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Menstrual Disorders MEGAN JARMAN OLLIE BIGGSWhat We’re Going to Cover q The Menstrual Cycle q Primary / Secondary Amenorrhea q Menorrhagia q Dysmenorrhea q And Much More (!)The Menstrual Cycle Cycle length can vary. Important to establish menstrual history. Think about what blood tests can be taken and when in a woman’s cycle. Think about the action of contraception on this cycle. Primary Amenorrhea q Not starting menstruation by 13 years old when there is no evidence of secondary sexual characteristics q Not starting menstruation by 15 years old when there are signs of secondary sexual characteristics q Multiple causes q HypERgonadotropic hypOgonadism (primary hypogonadism) q HypOgonadotropic hypOgonadism (secondary hypogonadism) q Structural q Many more (!) HypERgonadotropic HypOgonadism HypOgonadism means the ovaries (or testes) aren’t producing sex hormones. The hypER or hypO gonadotropic bit decides where the problem is. In hypERgonadotropic hypOgonadism there is nothing wrong with the hypothalamus and pituitary The problem is in the ovaries as they are not being stimulated by FSH and LH o Previous damage to gonads (e.g. torsion, cancer or infections) Ovary o Congenital absence of the ovaries o Turner’s syndrome (XO) (most common cause) Decreased progesterone HypOgonadotropic HypOgonadism HypOgonadism means the ovaries (or testes) aren’t producing sex hormones. In hypOgonadotropic hypOgonadism there is nothing wrong with the ovaries The problem is in the brain as they are not producing GnRH or FSH and LH o Hypopituitarism (under production of pituitary hormones) o Damage to the hypothalamus or pituitary Ovary Ovary o Significant chronic conditions can temporarily delay puberty o Excessive exercise or dieting can delay the onset of menstruation in girls oestrogen +ed o Constitutional delay in growth and development progesteronen + progesteroneStructural Sometimes structural abnormalities in the pelvis can Causes include prevent menstruation • Imperforate hymen (bulging on speculum) • Female genital mutilation (THINK SAFEGUARDING) These girls will have secondary sexual characteristics but no • Transverse vaginal septae periods. • Vaginal agenesis • Absent uterus These girls will also often have cyclical pain associated with menstruation Hypothalamus Secondary Amenorrhea Protects the body from pregnancy if conditions not suitable by not secreting GnRH q No menstruation for more than three months after previous regular menstrual periods. • Underweight q Causes • Stress • Chronic disease q Pregnancy is the most common cause • Excessive exercise q Menopause and premature ovarian failure q Hormonal contraception (e.g. IUS or POP) q Hypothalamic or pituitary pathology Pituitary q Ovarian causes such as polycystic ovarian syndrome Think tumour or failure q Uterine pathology such as Asherman’s syndrome q Thyroid pathology • Prolactinoma q Hyperprolactinaemia • Sheehan’s syndrome Blood results Premature ovarian failure – high FSH PCOS – high LH or LH:FSH ratio Prolactinoma – high prolactin Raise TSH and lowT3 and T4 indicatehypothyroidism Low TSH and raised T3 and T4 indicatehyperthyroidismPolycystic Ovary Syndrome Rotterdam Criteria Presentation • A diagnosis requires at least two of • Oligomenorrhoea or amenorrhoea the three key features: • Infertility • Oligoovulation or anovulation, • Obesity (in about 70% of patients presenting with irregular or absent with PCOS) menstrual periods • Hyperandrogenism, characterised • Hirsutism by hirsutism and acne • Acne • Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3Polycystic Ovary Syndrome Investigations Management • Bloods • General • Raised luteinising hormone • Raised LH to FSH ratio (high LH compared with • Weight loss if appropriate FSH) • Combined oral contraceptive pill can • Raised testosterone help to regulate cycle and help acne and • Raised insulin hirsutism • Normal or raised oestrogen levels • Hirsutism and Acne • 1st line: COC • Imaging • 2nd line: Topical eflornithine • Pelvic ultrasound is required when suspecting • Infertility PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. • Clomifene The follicles may be arranged around the • ?Metformin in obese patients appearance.f the ovary, giving a “string of pearls” Menorrhagia Ø Heavy menstrual bleeding Causes Ø Difficult to measure Ø Polyps Ø Previously defined as blood loss over 80ml / Ø Fibroids bleeding through pads every 1-2 hours. Ø Endometriosis Ø Now defined as self-reported heavy bleeding that Ø Malignancy negatively affects a woman’s life. Ø Extremes of reproductive age Ø Dysfunctional uterine bleedingINVESTIGA TIONS Rule out pathology ◦ Ultrasound ◦ Speculum examination (checking for cervicitis, cervical polyp and cervical growth) ◦ ?Referral for hysteroscopy FBC Once ruled out Contraception No contraception • Mirena coil (1 line) • Tranexamic acid (bleeding no pain) • Combined pill • Mefenamic acid (bleeding and pain) • Progesterone pill (cyclical) INTERMENSTRUAL DYSMENORRHEA BLEEDING Endometriosis RED FLAG ◦ There is ectopic endometrial tissue outside Cervical cancer the uterus ◦ Tends to affect younger women ◦ The exact cause of endometriosis is not clear ◦ Endometriosis can lead to reduced fertility ◦ Intermenstrual bleeding ◦ Dyspareunia ◦ Pelvic pain ◦ Worse on period ◦ Post coital bleeding (importance of speculum) ◦ Deep dyspareunia ◦ Strongly associated with human papillomavirus ◦ Systemic symptomsHISTORY T AKING Presenting complaint Past medical history History of presenting complaint Medication history ◦ Pain ◦ Bleeding ALLERGIES ◦ Discharge Family history ◦ Could you be pregnant? ◦ Contraception Social history ◦ Systemic symptoms ◦ Safe at home? ◦ SMOKING Menstrual history ◦ Regularity ◦ How long cycle ◦ When was the first day of your last period?