Disorders of Menstruation and the Uterus Flashcards
1. What is amenorrhea? Describe what would consitute amenorrhea in the following ages: 2. By age 15 in presence of what? 4 3. At age 13 in the absence of what? 4. At age 12-13 evaluate what?
- DEFINITION: No history of any menses
- normal growth and secondary sexual characteristics
- secondary sexual characteristics
- evaluate cyclic menstrual pain
(inperforate hymen)
Amenorrhea: Primary
Etiologues?
5
- Chromosomal abnormality (gonadal dysgenesis, Turner’s syndrome) 50%
- Hypothalamic hypogonadism 20%
- Mullerian agenesis (absence of uterus, cervix and vagina 15%
- Transverse vaginal septum or imperforate hymen 15%
- Other:
- CAH,
- PCOS,
- androgen insensitivity
Amenorrhea: Primary
Hx findings?
9
1, cyclic pelvic pain,
- other stages of puberty,
- headaches,
- virilization,
- galactorrhea,
- medications,
- stressors, weight change
- illness
- FH of delayed puberty
Amenorrhea: Primary
Possible Exam findings?
3
- Tanner Staging (Breast development is a marker for Estrogen = Ovary)
- Pelvic exam to confirm patent hymen and presence of vagina
- Signs of Turner’s (low hairline, web neck, widely spaced nipples with shield chest)
Amenorrhea: Primary
1. Initial Lab?
- Further lab based upon what? 2
- What could these furthers labs be? 5
- Initial imaging? 1
- FSH
- FSH and
- presence or absence of breast development and uterus
- could include
- karyotype,
- testosterone,
- TSH,
- prolactin and
- pregnancy test - Initial imaging: ultrasound to confirm uterus
Amenorrhea: Secondary 1. RULE OUT WHAT? 2. Ovarian causes? 2 3. Hypothalamic causes? 3 (What is decreased in hypothalamic causes?)
- PREGNANCY
- OVARIAN 40%
- PCOS 20%
- Primary Ovarian Insufficiency (PCO) less than 40 yo - HYPOTHALAMIC
-Weight loss and exercise
-Nutritional deficiencies: low body fat; celiac
-Emotional stress or illness
(FUNCTIONAL (decreased GnRH))
Amenorrhea: Secondary
- Nonfunctional hypothalamic causes? 1
- Pituitary causes? 4
- Uterine causes? 2
1. Hypothalamic Infiltrative tumors (rare)
- Pituitary
- Hyperprolactinoma
- Other causes of elevated prolactin
- Injury to pituitary
- Hypothyroidism - Asherman’s syndrome (acquired scarring of cavity)
- Tuberculosis
What are some injuries to the pituitary that would cause secondary amenorrhea?
3
- Sheehan’s syndrome,
- radiation,
- infiltrative disease like hemochromatosis
Amenorrhea: Secondary
Hx questions?
9
- Menstrual hx
- Exercise and eating patterns,
- Medications that may increase prolactin
- Stress
- Post partum hemorrhage
- Radiation to head
- Headaches
- Hot flashes
- Uterine surgeries
Amenorrhea: Secondary
exam? 4
Initial labs? 6
- BMI,
- hirsutism
- galactorrhea
- UTERINE SIZE
- pregnancy test,
- FSH,
- TSH,
- prolactin,
- possibly testosterone and
- DHEA-S
What is dysmenorrhea?
Painful periods
- Describe what primary dysmenorrhea is?
- How does it typically present? 3
- Describe what secondary dysmenorrhea is? Associated with which dz processes? 3
- Primary: No obvious cause, typically
- begins in adolescence as -
- crampy,
- midline lower abdominal pain
- associated with onset of menses - Secondary: Symptoms attributed to specific problem like
- endometriosis,
- adenomyosis or
- fibroids or PID
Dysmenorrhea: Primary
Risk factors?
8
- Age less than 30
- BMI less than 20
- Smoking
- Menarche less than 12
- Irregular/prolonged/heavy menses
- Hx of sexual assault
- Family hx
- Younger age of first child and higher parity lower risk
- Dysmenorrhea: Primary
PP? - Uterine ischemia results in what?
- Prostaglandins released with endometrial sloughing induce contractions
- anaerobic metabolites which stimulates type C pain neurons
Dysmenorrhea: Primary
Presentation?
4
- Pain begins after ovulatory cycles established
- May start 1-2 days before menses; gradually diminishes over 12-72 hours
- Unilateral pain or non-cyclic pain suggests other dx
- Nausea, diarrhea, headache may be present
Dysmenorrhea: Primary
Dx?
4
- No physical exam findings
- No lab abnormalities
- No imaging study findings
- Dx by history and normal exam
Dysmenorrhea: Primary
- General evaluation?
- What things suggest secondary causes? 5
- EVALUATION: Focus on exclusion of secondary dysmenorrhea:
- Onset of symptoms >25
- Nonmidline pain
- Dyspareunia
- Progression of symptoms
- Abnormal uterine bleeding suggest secondary causes
Dysmenorrhea: Primary
Firstline Rx?
4
- Self-care: heating pad, exercise and relaxation techniques
- NSAIDs
- Suppression of menses with contraceptive hormones
- Limited data and small studies report reduced cramps with diet and supplements: low fat-vegetarian diet;3-4 dairy servings/day; vit E 2 days before thru 1st 3days of menses; 1-2 gm fish oil/d; Vit B1 100 mg/d; vit B6 200 mg/d
Dysmenorrhea: Secondary
Causes?
10
- Endometriosis 2. Adenomyosis
- Fibroids 4. Ovarian cysts
- Intrauterine/pelvic adhesions
- Obstructive endometrial polyps
- Obstructive mullerian anomalies
- Cervical stenosis 9. IUD
- Pelvic congestion syndrome
Abnormal Uterine Bleeding (AUB)
Basic labs? 5
- CBC
- Prolactin
- TSH
- Pregnancy test
- Chlamydia testing when indicated
Abnormal Uterine Bleeding: Diff Dx
9
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulation
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Abnormal Uterine Bleeding: Terms
- Polymenorrhea?
- Menorrhagia?
- Metrorrhagia?
- Oligomenorrhea?
- cycles less than 24 days
- heavy menstrual bleeding
- bleeding between periods
- cycles> 35 days
Abnormal Uterine Bleeding:Coagulation
20 % of women presenting with heavy menstrual bleeding have an underlying bleeding disorder
SUCH AS?
VonWillebrand’s
Abnormal Uterine Bleeding: Coagulation
IN ADDITION TO HEAVY MENSTRUAL PERIODS, REFER FOR HEMATOLOGIC EVALUATION :
- If also have one of the following?
3 - Refer with two of the following? 3
- Hx of postpartum hemorrhage
- Hx of unexplained bleeding with surgery
- Hx of bleeding with dental work
- Frequent gum bleeding
- Epistaxis or unexplained bruising 2X a month
- Family Hx of bleeding
Abnormal Uterine Bleeding: Ovulatory
1. Caused by what as a result of anovulation or oligo-ovulation?
- What may cause this?
- chronic unopposed estrogen influence
- Hyperandrogenic (PCOS)
- Hypothalamic dysfunction (anorexia)
- Thyroid disease
- Elevated prolactin
- Medications
- Iatrogenic
- Premature ovarian insufficiency
What is PMS and PMDD?
- PMS = Premenstrual Syndrome
- PMDD = Premenstrual Dysphoric Disorder
- Severity of symptoms are disruptive at home/social situations/at work
- Cyclic physical and/or behavioral symptoms that recur in the luteal phase and first few days of menses. (Present for at least 3 months)
PMS and PMDD: Risk Factors
4
- Genetics: variation of estrogen receptor alpha gene
- History of traumatic events/anxiety disorder/higher daily hassle scores
- Lower education
- Smoking
PMS and PMDD: Pathophysiology
Theories?
2
- Abnormal response to normal concentrations of estrogen and progesterone
- Cyclic changes in circulating estrogen and progesterone trigger an abnormal serotonin (neurotransmitter) response
PMS and PMDD
1. Usually starts when?
- Must cause significant what?
- Usually start in 20’s
2. Must cause significant distress or interference with normal activities
PMS and PMDD: Symptoms
Physical symtpoms? 6
PHYSICAL
- Abdominal bloating
- Extreme fatigue
- Breast pain
- Headache
- Hot flashes
- Dizziness
PMS and PMDD
Behavioral 4
- Mood swings
- Irritability/anger
- Depression/hopelessness/self-critical
- Anxiety/tension/feeling on edge
For dx of PMDD must have at least one of the above and a total of 1.__ symptoms, 2.__ of which can be from an expanded DSM-5 criteria.
- These symptoms should have been present when?
- 5
- 4
- for most of the preceding year in a cyclic pattern with menses
PMS and PMDD: Evaluation
- Confirm what first?
- Lab? 2
- Have patient complete what?
- Confirm regular menses and cyclic pattern of symptoms
- Lab: No specific test. Consider TSH and CBC
- Have patient complete a prospective symptom inventory
PMS and PMDD: Treatment
1. Mild? 2
- Moderate-Severe? 1
MILD
- Exercise and relaxation techniques
- No strong data that vitamins or supplements exceed the placebo response
MODERATE-SEVERE
1. SSRIs
-Fluoxetine, sertraline, extended release paroxetine all have FDA approval
60-70% response; try different SSRI
PMS and PMDD: Treatment
Refractory to SSRI? 3
Induce anovulation with
- continuous/short pill-free interval OC (Evidence strongest for drospirenone)
- GnRH agonist
- Surgery with BSO (and hysterectomy)
Endometriosis
1. What is it?
Psychological impact of the 2.___________ experienced by the patient is compounded by the possibility of 3._______?
Endometriosis has a prevalence rate of 20-50% in 4.________ women and as high as 80% in women with 5._________.
Common, poorly understood, and extremely debilitating benign gynecological condition.
- Cells that behave like the lining the uterus (endometrium) grow in other areas of the body, causing pain, irregular bleeding, and possible infertility.
- severe pain
- infertility
- infertile
- chronic pelvic pain
Endometriosis
Who can be affected by this? 2
- Affects menstruating women.
2. Postmenopausal endometriosis may be encountered in women who are on estrogen replacement therapy (ERT).
Occasionally, if ERT is administered after total abdominal hysterectomy, endometriosis can be stimulated in an what?
ovarian remnant.
Endometriosis
Etiology and pathophysiology of endometriosis is not well understood.
Theories (and describe them)? 3
- Retrograde menstruation
- Endometrial cells loosened during menstruation may “back up” through the fallopian tubes into the pelvis. Once there, they implant and grow in the pelvic or abdominal cavities. - Halban Theory: vascular and lymphatic dissemination
- Meyer Theory: metaplasia of multipotential cells
Each month ovaries produce hormones that stimulate the cells of the endometrium to multiply and prepare for a fertilized egg. The lining swells and gets thicker.
If these cells are outside the uterus, endometriosis results.
Why is this a problem? 3
- Unlike cells normally found in the uterus that are shed during menstruation, the ones outside the uterus stay in place.
- Cells bleed a little bit, but they heal and are stimulated again during the next cycle.
- Ongoing process leads to symptoms of endometriosis and can cause adhesions on the tubes, ovaries, and surrounding structures in the pelvis.