Menstrual Conditions

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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:

Secondary Causes of Menorrhagia

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:

This is where there is 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:

This is where there is 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

This is the failure to start menstruation for a girl by the age of 16. It can be due to a number of potential causes

 

Causes:

– Constitutional Delay

– Chromosomal conditions – Turner’s syndrome, Kallman’s syndrome

– Endocrine conditions – congenital adrenal hyperplasia

– Structural conditions – Imperforate hymen, Mayer-Rokitansky-Küster-Hauser syndrome 

 
Types of Aphasias
 

ii) Secondary Amenorrhea

This is the 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:

It can be due to natural phenomena such as pregnancy, lactation and menopause but there are also pathological causes (categorised by organ)

 

Uterine Conditions:

– Cervical stenosis

– Ashermann’s syndrome

 

Ovarian Conditions:

– Premature Ovarian Failure

– Polycystic Ovarian 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 diseases –> e.g. chronic heart/kidney/liver disease, IBD

 

Tests:

– Pregnancy test

– Blood tests –> FSH/LH, total testosterone levels, TFTs, Prolactin

– Transvaginal ultrasound –> used to assess for structural causes

– Genetic tests and karyotyping –> used to assess for genetic/chromosomal causes

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