Chapter 26 Reproductive disturbances in women

Case 26.1

1. Define menorrhagia and metrorrhagia.

• Menorrhagia refers to excessive menstrual blood loss (>80 ml loss over the days of bleeding).

• Metrorrhagia refers to bleeding from the uterus which is not a result of menstruation.

2. Based on this information only, what are the possible causes of her presentation?

Possible causes are:

• perimenopausal changes

• miscarriage

• fibroids

• stress

• functional ovarian cyst

• malignancy of reproductive tract (not a common presentation, however)

• combination of factors.

3. What questions would be especially important to ask this patient, in order to differentiate between these conditions?

• What has been the pattern of her menstrual cycle over the years, especially in the last year (cycle length, heaviness of flow, dysmenorrhoea)?

• Any abdominal pain with this episode?

• Any possibility of pregnancy?

• Any previous episodes in which her period was delayed?

• Is she under any stress?

• Any recent constipation, urinary frequency or development of varicose veins in the lower limbs?

• Any weight loss?

• Any abdominal distension?

• Any symptoms of menopause (eg: hot flushes, night sweats, vaginal dryness etc.)?

4. For each disorder named in question 2, explain how it could cause her symptoms.

	Possible mechanism for irregular menstruation	Possible mechanism for heavy blood loss
Perimenopausal changes	Variations in the levels of FSH/LH	Variations in the levels of FSH/LH effect oestrogen levels which affect growth of the endometrial lining and hence menstrual flow. (Oestrogen stimulates the growth of the endometrium)
Miscarriage	Bleeding is delayed while the pregnancy is viable, due to the influence of hormones	When the pregnancy becomes non-viable, the endometrial lining will shed due to removal of its hormonal support
Fibroids	Does not usually cause irregular cycles	Fibroids which protrude into the lumen will increase the surface area of the endometrium. There is hence more endometrium which will thicken under the influence of oestrogen, thus more which will eventually shed. The result is an increased blood loss
Stress	The hypothalamus is part of the limbic system. It influences FSH/LH levels via gonadotrophin regulating factors
Functional ovarian cyst	The irregularity is determined by the duration over which the oestrogen from the functional cyst is released. If oestrogen continues to be released, it will continue to support the endometrium and promote its thickening, hence delaying its shedding (ie: a delayed period results)	Oestrogen is available for a longer period of time due to its continual release from the functional cyst. This causes more growth of the endometrium, thus there is more to shed when this finally takes place
Malignancy of reproductive tract	Not common, but may occur if it is large enough to interfere with normal reproductive structure or function	May occur if the tumour invades a blood vessel

Case 26.2

1. Based on this information only, what are the possible causes of her presentation?

The pathology most likely involves either the vagina, cervix, or possibly the endometrium (due to presence of post-coital bleeding). Pathologies which may affect these structures, and hence cause bleeding, are:

• infection and/or inflammation (eg: vaginitis, cervicitis)

• dysplasias or neoplasia — cervical intraepithelial neoplasia (now referred to as high grade or low grade epithelial abnormality), cervical carcinoma, vaginal carcinoma or endometrial carcinoma

• trauma.

Note: if there was spotting but no post-coital bleeding, you need to consider hormonal fluctuations (eg: from oral contraceptive pill, stress etc.).

2. What questions would be especially important to ask this patient, in order to differentiate between the possible causes of her presentation?

• Any vaginal discharge?

• When was your last PAP smear?

• Any history of previous infections?

• Any pain?

• Has this ever occurred in the past?

• Do you have bleeding from any other part of your body?

• How is your health in general?

• Any urinary problems?

• Any bowel problems?

3. Does this patient need to be referred for investigations? Explain your answer.

Referral is required for the following investigations:

• PAP smear — to detect dysplastic or neoplastic cells from the cervix

• cervical smear — to detect evidence of any infection

• vaginal smear — to detect evidence of any infection.

If these tests reveal no abnormality, a pelvic ultrasound may reveal a pathology within the uterus. Cervical biopsy may be needed, depending on results of initial studies.

The cervical and vaginal smears involve microscopy and culture, and are followed by more specific tests as required for detection of particular micro-organisms.

Case 26.3

1. Define:

a dysmenorrhoea

This refers to painful menstruation.

b nulliparous

This refers to a woman who has never given birth to a viable child.

2. What type of dysmenorrhoea does this scenario typically describe?

Primary dysmenorrhoea.

3. Explain the mechanism by which pain occurs in this condition.

It is associated with an increase in the level of prostaglandins, specifically PG F₂. This causes an increase in contraction within the myometrium, in addition to vasoconstriction in the vessels of the endometrium.

4. Is her nulliparous state significance to her complaint?

Yes — primary dysmenorrhoea is more common in nulliparous women due to a tightness of the cervix.

Case 26.4

1. What is the most likely diagnosis?

Vaginal thrush, caused by the yeast Candida albicans.

2. Can it be sexually transmitted?

Yes.

3. Can it occur without sexual contact?

Yes, as the yeast is a commensal within the vagina.

4. In what situations is the disorder more likely to occur?

In patients who are:

• diabetic

• on systemic steroid medication

• immunosuppressed or immunocompromised.

Case 26.5

1. What disorder is classically described by this pattern of dysmenorrhoea?

Endometriosis.

2. Could there be any relationship between this disorder and:

a her past infection with chlamydia

No — infection is not a known factor in the pathogenesis of endometriosis.

b her difficulty in conceiving

Yes. Endometriosis can cause infertility or sub-fertility by a number of mechanisms. Endometrial cysts can be found in many places within the pelvic cavity, causing inflammatory changes and adhesions.

This may damage the ovaries or uterine tube, affecting ovulation, the pick-up of the ovum by the uterine tube, movement of the ovum throughout the tube, fertilisation, movement of sperm through the reproductive tract and the process through which implantation in the uterus occurs.

3. Describe the relationship between the clinical presentation of this disorder, and its pathology.

There is a complete clinical spectrum to endometriosis — it may be asymptomatic, even when quite extensive, or it may be a painful, sterilising, crippling condition.

The aetiology is generally unknown, but possibly due to either viable endometrial cells transported via lymphatics, metaplastic changes in remnant Mullerian cells, or by retrograde menstrual flow. Possible sites of implantation include ovaries, ducts, ligaments, colon, cervix, bladder and umbilicus. These endometrial cells respond to hormonal stimulation and thus bleed when oestrogen levels fall. It therefore results in the formation ‘chocolate’ cysts. Fibrous tissue can form, causing adhesions to surrounding tissue. The following clinical features may then occur:

a infertility (see question 2)

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