0
0
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
