • Infrequent menstruation defined by a cycle length between 6 weeks and 6 months
  • Usually due to a prolonged follicular phase
  • Can be constitutional
  • Most causes directly or indirectly rooted in hormonal imbalance
30
Q

What are the causes of oligomenorrhoea?

A
  • PCOS
  • Ovarian insufficiency
  • Perimenopause
  • Thyroid dysfunction
  • Excessive exercise
  • Eating disorders
  • Hormonal contraception
31
Q

What is menorrhagia?

A
  • Excessive (heavy) menstrual blood loss
  • Occurs regularly and interferes with a woman’s physical, emotional, social, and material quality of life
32
Q

How is excessive menstrual blood loss classified?

A
  • 80 ml or more
  • Duration of 7+ days
  • Need to change menstrual products 1-2 hourly
  • Passage of clots
  • Very heavy periods reported by woman
33
Q

What is dysfunctional uterine bleeding?

A
  • Menorrhagia with no underlying cause
34
Q

What does abnormal uterine bleeding involve other than menorrhagia?

A
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Post-menopausal bleeding
35
Q

Which uterine and ovarian pathologies can cause menorrhagia?

A
  • Uterine fibroids
  • Endometriosis and adenomyosis
  • Pelvic inflammatory disease and pelvic infection
  • Endometrial polyps
  • Endometrial hyperplasia/carcinoma
  • PCOS
36
Q

Which systemic diseases can cause menorrhagia?

A
  • Coagulation disorders
  • Hypothyroidism
  • Diabetes mellitus
  • Hyperprolactinaemia
  • Liver or renal disease
37
Q

What are the iatrogenic causes of menorrhagia?

A
  • Anticoagulant treatment
  • Intrauterine contraceptive device
38
Q

What are uterine fibroids?

A
  • Also called leiomyomas
  • Benign tumours
  • Caused by proliferation of smooth muscle cells and fibroblasts
  • These form hard, round tumours in myometrium
  • Develop in women of reproductive age
  • Regress after menopause
39
Q

What are the risk factors of leiomyomas?

A
  • Increasing age
  • Early menarche
  • Older age at first pregnancy
  • Black and Asian ethnicity
  • Family history
40
Q

How is menorrhagia managed?

A

Dysfunctional uterine bleeding:
- Ievonorgestrel intrauterine system (IUS)
- Tranexamic acid or NSAID (mefenamic acid)
- Combined pill or progesterone only
- All women should have an FBC
- Fibroids <3cm need referral

41
Q

What are some red flag symptoms of dysfunctional uterine bleeding?

A
  • Postmenopausal bleeding
  • Persistent intermenstrual bleeding
  • Post-coital bleeding
  • Pelvic mass
  • Bloating
  • Early satiety
  • Ascites
42
Q

What is dysmenorrhoea?

A
  • Painful cramping, usually in the lower abdomen, which occurs shortly before or during menstruation, or both
43
Q

What is primary dysmenorrhoea?

A
  • Occurs in young females
  • In absence of any identifiable underlying pelvic pathology
  • Starts 6-12 months after menarche once cycles are regular
  • Thought to be caused by production of uterine prostaglandins during menstruation
44
Q

What is secondary dysmenorrhoea?

A
  • Often starts after years of painless periods
  • Caused by underlying pelvic pathology e.g. endometriosis, adenomyosis, fibroids, endometrial polyps, pelvic inflammatory disease
  • Also caused by IUD insertion
45
Q

What is endometriosis?

A
  • Growth of endometrium-like tissue outside the uterus
  • Commonly on ovaries, uterosacral ligaments, pouch of Douglas, rectum, sigmoid colon, bladder, distal ureter
  • Extra-pelvic deposits are rare
  • Hormone mediated and associated with menstruation
  • Hormone changes of menstrual cycle induce bleeding, chronic inflammation and scar tissue formation
46
Q

Give some statistics about endometriosis

A
  • Affects 1/10 women
  • Affects 1.5 million women
  • Second most common gynaecological condition
  • Takes 7.5 years to get a diagnosis
47
Q

How is endometriosis diagnosed?

A
  • Laparoscopy
48
Q

What are the risk factors for endometriosis?

A
  • Early menarche
  • Late menopause
  • Delayed childbearing
  • Nulliparity
  • Family history
  • White ethnicity
  • Low BMI
  • Smoking
49
Q

What are the complications of endometriosis?

A
  • Endometriomas
  • Adhesion formation
  • Bowel obstruction
  • Chronic pain
  • Reduced quality of life
  • Infertility
  • Potential association with ovarian cancer
50
Q

What is primary management of dysmenorrhoea?

A
  • NSAID or paracetamol
  • Oral contraceptive trial for 3-6 months
  • Conservative advice
51
Q

What is secondary management of dysmenorrhoea?

A
  • Referral if any red flags or severe symptoms
  • Management of symptoms - NSAID, hormonal contraceptive
  • Surgical management

Reproductive systems (20 decks)

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