Complications of Menstruation & Abnormal Uterine Bleeding CH 38 Flashcards
premenstrual syndrome, what is it
cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predictable relationship to menses. psychoneuroendocrine disorder
premenstrual syndrome symptoms
Mood (irritability, mood swings, depression, anxiety), physical (bloating, breast tenderness [mastodynia], insomnia, fatigue, hot flashes, appetite changes) and cognitive (confusion, and poor concentration)
symptoms of premenstrual dysphoric disorder
headache, breast tenderness, pelvic pain, bloating, premenstrual tension along with irritability, dysphoria, and mood liability that disrupt daily functioning
pathogenesis of premenstrual syndrome
estrogen/progesterone imbalance, excess aldosterone, hypoglycemia, hyperprolactinemia, serotonin dysfunction, decreased GABA levels and psychogenic factors along with trigger of physiologic ovarian function
diagnosis of premenstrual syndrome
patient medical history. need at least 1 affective symptom and somatic symptom during the 5 days prior to menses in each of the 3 prior menstrual cycles. symptoms should be relieved within 4 days of onset of menses. must also repeat for next 2 cycles after prospective reading
premenstrual syndrome differential diagnosis
r/o neoplasm (for breast pain), r/o psych illness
premenstrual syndrome tx
diet changes (limit caffeine, alcohol, tobacco, chocolate sodium), stress management, pharmacological ( calcium carbonate, magnesium, vitamin b6, vitamin, and nsaids, hormonal interventions, GnRH
dysmenorrhea
painful menstruation that prevents normal activity and requires medication, one of the most common gyn complaints.
membranous dysmenorrhea
rare, causes intense cramping due to passage of a cast of endometrium through an undilated cervix
dysmenorrhea pathogenesis
abnormal and increased prostanoid and possibly eicosanoid secretion that induces uterine contractions, that reduce blood floow, leading to uterine hypoxia. increased leukotriene also a factor
dysmenorrhea clinical findings
subjective pain, starts in adolescence, nausea, vomiting, diarrhea and headache may accompany. , generalized pelvic tenderness. use US to rule out pelvic abnormalities
dysmenorrhea differential diagnosis
adenomyosis, secondary dysmenorrhea, endometriosis (pain begins 1 to 2 weeks before menses)
main dysmenorrhea tx
NSAIDs, tylenol, heat; more severe pain may need codeine or stronger analgesics; antiprostaglandins
antiprostaglandins
treat dysmenorrhea, help by reducing prostaglandin. should start 1 to days before expected pain
COX 2 inhibitors
treat dysmenorrhea, same effectiveness as naproxen, has adverse effects
oral contraceptives for dysmenorrhea
cyclic administration of oral contraceptive in lowest dosage but increased estrogen, helps prevent pain with those who don’t get relief with regular means. tx for 6 to 12 months then pain usually stays away
surgical tx of dysmenorrhea
cervical dilation doesn’t help, may need hysterectomy without removal of ovaries
abnormal uterine bleeding means and causes
abnormal menstrual bleeding and bleeding due to other causes, like pregnancy (always consider complication of pregnancy), systemic dz, and cancer
menorrhagia (hypermenorrhea) meaning
heavy (gushing or open faucet) or prolonged menstrual flow, may pass clots
causes of menorrhagia
submucous myomas, complication of pregnancy, adenomyosis, IUD, endometrial hyperplasia, malignant tumor, dysfunctional bleeding
Hypomenorrhea (crytomenorrhea) meaning
unusually light menstrual flow, sometimes only spotting
causes of hypomenorrhea
obstruction (hymenal or cervical stenosis), uterine synechiae (asherman’s syndrome) can be diagnosed by hysterogram or hysteroscopy, oral contraceptive use
metrorrhagia (intermenstrual bleeding) meaning
bleeding that occurs between menstrual periods
causes of metrorrhagia
ovulatory bleeding, endometrial polyps, endometrial and cervical CA, exogenous estrogen administration
polymenorrhea meaning
periods that occur frequently
polymenorrhea causes
anovulation, shortened luteal phase
menometrorrhagia meaning
bleeding at irregular intervals
menometrorrhagia causes
malignant tumors, complication of pregnancy, ovulatory bleeding, endometrial polyps, endometrial and cervical CA, exogenous estrogen administration
oligomenorrhea meaning
menstrual periods that occur more than 35 days apart (if more than 6 months diagnose with amenorrhea),
causes of oligomenorrhea
anovulation, excessive weight loss, estrogen secreting tumors
contact bleeding (postcoital bleeding)
spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse
causes of contact bleeding
cervical CA, cervical polyps, cervical eversion, cervical/vaginal infection, atrophic vaginitis. colposcopy and/or biopsy may be needed for diagnosis
blood test to eval uterine bleeding
CBC, assay of beta subunit of hCG, TSH; used to rule out systemic disease, trophoblastic dz, and pregnancy
physical exam findings for myoma
abdominal masses, enlarged irregular uterus
physical exam findings for adenomyosis and endometrial CA
symmetrically enlarged uterus
decidual reaction of cervix
during pregnancy, velvety, friable erythematous lesion on ectocervix
reason for cytologic exam
diagnose asymptomatic intraepithelial lesions of cervix, presence of endometrial cells could mean endometrial CA, tubal and ovarian CA can be suspected with smear
sonohysterography
modification of pelvic US, performed following injection of saline by thin catheter into uterus. used to evaluate endometrial cavity for polyps, fibroids and other abnormalities
Transvagainal US vs transabdominal US
transvaginal US done with empty bladder and enables greater look at pelvic organs. transabdominal US done with full bladder to enable wider and less discriminative exam of pelvis
endometrial biopsy
done with Novak suction curette, Duncan curette, Kevorkian curette, or Piprllr. No cervical dilation needed. Small areas are sampled. If source of bleeding cannot be found, pt may need hysteroscopy or D&C
disadvantage of D&C
blind procedure, accuracy is not good
tx for menorrhagia
antifibrinolytic therapy, prostaglandin synthetase inhibitor, long acting intramuscular progestin (Depo Provera) administraion (can result in erratic bleeding or even amenorrhea), IUD
nongynecologic reasons for abnormal bleeding
rectal and urological disorders, myxedema (amenorrhea), less severe hypothyroidism (abnormal uterine bleeding), liver disease, blood dyscraias, coagulation abnormalities. extreme weight loss, pts receiving anticoagulants or adrenal steroids
overall tx of dysfunctional uterine bleeding
for adolescents and young women: rule out pathologic causes then give oral estrogens followed by medroxyprogesterone; for premenopaual women take careful consideration of pathologic causes and eval with endometrial biopsy or hysteroscopy
surgical measures for dysfunctional uterine bleeding
if bleeding causes pt to be symptomatically anemic and alters lifestyle, D&C, IUD, or endometrial ablation may be needed. hysterectomy is last choice
postmenopausal bleeding meaning
bleeding that occurs after 12 months of amenorrhea in middle aged woman.
causes of postmenopausal bleeding
may be non gynecological, atrophic/proliferative endometrium, use of exogenous hormones
clinical findings of vaginal atrophy
bleeding from lower reproductive tract, thin tissue with ecchymosis. tears may (rarely) require suturing
clinical findings of vulvar dystrophies
white area and cracking of skin of vulva, immature epithelial cells with or without inflammation on cytologic study.
differentiating tumors of reproductive tract
uterine sampling must be done and tissue should be obtained. endocervical curettage should be done with endometrial sampling. if no diagnosis can be made, pt may need D&C. may be helpful to use pelvic US and hysteroscopy to locate and diagnose tumors
