Menstrual Problems
  • Premenstrual syndrome (PMS)

This describes the distressing physical, psychological and behavioural symptoms in the absence of organic disease that regularly occur during the luteal phase of the menstrual cycle
– This occurs in most women and encompasses a whole spectrum of severity from minor to debilitating.
– Cause unknown but associated with change in levels of oestrogen + 5-HT levels at the beginning of cycle

 

Symptoms:
– Psychological ➔ depression, anxiety, irritability
– Physical ➔ fatigue, bloating, mastalgia, acne

 

Management
– If mild, then reduce salt, caffeine and stress
– 1st line is Combined oral contraceptive pill
– 2nd line is SSRIs

 

  • Menorrhagia

This is excessive menstrual blood loss that occurs regularly and interferes with a woman’s quality of life.
– In 50% of women no underlying cause if found  – this is known as dysfunctional uterine bleeding
– Menorrhagia can also occur secondary to underlying disease:

 

Uterine:
– Endometriosis
– Adenomyosis
– Fibroids
– PID
– Endometrial hyperplasia and cancer

 

Endocrine:
– PCOS
– Hypothyroidism
– Hyperprolactinaemia

 

Iatrogenic:
– Copper IUD

 

Haematological:
– Anticoagulants
– Coagulopathy

 

Tests
– For all women, carry out FBC to check for iron-deficiency anaemia as a result of excessive bleeding
– NICE1 advises that the need for investigation into the cause depends on the woman’s presentation:

i) If menorrhagia with no other symptoms –> Can start treatment without further     investigation

 

ii) If menorrhagia + intermenstrual bleeding, pelvic pain, pressure symptoms –> suggests underlying pathology
– First perform an abdominal and bimanual examination
– Then do investigation for the particular cause:
– Structural uterine cause suspected (e.g. fibroids/endometrial pathology) -> refer for USS/hysteroscopy
– Hypothyroidism suspected -> TFTs
– Coagulation disorder suspected (suspect if menorrhagia since menarche + family/personal history suggesting coagulation disorder) -> coagulation screen
– Infection suspected -> vaginal or cervical swab

 

Management
– If underlying cause found, follow management for that condition, else:
– 1st line is Mirena progesterone coil
– 2nd line options:
– Hormonal = COCP or cyclical oral progestogen
– Non-hormonal = tranexamic acid or NSAID (mefenamic acid)
– If menorrhagia persists, refer to gynaecology for further investigation, endometrial ablation or hysterectomy

 

  • Dysmenorrhoea

A condition which is defined by excessive amount of pain during the menstrual cycle, divided into 2 types:

 

i) Primary Dysmenorrhoea ➔ Excessive pain without underlying pelvic pathology
– It usually occurs 6-12 months after menarche
– Thought to be related to excessive endometrial prostaglandin synthesis during menstruation

 

Symptoms
– Pain starts just before/within a few hours of the period starting and improves later in the period
– Cramping lower abdominal pain which can radiate to the back or down the thigh
– May be accompanied by nausea, vomiting, fatigue, headache and emotional symptoms

 

Management
– Stop smoking (clear link between smoking and dysmenorrhoea)
– 1st line is NSAIDs (these inhibit prostaglandin synthesis) +/- paracetamol
– 2nd line is combined oral contraceptive pill

 

ii) Secondary Dysmenorrhoea ➔ Excessive pain as a result of underlying pathology
– It usually starts many years after menarche, after years of normal painless periods Causes – Endometriosis, adenomyosis, pelvic inflammatory disease, fibroids, IUD

Symptoms
– Pain that is not consistently related to menstruation
– Pain may continue after period has ended or may be constantly present but worse during menstruation
– Accompanied by symptoms of the underlying pathology

Management
– Identify underlying cause and treat accordingly

 

  • Amenorrhoea

This is defined as the lack of a normal period. It is typically divided into two types:

 

i) Primary Amenorrhea ➔ the failure to start menses by age 16, due to a number of potential causes:

Constitutional delay –> a general delay in pubertal development.
– Not pathological and normal maturation usually occurs spontaneously by 18 years of age.
– Often a family history of late puberty/menarche.

 

Structural malformations –> including imperforate hymen, transverse septum, absent vagina/uterus.

– Mayer-Rokitansky-Küster-Hauser syndrome ➔ agenesis of the Mullerian duct result in absence of the uterus and upper 2/3 of the vagina
– Imperforate hymen ➔  May cause amenorrhoea with cyclical pelvic pain (as endometrium builds up but cannot shed via the vagina).

 

Turner’s syndrome (45XO) -> individuals possess only one X chromosome.
– In Turner’s syndrome there is gonadal dysgenesis and early loss of ovarian function. The absence of ovarian hormones results in amenorrhoea as well as failure to develop secondary sexual characteristics.

 

•Kallman’s syndrome –> X-linked recessive condition caused by defective development of GnRH neurons. Characterised by anosmia + absent puberty/menarche.

Congenital adrenal hyperplasia -> in most cases caused by partial deficiency of 21-hydroxylase.
– This enzyme catalyses aldosterone and cortisol synthesis. Deficiency causes build-up of precursors, so they are instead converted into testosterone raising levels.

 

ii) Secondary Amenorrhea ➔ cessation of established, regular menstruation for 6 months or longer
– Many conditions that give secondary amenorrhoea also give primary amenorrhoea if they occur before menarche

Causes:
Natural phenomena such as pregnancy, lactation and menopause but also pathological (divided by organ)

 

Uterine Conditions

– Cervical stenosis
– Ashermann’s syndrome

Ovarian Conditions

– Premature ovarian failure
– Polycystic ovary syndrome

 

Endocrine Conditions

– Prolactinomas –> prolactin suppresses GnRH secretion
– Sheehan syndrome –> pituitary infarction due to massive obstetric haemorrhage which occurs after a complicated delivery.
– Contraception –> COCP taken continuously, progestogen implants/injections
– Hyper or hypothyroidism
– Cushing’s syndrome

Hypothalamic Conditions

– Hypothalamic amenorrhoea -> dysfunction of the hypothalamus caused by stress, excessive exercise affecting GnRH secretion
– Eating disorders –> lead to very reduced calorie intake
– Chronic disease –> e.g. chronic heart/kidney/liver disease, IBD

Tests
– Primary amenorrhoea is usually referred to specialist for investigations. These include:
– Pregnancy test
– Blood tests ➔ Sex hormones –> FSH/LH, total testosterone levels                    ➔ Endocrine –> TFTs, Prolactin,
– Transvaginal ultrasound ➔ used to assess for structural causes
– Genetic tests and karyotyping ➔ used to assess for genetic/chromosomal causes

Management
– Treat the underlying cause

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