Menstrual Disorders

Question 1

What is amenorrhoea?

Answer 1

Absence or cessation of menstruation

Question 2

What is primary amenorrhoea?

Answer 2

Failure to establish menstruation by:
- 15 years old in girls with normal secondary sexual characteristics
- 13 years old in girls with no secondary sexual characteristics

Question 3

What is secondary amenorrhoea

Answer 3

Cessation of menstruation
- for 3-6 months in women with previously normal + regular periods
- for 6-12 months in women with pervious oligomenorrhoea

Question 4

What is oligomenorrhoea?

Answer 4

Irregular periods defined by cycle length between 6 weeks + 6 months

Question 5

What is menorrhagia?

Answer 5

Heavy periods
>80ml and/or duration of >7 days

Question 6

What is dysmenorrhoea?

Answer 6

Painful periods

Question 7

What is mullerian agenesis?

Answer 7

Atresia of vagina or uterus due to embryological underdevelopment of paramesonephric/Müllerian duct

Question 8

What is the Karyotype in Turner’s syndrome?

Answer 8

45, XO

Question 9

What is SWYER syndrome?

Answer 9

Individuals has female phenotype with female external genital organs but have 46 XY karyotype + underdeveloped gonads

Question 10

What are the most common causes of primary amenorrhoea with normal secondary sexual characteristics?

Answer 10

Anatomical causes:
- imperforate hymen
- vaginal septum
- absent vagina
- absent uterus

Question 11

What is an imperforate hymen?

Answer 11

Congenital disorder where a hymen without an opening completely obstructs the vagina

Question 12

What does primary amenorrhoea without secondary sexual characteristics suggest?

Answer 12

Underlying chromosomal or hormonal cause
e..g Turner’s syndrome, hypothalamic-pituitary dysfunction

Question 13

How can you differentiate between primary amenorrhoea without secondary sexual characteristics being due to problem with the hypothalamus/pituitary or the gonads?

Answer 13

• Hypothalamus/pituitary: low FSH/LH
• Gonads: high FSH/LH

Question 14

What are causes of primary amenorrhoea without secondary sexual characteristics due to issues with the hypothalamus/pituitary?

Answer 14

• genetic: kallmann syndrome, isolated gonadotrophin deficiency
• acquired: CNS tumour, brain injury/injection
• functional: stress, weight loss, hypothyroidism

Question 15

Physiological causes of amenorrhoea

Answer 15

Pregnancy
Breastfeeding
Menopause

Question 16

Causes of secondary amenorrhea

Answer 16

• pregnancy, breastfeeding, menopause
• hormonal contraception
• PCOS
• stress
• low weight/eating disorders
• cervical stenosis
• primary ovarian insufficiency
• hyper/hypothyroidism
• hyperprolactinaemia

Question 17

What is PCOS?
What issues does it cause?

Answer 17

Polycystic ovary syndrome
- triad of issues: menstrual irregularity, androgen excess + obesity
- raised insulin resistance

Question 18

PCOS symptoms

Answer 18

• hair loss
• oligomenorrhoea
• acne
• obesity
• pelvic pain
• infertility
• high testosterone levels
• Hirsutism

Question 19

Diagnosis of PCOS

Answer 19

• oligomenorrhoea or amenorrhoea
• polycystic ovaries on ultrasound
• clinical signs of hyperandrogenism e.g. Hirsutism, acne, elevated levels of testosterone

Question 20

What is Hirsutism?

Answer 20

Masculine hair growth on women

Question 21

Causes of oligomenorrhoea

Answer 21

• PCOS
• ovarian insufficient
• perimenopause
• thyroid dysfunction
• excessive exercise
• eating disorders
• hormonal contraception

Question 22

What is dysfunctional uterine bleeding?

Answer 22

Menorrhagia with no underlying cause

Question 23

What is the most common cause of Menorrhagia?

Answer 23

Dynfunctial uterine bleeding (no underlying cause)

Question 24

Causes of menorrhagia - uterine + ovarian pathologies

Answer 24

• uterine fibroids
• pelvic inflammatory disease
• endometrial polyps
• endometrial hyperplasia
• endometrial cancerr
• adenomyosis
• PCOS

Question 25

Causes of menorrhagia - systemic diseases

Answer 25

- coagulation disorders *e.g. von Willebrand disease* - hypothyroidism - diabetes mellitus - hyperprolactinaemia - liver or renal disease

Question 26

Iatrogenic causes of menorrhagia

Answer 26

- anticoagulant treatment - IUD

Question 27

What are uterine fibroids?

Answer 27

Benign tumours which are caused by proliferation of smooth muscle cells + fibroblasts > form hard, round tumours in **myometrium**

Question 28

Risk factors of uterine fibroids

Answer 28

- increasing age (until menopause) - early menarche - older age at first pregnancy - black + Asian ethnicity - family history

Question 29

Examples of abnormal uterine bleeding?

Answer 29

- intermenstrual bleeding - postcoital bleeding - post menopausal bleeding

Question 30

What is intermenstrual bleeding?

Answer 30

Bleeding in between periods

Question 31

What is postcoital bleeding?

Answer 31

Bleeding after sex

Question 32

Management of dysfunction uterine bleeding

Answer 32

- IUS: Ievonorgestral intrauterine system (IUD with hormones) - tranexamic acid or NSAID - combined pill or progesterone only

Question 33

What are the red flags in menorrhagia which need a referral?

Answer 33

- post menopausal bleeding - persistent intermenstrual bleeeding - postcoital bleeding - pelvic mass - bloating - ascites

Question 34

What is primary dysmenorrhea

Answer 34

Painful periods with an absence of any indentifiable underlying pelvic pathology

Question 35

What is secondary dysmenorrhoea?

Answer 35

Painful periods caused by underlying pelvic pathology + often starts after several years of painless periods

Question 36

Causes of secondary dysmenorrhoea

Answer 36

**underlying pelvic pathology**: - endometriosis/adenomyosis - fibroids - endometrial polyps - pelvic inflammatory disease - IUD insertion

Question 37

What is endometriosis?

Answer 37

- Presence of endometrial glands + stroma outside of endometrial cavity - Ectopic tissue induce an oestrogen dependent chronic inflammatory process > fibrosis + scaring

Question 38

Risk factors for endometriosis

Answer 38

- early menarche - late menopause - delayed childbearing - nulliparity - family history - vaginal outflow obstruction *e.g. imperforate hymen* - white ethnicity - low BMI - autoimmune disease - late first sexual encounter - smoking

Question 39

What is nulliparity?

Answer 39

Women has never been pregnant or given birth

Question 40

What is adenomyosis?

Answer 40

Endometrial tissue found deep within myometrium

Question 41

What is an endometrioma?

Answer 41

Ovarian cyst containing blood + endometriosis like tissue

Question 42

Complications of endometriosis

Answer 42

- infertility due to scarring in fallopian tubes - chronic pain - reduced quality of life - adhesions - bowel obstruction - endometriomas

Question 43

Management of primary dysmenorrhoea

Answer 43

- NSAID or paracetamol - oral contraceptive - conservative advise

Question 44

Management of secondary dysmenorrhoea

Answer 44

- referral if any red flag symptoms - NSAID - hormonal contraceptive - surgical management if fertility is a priority

Question 45

Diagnosis of endometriosis

Answer 45

Only by laparoscopic visualisation of pelvic

Question 46

What is dyspareunia?

Answer 46

Painful intercourse

Question 47

What test must be done on all women who hae menorrhagia?

Answer 47

**Full blood count** (Possible anaemia)

Question 48

Two most common causes of secondary amenorrhoea

Answer 48

Decreased in body weight Pregnancy

Question 49

Managment of PCOS

Answer 49

- Lifestyle advice - Screening for type 2 diabetes mellitus - Combined oral contraceptive pill