Abnormal Menstruation Flashcards
Two most common causes of secondary dysmenorrhea?
endometriosis
uterine fibroids
dysmenorrhea =
painful menses; aka menstrual cramps
Menorrhagia =
heavy or prolonged menses bleeding
Metrorrhagia =
Intermenstrual bleeding, spotting or breakthrough bleeding
Polymenorrhea =
Menstrual interval < 21 days
Oligomenorrhea =
Menstrual interval > 35 days
Primary dysmenorrhea onset and pathophysiology?
adolescence, usually starts 2 yrs after menarche but may be immediate
uterine “angina” caused by prostaglandins
Lab tests that are mandatory if sexually active teen
Chlamydia and GC
HIV and RPR (VDRL)
Treatment of primary dysmenorrhea
Heat, diet/supplements, behavior modification, TENS, exercise
NSAIDS (ibuprofen, Naproxen sulfate)
Oral contraceptives if no relief from aggressive NSAID tx
Dosing of ibuprofen or Naproxen (Aleve) for menstrual cramps?
Ibuprofen: 400-600 mg q 4-6 hours or 800 mg q 8 hours to a max dose of 2400 mg/day with food
Naproxen (Aleve): 500 mg to start, then 250 -500 q 8-12 hours
How do oral contraceptives help with primary dysmenorrhea?
they thin endometrium which results in less prostaglandin production
secondary dysmenorrhea =
painful abd cramping with menses WITH pelvic pathology
What is endometriosis?
Endometrial tissue growing outside of endometrial cavity and uterus, most commonly in pelvis
PE findings of endometriosis
- Pelvic tenderness with uterine movement
- Palpable nodules on exam
- Fixed, tender, enlarged adnexa (appendages)
Best diagnostic imaging for endometriosis
Laparoscopy
- may miss with U/S
Endometriosis treatment
Goal: manage pelvic pain and prevent infertility
- NSAIDs and/or OC’s
- Refer to gynecology for surgery vs hormonal interventions
Benign tumors in smooth muscle cells of myometrium. Most common tumor of the female pelvis.
Uterine Leiomyomata (fibroids)
Epidemiology of Uterine Leiomyomata (or fibroids)
More common in African Americans
Occurs in 30-40s
Labs to determine cause of secondary dysmenorrhea
Pregnancy testing STI testing CBC UA Pelvic U/S Laproscopy
What increases risk of uterine fibroids?
Early menarche Meat consumption Family history Beer History of uterine infection Vitamin D deficiency Obesity (>30% body fat)
When is there decreased risk for fibroids?
menopause
> 1 pregnancy
use of OC’s
Therapy for uterine fibroids
- Watchful waiting
- Prophylactic myomectomy (prevents infertility, more complicated) vs. hysterectomy
- Oral contraceptive pills
- Lupron (GnRH analog)
Best contraceptive for young girl who is not sexually active but has primary dysmenorrhea?
transdermal patch
When do symptoms of PMS occur in cycle?
luteal phase; 7-10 days before onset of menses
symptoms resolve soon after flow begins and are absent during follicular phase
Way for patient to help you diagnosis and monitor her PMS?
COPE calendar
Nutritional modification to relieve PMS
Limit salt, refined sugar, caffeine, alcohol, fat
Increase complex carbohydrates and fiber
Vit B or calcium supplements
Evening Primrose Oil
PMS + one affective symptom (anger, irritability, internal tension). Dx’d by DSM-IV criteria
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder treatment
- OCP with 4 pill-free interval (Yaz)
- SSRIs
- Tranquilizers during luteal phase if very severe (Xanax or Ativan)
When is woman at risk for increased PMS symptoms?
perimenopausal
Define primary amenorrhea
- No menses by age 15 with normal development
- No menses after 2 yrs of completing sexual maturation
pathophysiology of primary amenorrhea
dysfunction at hypothalamus or pituitary; usually functional (emotional stress, athletics, weight)
dysfunction at ovaries; Turner Syndrome (XO)
dysfunction at uterus or vagina; menses can’t occur d/t anatomic abnormality
Most common of all primary amenorrhea? What are signs?
Turner Syndrome
short stature, webbed neck, short 4th metacarpal, nail dysplasia, high-arched palate, wide-space nipples (broad square chest), hypertension, renal abnormalities
causes of secondary amenorrhea
PREGNANCY!!! hypothalamic dysfunction hypothyroidism pituitary tumor, hyperprolactinemia Polycystic ovary syndrome Ovarian failure = menopause Asherman's Syndrome
Definition of secondary amenorrhea
absence of menses for 3-6 months after having at least 1 menses
What can cause hypothalamic dysfunction in women?
female athlete triad
emotional stress and illness
idiopathic
What is Asherman’s Syndrome? How is it eval’d and treated?
Secondary amenorrhea due to scarring of endometrial lining from previous infection or surgery
Eval with Pelvic U/S, and Progestin challenge
TX: Hysteroscope lysis of adhesions; estrogen therapy to regrow endometrium
First thing to do to eval for secondary amenorrhea
Pregnancy test
PALM-COEIN classification system for causes of abnormal uterine bleeding
P = polyps A = adenomyosis L = Leiomyomas (fibroids) M = malignancy and hyperplasia
C = coagulopathy O = ovulatory dysfunction E = endometritis I = iatrogenic N = not yet classified
Any bleeding in _______ women is abnormal. Concern?
post-menapausal
endometrial cancer
Most common etiology of endometrial hyperplasia and cancer
chronic unopposed estrogen stimulation
exogenous - estrogen therapy w/o progestin
endogenous - chronic anovulation
Risk factors for endometrial cancer
Increasing age (peak 50-60s) Unopposed estrogen therapy Late menopause Obesity Polycystic ovary DM Tamoxifen therapy (used post breast cancer) FHX of cancer (BRCA 1,2)
Diagnosis of endometrial hyperplasia and cancer
Pelvic U/S with thickened endometrial stripe
Then endometrial biopsy
D&C to further eval biopsy results
When should woman undergo eval for endometrial cancer?
- over 40 with abnormal uterine bleed
- under 40 with abnormal uterine bleed + risk factors
- Failure to respond to treatment for bleed
- Presence of atypical glandular cells on cervical cytology
- Presence of endometrial cells in woman > 40
What is D&C?
= Dilation and Curettage
brief surgical procedure in which cervix is dilated and a special instrument is used to scrape the uterine lining
Endometrial Hyperplasia & Cancer treatment?
endometrial hyperplasia without atypia -> Progestin
endometrial hyperplasia with atypia -> Hysterectomy
endometrial cancer diagnosed on endometrial biopsy -> Referral to gynecologic oncologist
When should coagulopathy causes of uterine bleeding be suspected?
Heavy or prolonged menses at menarche
Family history of coagulopathy
Signs such as easy bruising, prolonged bleeding from mucosal surfaces
Taking meds that increase bleeding tendency - warfarin
Causes of ovarian dysfunction-related uterine bleeding?
Puberty Perimenopause Obesity Polycystic ovary syndrome Cigarette Smoking
Iatrogenic causes of uterine bleeding
copper releasing IUD
hormonal contraceptive
Treatment of uterine bleeding in younger sexually active female
think infection -> antibiotics
Endometrial ablation is effective treatment
Treatment of uterine bleeding in postmenopausal women
CANCER UNLESS PROVEN OTHERWISE
Treat benign lesions as found, but if bleeding recurs or persists, work up aggressively
Causes of cervical bleeding?
Cervical cancer
Cervicitis
Polyps
When is D&C done for uterine bleeds?
if endometrial biopsy shows endometrial hyperplasia WITHOUT atypia
- need treatment if biopsy with atypia
What serum level suggests ovarian failure?
high FSH
- ovaries release less estrogen, so pituitary increases FSH to increase estrogen
