This document discusses several gynecological conditions including dysmenorrhoea (painful periods), premenstrual syndrome (PMS), amenorrhoea (absence of periods), polycystic ovarian syndrome (PCOS), and post-menopausal bleeding. It provides details on the definitions, causes, diagnostic approaches and treatment options for each condition. Key points include that dysmenorrhoea affects 45-95% of women and can be caused by endometriosis or adenomyosis; PMS involves physical and emotional symptoms before a woman's period; amenorrhoea can be primary or secondary; PCOS involves irregular periods, excess androgen levels and polycystic ovaries; and post

1. Dysnemorrhoea
Premenstrual syndrome
Amenorrhoea/oligomenorrhoea
Polycystic ovarian syndrome
Post-menopausal bleeding

2. Dysmenorrhoea is defined as painful
menstruation. It is experienced by 45-95 per
cent of women of reproductive age; there
may not be identifiable pelvic pathology.
dysmenorrhoea improves after childbirth,
and it decline with increasing age.
Aetiology includes:
 endometriosis and adenomyosis;
 pelvic inflammatory disease;
 cervical stenosis and haematometra (rarely).

3. It is the presence of endometrial tissue
outside the uterine cavity, Laparoscopy is
the ‘gold standard’ diagnostic tool.
Adenomyosis is the presence of ectopic
endometrial tissue within the myometrium.
It is associated with previous procedures
which may break the barrier between the
endometrium and the myometrium, i.e.
Caesarean section or suction termination of
pregnancy.

4. Patients will have different ideas as to what constitutes
a painful period. To ascertain the severity of the pain,
the following questions may be useful:
 Do you need to take painkillers for this pain?
 Which tablets help?
 Have you needed to take any time off work/school
due to the pain?
 An abdominal and pelvic examination should be
performed. Certain signs associated with
endometriosis include a pelvic mass, a fixed uterus (if
adhesions are present) and endometriotic nodules
(palpable in the pouch of Douglas or on the
uterosacral ligaments).

5.  Hgh vaginal and endocervical swabs to exclude pelvic infection, in
particular Chlamydia trachomatis and Neisseria gonarrhoea.
 Pelvic ultrasound scan,Pelvic ultrasound scan may be useful to detect
endometriomas or appearances suggestive of adenomyosis (enlarged
uterus with heterogeneous texture).
 Diagnostic laparoscopy
Diagnostic laparoscopy if performed:
 when the history is suggestive of endometriosis;
 when swabs and USS are normal, yet symptoms persist;
 when the patient wants a definite diagnosis or wants reassurance that
their pelvis is normal,
Discussion about laparoscopy should include:
 the risks of the procedure, including anaesthetic complications, damage
to blood vessels, bladder, bowel and infection;
 the fact that this investigation may show no obvious causes for their
symptoms.
 If features in the history suggest cervical stenosis, ultrasound and
hysteroscopy can be used to investigate further.

6. Non-steroidal anti-inflammatory drugs: It is effective in a large proportion of
women. Some examples are naproxen, ibuprofen and mefenamic acid.
Oral contraceptives
LNG-IUS (the Mirena IUS ): There is recent evidence that this is beneficial for
dysmenorrhoea and indeed can be an effective treatment for underlying
causes, such as endometriosis and adenomyosis.
Lifestyle changes: low fat, vegetarian diet may improve dysmenorrhoea.
exercise may improve symptoms by improving blood flow to the pelvis.
GnRH analogues: This is neither a first-line treatment nor an option for
prolonged management due to the resulting hypo- oestrogenic state. If
the pain does not settle with the GnRH analogue, it is unlikely to be
resolved by removing the ovaries at hysterectomy.
Heat: Although this may seem a rather old-fashioned method for helping
dysmenorrhoea, there is strong evidence to prove its benefit. It appears
to be as effective as NSAIDs.
surgical approach with laser, diathermy or excision of endometriotic tissue.

7. Dyspareunia is defined as pain during sexual
intercourse. This can be superficial or deep,
the latter sometimes associated with
pathology such as endometriosis or pelvic
inflammatory disease. On many occasions,
despite appropriate investigations, no cause
can be found and psychological support
should be offered.

9. Combined oral contraceptive pill: The most effective preparation appears to
be Yasminm, which contains an anti-mineralocorticoid and an anti-androgenic
progestogen. The most effective regime appears to be
bicycling or tricycling pill packets (i.e. taking two or three packets in a
row without a scheduled break).
Transdermal oestrogen:This has been shown to significantly reduce PMS
symptoms.
GnRH analogues: ovarian activity is switched off However; this is generally a
short-term treatment.
Selective serotonin reuptake inhibitors.
Hysterectomy with bilateral salpingo-oopherectomy: If all other treatments
have failed.
Vitamins: magnesium, calcium and isoflavones may be useful in treating
PMS.
Alternative therapies
Evening primrose oil is commonly used.
Cognitive-behavioral therapy

10. Premenstrual syndrome
(PMS) is the occurrence
of cyclical somatic,
psychological and
emotional symptoms
that occur in the luteal
(premenstrual) phase of
the menstrual cycle and
resolve by the time
menstruation ceases.

11. Aetlology
The precise
aetiology of PMS
is unknown, but
cyclical ovarian
activity and the
effects of
oestradiol and
progesterone on
certain
neurotransmitters
, including
serotonin, appear
to play a role.

14. Amenorrhoea is defined as the absence of menstruation.
* Primary amenorrhoea is when girls fail to menstruate
by 16 years of age.
* Secondary amenorrhoea is absence of menstruation for
more than six months in a normal female of reproductive
age that is not due to pregnancy, lactation or the
menopause.

15.  Asherman’s syndrome; is the presence of
intrauterine adhesions which prevent
menstruation, the most common cause being
over-vigorous uterine curettage.
 Mullerian agenesis; is a congenital
malformation where the Mullerian ducts fail
to develop resulting in an absent uterus and
variable malformations of the vagina.
 Transverse vaginal septum;
 Imperforate hymen.

16.  Anovulation (polycystic ovarian syndrome,)
 Premature ovarian failure (POF): POF is
defined as cessation of periods before 40
years of age. It is usually unexplained, but
may be due to chemotherapy, radiotherapy,
autoimmune disease or chromosomal
disorders (e.g. Turner’s 45XO/46XX).

17.  Adenomas of which prolactinoma is most
common.
 Pituitary necrosis, e.g. Sheehan’s syndrome
(due to prolonged hypotension following
major obstetric haemorrhage).

18.  Excessive exercise, weight loss and stress can switch
off hypothalamic stimulation of the pituitary
 Hypothalamic lesions (craniopharyngioma, glioma)
can compress hypothalamic tissue or block dopamine
 Head injuries
 Kallman’s syndrome (X-linked recessive condition
resulting in deficiency in GnRH causing
 underdeveloped genitalia)
 Systemic disorders including sarcoidosis, tuberculosis
resulting in an inliltrative process inthe hypothalamo-hypophyseal
region
 Drugs: progestogens, HRT or dopamine antagonists.

19. Findings from the history should guide the examination A general
inspection of the patient should be carried out to assess body mass
index (BMI), secondary sexual characteristics (hair growth, breast
development) and signs of endocrine abnormalities (hirsutism,
acne, abdominal striae, Moon-face, skin changes). If the history is
suggestive ofa pituitary lesion, an assessment of visual fields is
indicated. External genitalia and a vaginal examination should be
performed to detect structural outflow abnormalities or
demonstrate atrophic changes consistent with hypoestrogenism.

23. PCOS is a syndrome of ovarian dysfunction
along with the cardinal features of
hyperandrogenismand polycystic ovary
morphology. Its clinical manifestations include
menstrual irregularities, signs of androgen
excess (e.g. hirsutism) and obesity. Elevated
serum LH levels and insulin resistance and are
also common features. PCOS is associated
with an increased risk of type 2 diabetes and
cardiovascular events. It affects around 5-10
per cent of women of reproductive age. The
prevalence of polycystic ovaries seen on
ultrasound is much higher at around 25 per
cent

24. The aetiology of
PCOS is not
completely clear,
but there is often
a family history. It
seems likely that a
gene is important
in its
development.

28.  Patients must have two out of
the three features below:
 amenorrhoea/oligomenorrhoea;
 clinical or biochemical
hyperandrogenism;
 polycystic ovaries on
ultrasound.
 The ultrasound criteria for the
diagnosis of a polycystic ovary
are eight or more subcapsular
follicular cysts <10 mm in
diameter and increased ovarian
stroma. While these findings
support a diagnosis of PCOS,
they are not by themselves
sufficient to identify the
syndrome.

29. Regulate menstruation:
 Cyclical oral progesterone: This too can be used to regulate
menstruation.
 Metformin: This is beneficial in a subset of patients with PCOS, those
with hyperinsulinaemia and cardiovascular risk factors. It is less
effective than clomiphene for ovulation induction and it does not
improve pregnancy outcome. It should be discontinued when
pregnancy is detected.
 Clomiphene: This can be used to induce ovulation where subfertility
is a factor.
 Lifestyle advice: Dietary modification and exercise is appropriate in
these patients as they are at an increased risk of developing diabetes
and cardiovascular disease later in life.
 Weight reduction.
Hirsutism:
 Eflornithine cream (Vaniquam) applied topically;
 Cyproterone acetate (Dianettem, anti-androgen contraceptive pill);
 Metformin: improves parameters of insulin resistance,
hyperandrogenemia, anovulation and acne in PCOS;
 GnRH analogues with low-dose HRT: this regime should be reserved
for women intolerant of other therapies;
 Surgical treatments, e.g. laser or electrolysis.

31. Post-menopausal bleeding (PMB) is defined as vaginal bleeding after the
menopause. In women who are not taking HRT,
Aetiology
atrophic vaginitis;
endometrial polyps;
endometrial hyperplasia;
endometrial carcinoma;
cervical carcinoma.
10 per cent of patients with PMB will have endometrial cancer,
History and examination
Some useful questions include:
When was your last period? (i.e. confirmmenopausal)
Was the bleeding post-coital? (i.e. think cervical polyp/cervical
malignancy)
When was your last smear done? Have they always been normal?
Examination should include an abdominal and vaginal examination to
detect any pelvic masses and a speculum to visualize the vaginal
tissues for atrophy and the cervix for polyps or potential carcinoma. A
smear should be taken if due.

32. An ultrasound scan should be carried out in all women to assess
endometrial thickness. I£ at ultrasound, the endometrial thickness
is 3 mm or less (or 5 mm or less for women on HRT) patients can
be reassured that the likelihood of endometrial carcinoma is
extremely low and no further investigation is required. For those
with an endometrial thickness greater than 3 mm (5 mm for those
on HRT), further endometrial assessment is warranted in the form
of an endometrial biopsy.The exception to this rule is women on
tamoxifen as ultrasound will not assist with a diagnosis.
Most women on tamoxifen will have a thickened, irregular and
cystic endometrium. Immediate direct visualization of the cavity
by hysteroscopy and an endometrial biopsy is the investigation of
choice for such women.

34. Endometrial cancer is most prevalent in the post-menopausal age
group. It typically presents with PMB.
Risk factors include nulliparity, obesity, early menarche, late
menopause and tamoxifen exposure.
Diagnosis is by endometrial biopsy. Endometrial cancer treatment
should begin with staging which involves total abdominal
hysterectomy with washings, bilateral salpingo-oophorectorny
and lymph node evaluation.
The need for postoperative adjuvant radiotherapy is determined by
recurrence risk. Patients with disease confined to the
endometrium with little or no invasion into uterine muscle uterus
often require only surgery.
Where the cancer has deeply invaded into the uterine muscle or
spread outside the uterus, adjuvant therapy in the form of radio-or
chemotherapy is indicated. The prognosis is good when the
disease is detected early.