Repro9 - Menstrual Disorders

Question 1

5 parameters asked about for abnormal uterine bleeding (AUB)

Frequency x4
Regularity x2
Duration x2
Objective Volume x3
Subjective Volume

Answer 1

1. ) Frequency - how often
   - absent: amenorrhoea
   - infrequent: oligomenorrhoea (> 38 days)
   - normal: 24-38 days
   - frequent: < 24 days
2. ) Regularity - how many days apart
   - regular: < 7-9 days
   - irregular: metrorrhagia > 7-9 days
3. ) Duration
   - normal: lasts for < 8 days
   - prolonged: lasts > 8 days
4. ) Objective Volume - numerical volume
   - normal: 5-80ml
   - heavy: menorrhagia (> 80 ml)
   - light: < 5ml
5. ) Subjective Volume - patient’s perspective
   - normally doesn’t significantly affect QoL

Question 2

6 different types of menorrhoea

Primary Amenorrhoea
Secondary Amenorrhoea
Oligomenorrhoea
Irregular Periods
Menorrhagia
Dysmenorrhoea

Answer 2

1. ) Primary Amenorrhoea - no periods by age 16
2. ) Secondary Amenorrhoea - no periods for > 6 months
3. ) Oligomenorrhoea - menstruation that has reduced in frequency, cycle length > 35 days
4. ) Metrorrhagia - irregular periods (>7-9 days difference)
   - possible causes: hormonal contraception, menopause, hormone secreting ovarian cysts, infection
5. ) Menorrhagia - heavy menstrual bleeding
   - causes include structural problems such as benign or malignant growth in the endometrium, clotting disorders, anticoagulation therapy
   - look for signs of anaemia
6. ) Dysmenorrhoea - painful periods affecting QoL
   - often leads to chronic pelvic pain
   - can be a result of obstructive structural causes
   - common cause is endometriosis
   - primary (since menarche) or secondary (over time)

Question 3

4 causes of primary amenorrhoea

2 Genetic Causes
Hormonal Cause
Anatomical Cause x3

Answer 3

1. ) Turner’s Syndrome - genotype is 45,X0
   - ovary doesn’t complete normal development
   - high FSH and LH but low oestrogen
   - low oestrogen means no pubertal changes
2. ) Complete Androgen Insensitivity Syndrome
   - resistant to testosterone due to receptor defect
   - 46,XY but has female external genitalia with internal male genitalia (testes can be palpable in groin/abdo)
   - bilateral orchidectomy should be carried out to reduce the risk of testicular cancer
3. ) Isolated GnRH Deficiency - idiopathic hypogonadotropic hypogonadism (no GnRH secretion)
   - poor development of secondary sexual characteristics
   - if it occurs with anosmia (loss of sense of smell), it is Kallmann syndrome
4. ) Anatomical Causes - produces 20% of cases
   - imperforate hymen (no vaginal opening)
   - transverse vaginal septum
   - mullerian agenesis (variable uterine development)

Question 4

5 causes of secondary amenorrhoea

Physiological
Endocrine
HPG Axis
Anatomical
PCOS

Answer 4

1.) Physiological Causes - pregnancy and menopause

2. ) Endocrine - thyroid diseases and hyperprolactinemia
   - menstrual abnormalities in hyper and hypothyroidism
   - hyperprolactinemia causes androgen excess
3. ) Hypothalamic and Pituitary Disease - abnormal GnRH secretion -> no LH surge -> anovulation -> low oestrogen
   - e.g. prolactinoma, pituitary necrosis
4. ) Anatomical Causes
   - scarring due to cervical stenosis or intrauterine adhesions (asherman syndrome)
   - primary ovarian insufficiency (POI) causing premature menopause
5. ) Polycystic Ovarian Syndrome (PCOS)
   - separate flashcard

Question 5

5 features of polycystic ovarian syndrome (PCOS)

Definition
Mechanism
Hyperandrogenism
Chronic Anovulation
Presentation

Answer 5

1. ) Definition - syndrome of clinical or biochemical hyperandrogenism and chronic anovulation
   - menstrual irregularity + androgen excess + obesity
2. ) Mechanism - related to lack of pulsatile GnRH release
   - many follicles begin to develop but a dominant follicle is not selected to mature
3. ) Hyperandrogenism - LH dependent excess androgen production from ovaries and adrenals
   - abnormal oestrogen secretion increases risk of endometrial malignancy
   - also have insulin resistance which increases risk of diabetes and cardiovascular disease
4. ) Chronic Anovulation - ovaries do not release an oocyte during ovulation
   - due to inappropriate feedback signals from the ovary to the hypothalamus/pituitary
5. ) Presentation - asymptomatic or ‘triad of symptoms’
   - anovulatory: secondary amenorrhoea, infertility
   - androgen excess: hirsutism (hair growth), acne
   - obesity

Question 6

4 different classifications of abnormal uterine bleeding

Acute
Chronic
Structural Causes (PALM)
Non-structural Causes (COEIN)

Answer 6

1. ) Acute AUB - heavy bleeding of sufficient quantity to require immediate clinical intervention to stop further blood loss
2. ) Chronic AUB - bleeding of abnormal volume, duration, regularity, or frequency that has been present for most of the previous 6 months
3. ) Structural Causes - PALM
   - Polyps
   - Adenomyosis (lining breaks through myometrium)
   - Leiomyoma (fibroids)
   - Malignancy (or hyperplasia)
4. ) Non-structural Causes - COEIN
   - Coagulopathy
   - Ovulatory Dysfunction (inc thyroid)
   - Endometrial
   - Iatrogenic
   - Not yet classified (dysfunctional uterine bleeding)

Question 7

4 features of dysfunctional uterine bleeding (DUB)

Definition
Diagnosis
Occurrence
Divisions

Answer 7

1.) Definition - bleeding of endometrial origin

2. ) Diagnosis of Exclusion - heavy menstrual bleeding without sign of pathology
   - unpredictable regularity and duration
3. ) Occurrence - at extremes of reproductive life
   - adolescence and menopause
4. ) Divisions - anovulatory and ovulatory
   - anovulatory: inadequate signal –> impaired +ve FB
   - ovulatory: idiopathic

Question 8

5 features of dysmenorrhoea

Definition
Types
Causes
Consequences
Management

Answer 8

1.) Definition - painful periods affecting QoL

2. ) Types - primary or secondary
   - primary is when it occurs from menarche (no cause)
   - secondary is when it occurs overtime
3. ) Causes - common cause is endometriosis
   - can also be a result of obstructive structural causes

4.) Consequences - often leads to chronic pain

5. ) Management - drugs, surgery, other
   - NSAIDs, hormonal contraceptives, GnRH analogues
   - adhesiolysis, hysterectomy (last resort)
   - heat, ginger, acupuncture, TENS (nerve stimulation)

Question 9

5 features of endometriosis

Definition
Effect of Oestrogen
Common Sites
Risk Factors
Consequences

Answer 9

1. ) Definition - ectopic endometrial tissue that occurs outside the uterine cavity
2. ) Oestrogen Dependent - responds to cyclical hormonal changes
3. ) Common Sites - ovaries, bladder, rectum, peritoneal lining and pelvic side walls, myometrium (adenomyosis)
4. ) Risk Factors - early menarche, short cycles, heavy bleeding, low BMI
5. ) Consequences - dysmenorrhoea, chronic pain, dyspareunia (painful intercouse) and infertility

Question 10

4 features of fibroids (leiomyoma)

Definition
Triggers
Pain
Consequences

Answer 10

1. ) Definition - benign tumours of the myometrium
2. ) Oestrogen Dependent - worse during pregnancy but regresses during menopause
3. ) Not Painful - pain present if degenerated or torted
4. ) Consequences - bleeding, infertility, malignancy
   - heavy menstrual bleeding and intermenstrual bleeding
   - infertility and recurrent pregnancy loss
   - can become malignant (leiomyosarcoma), but rare

Question 11

3 steps in forming a differential diagnosis

Answer 11

1. ) Hormonal - look at HPG axis
   - is there a problem somewhere along the axis?
2. ) Structural - problem with the uterus or vagina?
   - use an ultrasound, MRI or more intensive imaging:
   - hysteroscopy, hysterosalpingography, laparoscopy
3. ) System Review - thyroid disorders can cause patients to have menorrhagia or oligomenorrhoea
   - consider thyroid function tests