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*
