4. Disorders of Menstruation Flashcards
Name DDX of primary amenorrhea with: Normal breast and pelvic (4)
- Hypothyroidism
- Hyperprolactinemia
- PCOS
- Hypothalamic dysfunction
Name DDX of amenorrhea with: Normal breast, abnormal uterine development (4)
- Androgen insensitivity
- Anatomic abnormalities
- Müllerian agenesis
- uterovaginal septum
- imperforate hymen
Name DDX of primary amenorrhea with: High FSH (hypergonadotropic hypogonadism) (2)
- Gonadal dysgenesis
- Abnormal sex chromosome (Turner’s XO)
- Normal sex chromosome (46XX, 46XY)
Name DDX of primary amenorrhea with: Low FSH (hypogonadotropic hypogonadism) (8)
- Constitutional delay (rare in girls)
- Congenital abnormalities Isolated
- GnRH deficiency
- Pituitary failure (Kallman syndrome, head injury, pituitary adenoma, etc.)
- Acquired endocrine disorders (type 1 DM)
- Pituitary tumours
- Systemic disorders (IBD, JRA, chronic infections, etc.)
- Functional hypothalamic amenorrhea
Name: Most Common Causes of Primary Amenorrhea (3)
- Müllerian agenesis
- Abnormal sex chromosomes (Turner’s syndrome)
- Functional hypothalamic amenorrhea
Name the most common cause of secondary amenorrhea
Functional hypothalamic amenorrhea
Name ddx secondary amenorrhea: With Hyperandrogenism (4)
- PCOS
- Autonomous hyperandrogenism (androgen secretion independent of the HPO axis)
- Ovarian: tumour, hyperthecosis Adrenal androgen-secreting tumour
- Late onset or mild congenital adrenal hyperplasia (rare)
Name DDX secondary amenorrhea: Without Hyperandrogenism (5)
- Hypergonadotropic hypogonadism (i.e. primary ovarian insufficiency: high FSH, low estradiol)
- Idiopathic
- Autoimmune: type 1 DM, autoimmune thyroid disease, Addison’s disease
- Iatrogenic: cyclophosphamide drugs, radiation
- Hyperprolactinemia
- Endocrinopathies: most commonly hyper or hypothyroidism
- Hypogonadotropic hypogonadism (low FSH):
- Pituitary compression or destruction: pituitary adenoma, craniopharyngioma, lymphocytic hypophysitis, infiltration (sarcoidosis), head injury, Sheehan’s syndrome
- Functional hypothalamic amenorrhea (often related to stress excessive exercise and/or anorexia)
Describe diagnostic approach to amenorrhea (figure)
Describe investigation: Amenorrhea (4)
- β-hCG, hormonal workup (TSH, prolactin, FSH, LH, androgens, estradiol)
- progesterone challenge to assess estrogen status
- medroxyprogesterone acetate (Provera®) 10 mg PO OD for 10-14 d
- any uterine bleed within 2-7 d after completion of Provera® is considered to be a positive test/ withdrawal bleed
- withdrawal bleed suggests presence of adequate estrogen to thicken the endometrium; thus withdrawal of progesterone results in bleeding
- if no bleeding occurs, this may be secondary to inadequate estrogen (hypoestrogenism), excessive androgens, or progesterones (decidualization) or pregnancy
- karyotype: indicated if primary ovarian insufficiency or absent puberty
- U/S to confirm normal anatomy, identify PCOS
Describe management of Primary Amenorrhea: Androgen insensitivity syndrome (3)
- Gonadal resection after puberty
- Psychological counselling
- Creation of neo-vagina with dilation
Describe management of Primary Amenorrhea: Müllerian dysgenesis (MRKH syndrome) (3)
- Psychological counselling
- Creation of neo-vagina with dilation
- Diagnostic study to confirm normal urinary system and spine
Describe management of Primary Amenorrhea:
Describe management of Primary Amenorrhea:
Anatomical
- Imperforate hymen
- Transverse vaginal septum
- Cervical agenesis
- Imperforate hymen: Surgical management
- Transverse vaginal septum: Surgical management
- Cervical agenesis: Suppression and ultimately hysterectomy
Describe management of Secondary Amenorrhea: HP-axis dysfunction (2)
- Identify modifiable underlying cause
- Combined OCP to decrease risk of osteoporosis, maintain normal vaginal and breast development (NOT proven to work)
Describe management of Secondary Amenorrhea: Hyperprolactinemia (3)
- MRI/CT head to rule out lesion
- If no demonstrable lesions by MRI
- Bromocriptine, cabergoline if fertility desired
- Combined OCPs if no fertility desired
- Demonstrable lesions by MRI: surgical management
Describe management of Secondary Amenorrhea: Premature ovarian failure (2)
- Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
- Hormonal therapy with estrogen + progestin to decrease risk of osteoporosis; can use OCP after induction of puberty
Describe management of Secondary Amenorrhea: Uterine defect, Asherman’s syndrome (2)
- Evaluation with hysterosalpingography or sonohysterography
- Hysteroscopy: excision of synechiae
Describe: Diagnostic approach to abnormal uterine bleeding (figure)
Describe approach to abnormal uterine bleeding (5)
- menstrual bleeding should be evaluated by ascertaining: frequency/regularity of menses, duration, volume of flow, impact on quality of life, and timing (inter or premenstrual or breakthrough)
- is it regular?
- regular: cycle to cycle variability of <20 d – “Can you predict your menses within 20 days?”
- irregular: cycle to cycle variability of ≥20 d
- is it heavy?
- ≥80 cc of blood loss per cycle or
- ≥8 d of bleeding per cycle or
- bleeding that significantly affects quality of life
- is it structural?
- PALM
- is it non-structural?
- COEIN
Name STRUCTURAL etiologies of Abnormal Uterine Bleeding (4)
- Polyps (AUB-P)
- Adenomyosis (AUB-A)
- Leiomyoma (AUB-L)
Submucosal (AUB-Lsm)
Other (AUB-Lo)
- Malignancy and Hyperplasia (AUB-M)
Name NON-STRUCTURAL etiologies of Abnormal Uterine Bleeding (5)
- Coagulopathy (AUB-C)
- Ovulatory dysfunction (AUB-O)
- Endometrial (AUB-E)
- Iatrogenic (AUB-I)
- Not yet classified (AUB-N)
Describe investigations and management: Polyps (AUB-P) (2)
- Investigations:
- Transvaginal sonography
- Saline infusion sonohysterography
- Management: Polypectomy (triage based on symptoms,polyp size, histopathology and patient age)
Describe investigations and management: Adenomyosis (AUB-A) (2)
- Investigations:
- Transvaginal sonography
- MRI
- Management: See Adenomyosis, GY13
Describe investigations and management:
Leiomyoma (AUB-L)
Submucosal (AUB-Lsm)
Other (AUB-Lo)
- Investigations:
- Transvaginal sonography
- Saline infusion sonohysterography
- Diagnostic hysteroscopy
- Management: See Fibroids (Leiomyomata), GY13
Describe investigations and management: Malignancy and Hyperplasia (AUB-M) (3)
- Investigations:
- Transvaginal sonography
- Endometrial biopsy for all women >40 yr with AUB, for women <40 yr with persistent AUB or endometrial cancer risk factors
- Management: Dependent on diagnosis
Describe investigations and management: Coagulopathy (AUB-C) (2)
- Investigations: CBC, coagulation profile (especially in adolescents),
vWF, Ristocetin cofactor, factor VIII
- Management: Dependent on diagnosis (hormonal modulation (e.g. OCP), Mirena IUS, endometrial ablation)
Describe investigations and management: Ovulatory dysfunction (AUB-O) (2)
- Investigations:
- Bloodwork: β-hCG, ferritin, prolactin, FSH, LH, serum androgens (free testosterone, DHEA), progesterone, 17-hydroxy progesterone, TSH, free T4
- pelvic ultrasound
- Management: See Infertility, GY22
Describe investigations and management: Endometrial (AUB-E) (5)
- Investigations: Endometrial biopsy
- Management:
- Tranexamic acid
- Hormonal modulation (e.g. OCP)
- Mirena IUS
- Endometrial ablation
Describe investigations and management: Iatrogenic (AUB-I) (4)
- Investigations:
- Transvaginal sonography (rule out forgotten IUD)
- Review OCP/HRT use
- Review meds (especially neuroleptic use)
- Management: Remove offending agent
Describe tx: Abnormal Uterine Bleeding (4)
- resuscitate patient if hemodynamically unstable
- treat underlying disorders
- if anatomic lesions and systemic disease have been ruled out, consider AUB
- medical: mild vs acute,severe
- surgical
Describe medical tx: MILD Abnormal Uterine Bleeding (6)
- NSAIDs
- anti-fibrinolytic (e.g. Cyklokapron®) at time of menses
- combined hormonal contraceptive
- progestins (Provera®) on first 10-14 d of each month or every 3 mo if AUB-O
- Mirena® IUD
- correct anemia - iron
Describe medical tx: ACUTE, SEVERE Abnormal Uterine Bleeding (4)
– replace fluid losses, consider admission
- estrogen (Premarin®) 25 mg IV q4h x 24 h with Gravol® 50 mg IV/PO q4h or anti-fibrinolytic (e.g. Cyklokapron®) 10 mg/kg IV q8h (rarely used)
- tapering OCP regimen, 35 µg pill tid x7d then taper to 1 pill/d for 3wk with Gravol® 50 mg IV/ PO q4h
– or taper to 1 tab tid x 2 d s bid x 2 d s OD (more commonly used)
- after (a) or (b), maintain patient on monophasic OCP for next several months or consider alternative medical treatment
- medical (can also consider):
- high dose progestins
- danazol (Danocrine®)
- GnRH agnosits (e.g. Lupron ®) with add-back if taken for >6 mo
- ulipristal acetate
- medical (can also consider):
Describe surgical tx: Abnormal Uterine Bleeding (2)
- endometrial ablation
- if finished childbearing
- repeat procedure may be required if symptom recur, especially if <40 yr
- hysterectomy: definitive treatment
Define: Primary Dysmenorrhea (1)
Recurrent crampy lower abdominal pain during menses in the absence of demonstrable disease
Define: Secondary Dysmenorrhea (1)
Pain during menses that can be attributed to an underlying disorder (endometriosis, adenomyosis, fibroids)
Name etiologies of secondary Dysmenorrhea (12)
- endometriosis
- adenomyosis
- uterine polyps
- uterine anomalies (e.g. non-communicating uterine horn)
- leiomyoma
- intrauterine synechiae
- ovarian cysts
- cervical stenosis
- imperforate hymen, transverse vaginal septum
- pelvic inflammatory disease
- IUD (copper)
- foreign body
Describe features: Primary Dysmenorrhea (3)
- Recurrent, crampy lower abdominal pain
- that occurs during menses
- in the absence of demonstrable disease
Describe features: Secondary Dysmenorrhea (2)
- Similar features as primary dysmenorrhea
- but with an underlying disorder that can account for the symptoms, such as endometriosis, adenomyosis or uterine fibroids
Name signs and symptoms: Primary Dysmenorrhea (4)
- Colicky pain in abdomen
- radiating to the lower back, labia, and inner thighs beginning hours
- before onset of bleeding and persisting for hours or days (48-72 h)
- Associated symptoms: N/V, altered bowel habits, headaches, fatigue (prostaglandin-associated)
Name signs and symptoms: Secondary Dysmenorrhea (3)
Associated
- dyspareunia
- abnormal bleeding
- infertility
Describe diagnosis: Primary Dysmenorrhea (3)
- Assess for associated dyspareunia, abnormal bleeding, infertility (signs of 2º dysmenorrhea)
- Rule out underlying pelvic pathology and confirm cyclic nature of pain
- Pelvic examination not required; indicated for patients not responding to therapy or with signs of organic pathology
Describe diagnosis: Secondary Dysmenorrhea (3)
- Bimanual exam: uterine or adnexal tenderness, fixed uterine retroflexion, uterosacral nodularity, pelvic mass, or enlarged irregular uterus (findings are rare in women <20 yr)
- U/S, laparoscopy and hysteroscopy may be necessary to establish the diagnosis
- Vaginal and cervical cultures may be required
Describe treatment: Primary Dysmenorrhea (3)
- Regular exercise, local heat
- NSAIDs: should be started before onset of pain
- Combined hormonal contraceptives with continuous or extended use: suppress ovulation/ reduce menstrual flow
Describe treatment: Secondary Dysmenorrhea (1)
Treat underlying cause
