22: Menstrual cycle abnormalities Flashcards
Primary dysmenorrhea defined
thought to be due to ?
severe pain with menses that cannot be attributed to any identifiable cause, pain and cramping during menstruation that interferes with normal activities and requires OTC or prescription medication.
-thought to be due to increased levels of prostaglandins, typically before age 20
most primary dysmenorrhea is managed with ?
NSAIDs (antiPGs) and/or contraceptive steroids in pill (OCPs), patch, or ring form. TENS units, heating pads, exercise, massage, acupuncture, and hypnosis may also help.
-sx typically not useful
Secondary dysmenorrhea is painful menses due to an identifiable cause such as ?
adenomyosis, endometriosis, fibroids, cervical stenosis, or pelvic adhesions
PMS and PMDD represent a multifactorial disease spectrum with physiologic and psychological components including
headache, weight gain, bloating, breast fluctuation, irritability, fatigue, and a feeling of being out of control.
In order to make the diagnosis of dysmenorrhea, symptoms must occur when?
in the second half of the menstrual cycle with at least a 7-day symptom-free interval during the first half of the menstrual cycle.
-must occur in at least two consecutive cycles.
PMS/PMDD treatments
SSRIs (Prozac-fluoxetine, Zoloft-sertaline), OCPs (Yaz with drospirenone), as do diet modification, exercise, and vitamin supplementation (calcium, vitamin D, vitamin B6, and magnesium), carb-rich drinks
The normal menstrual cycle occurs, on average, every 28 days (range, 21 to 35 days) and lasts 3 to 5 days with ?of blood loss per cycle
30 to 50 mL
Menorrhagia ? Metrorrhagia ? menometrorrhagia ?
regular bleeding that is heavy or prolonged (more than 7 days, 80mL/cycle, 24 pads/day).
bleeding between periods
heavy or prolonged irregular bleeding
most common causes of heavy or prolonged bleeding include ?
polyps, fibroids, adenomyosis, cancer, and pregnancy complications.
The most common causes of oligomenorrhea (periods >35 days apart) include ?
chronic ovulation, PCOS, and pregnancy.
The initial evaluation of abnormal uterine bleeding should include ?
history and physical, laboratory tests (pregnancy test, TSH, prolactin, ± FSH), endometrial biopsy (for women 45 and older), and pelvic US
DUB is a diagnosis of ?
It is thought to be secondary to ?, and is therefore more prevalent in ?
exclusion when no other source for abnormal bleeding can be identified.
2/2 to anovulations or oligoovulation, more common in adolescents and perimenopausal women, if reproductive age think PCOS
Most women with DUB can achieve menstrual regularity using ?
a daily monophasic birth control pill, patch, ring, or by use of cyclic progestins when estrogens are contraindicated.
In cases of acute hemorrhage, ? can be used to stop acute bleeding. DUB that is not responsive to medical therapy may require surgical treatment with ?
IV estrogens and high-dose oral estrogens, OCP taper
D/C, Mirena IUD, endometrial ablation, or, rarely, hysterectomy.
The most common cause of postmenopausal bleeding is ?
Other causes ?
vaginal/endometrial atrophy
other causes: cancer of the upper and lower genital tract, endometrial polyps, exogenous hormonal stimulation, and bleeding from nongynecologic sources (rectal bleeding from hemorrhoids, anal fissures, rectal prolapse, low GI tumors).
All postmenopausal women with an ? or ? should have an endometrial biopsy to rule out endometrial hyperplasia and cancer.
endometrial stripe greater than 4mm or persistent bleeding
treating primary dysmenorrhea with OCPs: mechanism of relief is either ?
either secondary to the cessation of ovulation or due to the decrease in endometrial proliferation leading to decreased prostaglandin production
common causes of abnormal vaginal bleeding
adenomyoma, adenomyosis, endometrial polyps, uterine firoid, endometrial hyperplasia and cancer, cervical polyps
imaging pelvic adhesions
how to treat?
not visible on pelvic US, CT, MRI
- will occasionally respond to the antiprostaglandins
- diagnosed and treated via laparoscopy, may need laparotomy
hypotheses of PMS/PMDD etiologies
abnormalities in response to estrogen–progesterone changes, disturbance in the RAAS, excess PG and prolactin production, psychogenic factors, interaction between the serotonin and cyclic changes in the ovarian steroids
PALM-COEIN etiology of AUB
PALM (structural causes) Polyps Adenomyosis Leiomyomas Malignancy and hyperplasia COEIN (non-structural) Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
Teenagers with menorrhagia should be evaluated for ?
primary bleeding disorders such as von Willebrand disease, idiopathic thrombocytopenic purpura (ITP), platelet dysfunction, and thrombocytopenia from malignancy.
hypomenorrhea causes
hypogonadotropic hypogonadism (athletes, anorexia), atrophic endometrium: Asherman’s syndrome (intrauterine adhesions or synechiae), congenital malformations, infection, and intrauterine trauma, OCPs, Depo-Provera, and the progestin-containing IUDs, endometrial ablation, outlet obstruction
oligomenorrhea causes
(greater than 35 days apart)
hyperprolactinemia, thyroid disorders, PCOS, chronic anovulation, and pregnancy
besides women older than 45, who should get an EMB with oligomenorrhea ?
Obese patients with prolonged oligomenorrhea
-increased risk of endometrial hyperplasia and cancer due to the peripheral conversion of androgens into estrogens in their adipose cells.
adenomyosis treatment
combo OCPs, levonorgestrel-containing IUD (Mirena), Endometrial ablation or resection (may increase risk of pain/bleeding)
Endometrial hyperplasia treatment
progestin therapy if no cytologic atypia and occasionally with D&C or hysterectomy when atypia is present
Anovulation treatment
menstrual regulation with NSAIDs, estrogens and/or progestins and weight loss
a new antifibrinolytic agent, has been shown to decrease menstrual blood loss and is FDA approved for the treatment of menorrhagia
tranexamic acid (Lysteda)
ablation modalities
laser, roller bar/barrel, hydrothermal balloon, cryoablation, bipolar radiofrequency, microwave, and hydrothermal ablation (circulating hot water)
Success: reduction in uterine blood flow (NOT amenorrhea) and patient satisfaction
how anovulatory cycles cause bleeding
the ovary produces estrogen but no corpus luteum is formed, and thus no progesterone is produced–>continuous estrogen stimulation of the endometrium without the usual progesterone-induced bleeding–>endometrium continues to proliferate until it outgrows its blood supply, breaks down, and sloughs off in an irregular fashion
anovulation likely to occur when
adolescence, perimenopause, lactation, and pregnancy. Pathologic anovulation occurs in hypothyroidism, hyperprolactinemia, hyperandrogenism, and POI/PMOF.
in DUB cases check for evidence of anovulation how ?
basal body temperature, ovulation prediction kits (at-home tests for detecting the LH surge in urine), midluteal (day 21 to 23) serum progesterone level, EMB showing a decidualized or luteal phase endometrium (evidence of ovulation and progesterone effect upon the endometrium)
For chronic DUB, nonhormonal therapy with ? has been shown to decrease menstrual blood loss by 20% to 50%
NSAIDs (e.g., 800 mg ibuprofen TID × 5 days)
+/- estrogen/progesterone therapy
If an ovarian mass is identified, these tumor markers should also be considered
Ca-125, LDH, hCG, AFP, CEA, inhibin, and estradiol
endometrial cancer is usually treated with
TAHBSO performed in conjunction with possible lymph node dissection, radiation, or chemotherapy therapy
