Disorders of Menstruation and the Uterus Flashcards
Menstrual Cycle
See Study Guide!
Symptoms of PMS initiate during the ____ phase.
Luteal
What type of contraception is best for a woman with PMDD (severe PMS w/ functional impairment)?
Drospirenone (progestin)-containing OCP
Secondary dysmenorrhea is due to a pelvic pathology. What are some examples?
- Endometriosis
- Adenomyosis
- Leiomyomas
- Adhesions
- PID
Treatment options for dysmenorrhea include:
- NSAIDs!
- Ovulation suppression: OCPs, Depo, Vaginal ring
- Laparoscopy: to r/o secondary causes such as endometriosis or PID
The MC secondary cause of dysmenorrhea in younger patients is _____. A common cause of dysmenorrhea with increasing age is ______.
- Endometriosis
2. Adenomyosis
DUB is either due to:
- Chronic Anovulation (90%) OR
- Ovulatory
- Chronic Anovulation: Seen at EXTREMES OF AGE (teenagers after menarche and perimenopausal). Related to UNOPPOSED ESTROGEN. Without ovulation there is no progesterone. Leads to increased endometrial growth w/ irregular, unpredictable shedding/bleeding.
What tests and labs do you order for a DUB workup?
- hormone levels
- TVUS
- endometrial bx if endometrial stripe is > 4mm on TVUS or in woman > 35y/o to r/o endometrial hyperplasia or carcinoma
*If workup shows no evidence of organic cause and you have a negative pelvic exam then DUB is the dx
Acute severe bleeding in DUB is controlled how?
High dose IV estrogens or high dose OCPs
-D&C may be used if IV estrogen fails
1st line treatment for anovulatory DUB is _____.
OCPs
-Progesterone and GnRH agonists (Lupron) can be considered
Treatment for ovulatory DUB includes:
- OCPs
- Progesterone: orally or IUD
- Lupron
If not responsive to medical treatment for DUB then what surgical options are considered?
- Hysterectomy= definitive management
2. Endometrial ablation
What labs should be ordered in a patient with amenorrhea?
- Pregnancy!
- Serum prolactin
- FSH & LH
- TSH
Primary amenorrhea is defined as the failure of menarche onset by the age of ___ in the presence of secondary sex characteristics or ___ in the absence of secondary sex characteristics.
15- presence of secondary sex characteristics
13- absence of secondary sex characteristics
Amenorrhea in a patient with a uterus and breasts is most likely caused by what?
Outflow obstruction–> Transverse vaginal septum, imperforate hymen
Amenorrhea in a patient with a uterus but NO breasts is likely due to what?
IF…
- Elevated FSH and LH= Ovarian Cause
- Premature ovarian failure (46XX)
- Gonadal dysgenesis (Turner’s XO) - Normal/Low FSH and LH= Hypothalamus-Pituitary Failure
- Puberty delay (athletes, illness, anorexia)
Secondary amenorrhea is defined as absence of menses for > ___ (length of time) in a patient with previously normal menstruation, or > ___ in a patient who was previously oligomenorrheic.
- > 3 months
- > 6 months
______ is the MC cause of secondary amenorrhea.
Pregnancy
A 17 year old patient comes to the office stating she hasn’t had her period in 4 months (was previously regular). Her pregnancy test is negative. Lab work reveals:
- FSH and LH= LOW
- Estradiol= LOW
- Prolactin= Normal
What are some possible causes of her amenorrhea?
How should she be treated?
- Anorexia or weight loss
- Exercise
- Stress
- Nutritional deficiencies
- Systemic disease (celiac)
Treatment: Stimulate GnRH secretion. Clomiphene!
A 17 year old patient comes to the office stating she hasn’t had her period in 4 months (was previously regular). Her pregnancy test is negative. Lab work reveals:
- FSH and LH= LOW
- Prolactin= HIGH
What is the likely cause of her amenorrhea?
How should she be treated?
Prolactin-secreting pituitary adenoma
-prolactin inhibits GnRH
Treatment= Transsphenoidal surgery (removal of tumor)
A 17 year old patient comes to the office stating she hasn’t had her period in 4 months (was previously regular). Her pregnancy test is negative. Lab work reveals:
- FSH and LH= HIGH
- Estradiol= LOW
What is the likely cause of her amenorrhea?
How should she be treated?
Ovarian disorder= PCOS, Premature Ovarian Failure- follicular failure or resistance to FSH or LH or Turner’s (see symptoms of estrogen deficiency- similar to menopause)
If a patient completes the progesterone challenge test and has withdrawal bleeding this suggests that the cause of the amenorrhea is likely what?
Ovarian: patient is anovulatory or oligoovulatory (there is enough estrogen present that has built up the endometrial lining)
If a patient completes the progesterone challenge test and does NOT HAVE withdrawal bleeding this suggests that the cause of the amenorrhea is likely what?
Hypoestrogenic
1. Hypothalamus-Pituitary Failure OR
- Uterine!= Asherman’s or Uterine Outflow Tract Obstruction (Imperforate Hymen)
How is Asherman’s Syndrome (acquired endometrial scarring) diagnosed?
- Pelvic US (absence of normal uterine stripe)
- Hysteroscopy
*Treatment= estrogen to stimulate endometrial regeneration
Cessation of menses for > 1 year due to loss of ovarian function is known as ____.
Menopause
What are some estrogen deficiency changes associated with menopause?
- hot flashes
- mood changes
- skin/nail/hair changes
- increased risk of cardiovascular events
- HLD
- osteoporosis
- dyspareunia due to vaginal atrophy
- urinary incontinence
How is menopause diagnosed?
FSH ASSAY: MOST SENSITIVE INITIAL TEST
- increased serum FSH > 30 IU/mL
- decreased estrogen (due to depletion of ovarian follicles)
Name 5 medications that can be prescribed to treat vasomotor insufficiency.
- Estrogen
- Progesterone
- Clonidine
- SSRIs
- Gabapentin
Biphosphonates and SERM (Raloxifene and Tamoxifene) can be used to treat/prevent _____ in menopausal women.
Osteoporosis
What are the risks and benefits of estrogen only therapy?
- Risks:
- Increased risk of endometrial cancer (often used in hysterectomy patients)
- Thromboembolism (CVA, DVT, PE)
- Liver Disease - Benefits:
- Most effective symptomatic treatment
- No increased risk for breast cancer
What are the risks and benefits of Estrogen + Progesterone therapy?
- Risks:
- VTE
- Slightly increased risk for breast ca? - Benefits:
- Symptomatic relief, decreased heart and stroke risk, decreased risk of osteoporosis and dementia
- Protective against endometrial cancer!
