Disorders of Menstruation and Uterus Flashcards
Amenorrhea (Primary)
- definition
- etiology
- dx
Definition
- no hx of any menses
- -by age 15 in presence of normal growth and secondary sex characteristics
- -at age 13 in the absence of secondary sexual characteristics
Etiologies
- chromosomal abnormalities (50%)
- hypothalmic hypogonadism
- mullerian agenesis (absence of uterus, cervix, and vagina)
- transverse vaginal septum or imperforate hymen
Dx
- tanner staging (breast development is a marker for estrogen)
- pelvic exam to confirm patent hymen and presence of vagina
- signs of turners (low hairline, web neck, widely spaced nipples with shield chest)
- Initial lab: FSH
- other labs may include: karyotype, testosterone, TSH, prolactin, HCG
- initial imaging: US to confirm uterus
Amenorrhea (Secondary)
- MC cause
- other causes
- dx
MC cause is PREGNANCY
Other causes
- ovarian: PCOS, Primary ovarian insufficiency
- hypothalamic
- -functional (decreased GnRH):weight loss and exercise, nutritional deficiencies, emotional stress/illness
- -infiltrative tumors
- pituitary:hyperprolactinemia, sheehan’s syndrome(postpartum hypopituitarism), hypothyroidism
- uterine: Asherman’s syndrome (acquired scarring of cavity), TB
Dx
- BMI, hirsutism, galactorrhea, uterine size
- initial lab: HCG, FSH, TSH, prolactin, possible testosterone and DHEA-S
Dysmenorrhea
- Primary definition
- risk factors
- pathogenesis
- sx
- dx
- tx
Definition
-Painful periods with no obvious cause, typically begins as crampy, midline lower abd pain associated with the onset of menses
Risk factors
- Age under 30
- BMI under 20
- smoking
- menarche less than 12
- irregular/prolonged/heavy menses
- hx of sexual assult
- Family hx
Patho
-prostaglandins released with endometrial sloughing induce contractions
Sx
- may start 1-2 days before menses, gradually diminishes over 12-72 hours
- unilateral pain of non-cyclic pain suggest other dx
- nausea, diarrhea, HA
Dx
-dx by hx and normal exam
Tx
- self care: heating pad, exercise, relaxation
- NSAIDs**
- OCP to supress menses
Dysmenorrhea
- secondary definition
- causes
Definition
- painful periods with Sx attributed to specific problem like endometriosis, adenomyosis, or fibroids
- “i didn’t used to have painful peroids and now I do”
Causes
- endometriosis
- fibroids
- intrauterine/pelvic adhesions
- cervical stenosis
- IUD
- adenomyosis
- ovarian cysts
Abnormal Uterine Bleeding (AUB)
- basic labs for AUB
- What is PALM-COEIN used for? What does it stand for?
Labs
-CBC, prolactin, TSH, HCG, chlamydia
PALM-COEIN is the differential for abnormal uterine bleeding
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulation
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Define each
- Polymeorrhea
- Menorrhagia
- metrorrhagia
- oligomenorrhea
Polymeonorrhea: cycle less than 24 days
Menorrhagia: heavy menstrual bleeding
Metrorrhagia: bleeding between periods
Oligomenorrhea: cycles greater than 35 days
AUB: Coagulation
- MC underlying bleeding disorder
- What to refer for hematologic evaluation
MC underlying bleeding disorder is VonWillebrand’s
In addition to heavy menstrual periods, refer if the also have one of the following:
- hx of postpartum hemorrhage
- hx of unexplained bleeding with surgery
- hx of bleeding with dental work
refer with two of the following
- frequent gum bleeding
- epistaxis or unexplained bruising 2x a month
- family hx of bleeding
AUB: Ovulatory
-cause
caused by chronic unopposed estrogen influence as a result of anovulation or oligo-ovulation
- PCOS
- hypothalamic dysfunction (anorexia)
- thyroid disease
- elevated prolactin
- medication
- iatrogenic
- premature ovarian insufficiency
Go back to slide 31
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AUB: Endometriosis
- what is this
- consequence of endometriosis
- occurs in who
- etiology
What
-cell that behave like the lining of the uterus (endometrium) grow in other areas of the body, causing pain, irregular bleeding, possible infertility (they have their own menstrual cycle)
Consequences
- 20-50% become infertile and 80% have chronic pelvic pain
- large cysts in the pelvis
- depression
Occurs in
- menstruating women
- postmenopausal women on MHT (menopausal hormone therapy): MHT may stimulate an ovarian remnant
Etiology
- not well understood
- therories:
- -retrograde menstruation:endometrial cells loosened during menstruation may “back up” through the fallopian tubes into the pelvis
- -halban theory: vascualr and lymphatic dissemination
- -Meyer Theory: metaplasia of multipotential cell
AUB: Endometriosis
- risk factors
- sx
- MC site
- name of the lesion that this causes
- dx
Risk factors
- Family hx
- starting menstruation at an early age
- never having had children
- frequent menstrual cycles
- peroids that last more than 7 days
- imperforate hymen
Sx
- Pain (MC sx)**
- painful periods, pain in the lower abd or pelvic cramps felt a week or two before menstruation
- pain during or pollowing sex
MC site:
Ovary
Lesions are called endometriomas (chocolate cyst)
Dx
- Pelvic exam:tenderness on exam (best detected at the time of menses), nodularity of the uterosacral ligaments, uterus may be fixed in retroversion
- US: useful to ID chocolate cyst of the ovary
- MRI
- Pelvic laparoscopy: considered the primary diagnostic modality for endometriosis, classic lesions are blue-black or have a powder-burned appearance
What is an endometrioma?
- classic lesion is a chocolate cyst of the ovary that contains old blood that has undergone hemolysis
- intracystic pressure rises, the cyst perforated, spilling its contents within the peritoneal cavity causing the severe abd pain
- inflammatory response causes adhesions that further increase the morbidity of the disease
AUB: Endometriosis
-Tx
GnRH analogs
- used for 6 months to suppress ovulation
- Lupron
OCP
Medroxyprogesterone acetate
- used for 6-9 months, may need oral estrogen for breakthru bleeding
- Provera, Depa-provera
Danazol
- used for 4-6 months
- use lowest dose since it causes weight gain, hirsutism, acne
Aromatase inhibitors
- block synthesis of estrogen
- letrozole
AUB: Malignancy; Endometrial Cancer
- types
- risk factors
- signs and sx
Types:
- Type 1: endometrial adenocarcinoma
- Type 2: papillary serous/clear cell
Risk factors:
- unopposed estrogen** (chronic anovulation=PCOS, obesity. Nulliparity. Exogenous use of estrogen without progesterone. Tamoxifen)
- Genetics: Lynch syndrome
- smoking
Signs and sx:
- abnormal bleeding (postmenopausal, irregular menses, intermenstrual bleeding)
- abd pain, bloating, early satiety, change in bowel/bladder habits
Endometrial CA:
- dx
- tx
- prevention
Dx:
- endometrial bx*
- endometrial US
- vaginal probe US to measure endometrial thickness
Tx:
- total abd hysterectomy and bilateral salpingooophorectomy
- adjuvants: chemo, vaginal brachytherapy
Prevention:
-younger women with chronic anovulation are at risk for endometrial hyperplasia; oral contraceptives or cyclic progestin can reduce risk*
AUB: Leiomyoma
- aka
- what is this?
- cause
- risk factors
aka: uterine fibroids
What; benign, monoclonal smooth muscle tumors of myometrium
Cause:
-estrogen dependent so rarely occurs before menarche or after menopause
Risk factors:
- black
- FHx
- Menarche prior to age 10
- nulliparity
- significant red meat or ham consumption
Uterine Fibroids:
-signs and sx
Signs and sx:
- most women have no sx
- heavy/prolonged menstrual flows
- pelvic pain/pressure/prolapse
- infertility/miscarriage or preterm labor
AUB: Uterine Fibroids
-dx
Pelvic exam:
- uterus usually irregularly enlarged and asymmetric
- tender
- firm
- if mass moves with uterus likely to be leiomyoma..
Lab:
- evaluate for anemia
- UA if urinary sx
- pregnancy test
Imaging;
-usually complete pelvic sono
AUB:Uterine FibroidS:
-tx
heavy bleeding:
- trial of oral contraceptives, progestin implants, or levonorgestrel IUD
- Tranexamic acid (Lysteda)
- endometrial ablation
- uterine artery ablation
- myomectomy (preserves fertility
- hysterectomy*
AUB: Adenomyosis
- what is this?
- signs and sx
- dx
- tx
What: when endometrial tissue grows into the muscular uterine wall. muscle becomes irritated, inflamed, and hypertrophied.
Signs and sx:
- 2ndry dysmenorrhea
- menorrhagia (60%)
- uterine tenderness before and during menses
- uterine enlargement
Dx:
- definitive dx is hysterectomy
- MRI
- US best test to evaluate ovaries and uterus***
Tx:
- hormone manipulation: progestins, aromatase inhibitors, continuous oral contraception
- uterine artery embolization
- hysterectomy
- NSAIDS
AUB: Polyps
- what is this?
- cause
- signs and sx
- dx
- tx
what: localized hyperplastic overgrowth of endometrial glands.
Cause:
-increased estrogen: Tamoxfen, obesity, menopauseal hormone treatment.
Signs and sx:
-abnormal bleeding
Dx:
- dx is by histology*
- transvaginal sono
Tx:
-hysteroscopic removal if symptomatic! (bleeding)
Uterine Prolapse:
- cause
- risk factors
- sx
- dx
- sequelae
Cause: weakening of pelvic floor muscles and ligaments creating inadequate support for the uterus
Risk factors:
- multiparity
- Fhx
- postmenopausal
- obesity, chronic cough, frequent straining with BM
- repetitive heavy lifting
Dx:
-pelvic exam; bear down/cough (valsalva)
Sx:
- heaviness or pressure in pelvis
- tissue bulging
- urinary difficulties such as urine leakage or urine retention
- low back pain
- sensation of sitting on a small ball
- sexual concerns: difficulty with penetration
- sx more bothersome in the afternoon.
Sequelae: ulcers, cystocele, rectocele
Uterine Prolapse
-tx
education and reassurance
healthy weight
kegel exercises
avoid heavy lifting
Pessaries
PMS and PMDD:
- what are these?
- Risk factors
- cause
- sx
what:
PMS: premenstrual syndrome
PMDD: Premenstrual dysphoric disorder
*cyclic physical/behavioral sx that recur in the luteal phase and first few days of menses (present for at least 3mo)
Risk factors:
- genetics
- Hx traumatic events/anxiety disorder
- lower education
- smoking
cause: unknown; may be due to cyclic changes in circulating estrogen and progesterone trigger an abormal serotonin response.
Physical sx:
-abd bloating, extereme fatigue, breast pain, HA, hot flashes, dizziness
Behavioral:
-mood swings*, irritability, anger, depression, anxiety
PMS/PMDD
- dx
- tx
Dx:
- confirm regular menses and cyclic pattern of sx
- no specific test, consider TSH and CBC
- pt complete prospective sx inventory
Tx:
Mild: exercise and relaxation
Mod-severe: SSRI
-refractory to SSRI: induce anovulation with continuous/short pill-free interval OC. (Drospirenone*=steroidal progestin of spirolactone group)
