dysmenorrhea and amenorrhea Flashcards
why are women w/ PMDD emotional
decreased serotonin in the progesterone dominant luteal phase
progestone increases MAO ⇒ reduces serotonin availability
pharmacologic treamtent options for PMDD
*** SSRIs ***
oral contraceptives
NSAIDs (helps dysmenorrhea, mastodynia, leg edema)
spironolactone (decreases bloating)
GnRH agonists (refractory)
No secondary sex characteristics and high FSH
hyper gonadotropic hypogonadism
- swyer
- turners
- POI
secondary amenorrhea initial lab workup
urine/ serum hCG
FSH
prolactin
TSH
total testosterone (if hyperandrogenism)
pevlic US
pituitary MRI (if suspect pituitary etiology)
adrenal CT (if virilization + high T)
when evaluating primary amenorrhea, what are you looking for in the thyroid exam
goiter
abnormal DTR’s
molimina symptoms
breast tenderness
ovulatory pain
bloating
46 XX F
+
menopause before 40
Primary Ovarian Insufficiency
presents as secondary > primary amenorrhea
scarring of the endometrial lining
(secondary to postpartm hemorrhage/ uterine instrumentation such as D and C)
Ashermans Syndrome
pain not as much related to the first day of menses, not limited to menses
dyspareunia, infertility, AUB
30-40 y/o
secondary dysmenorrhea
how do you tx a hemodynamically unstable pt w/ acute AUB
admit
IV estrogen
+/- D and C
AUB is defined as menstrual bleeding of abnormal
- quantity =
- schedule=
- duration =
AUB is defined as menstrual bleeding of abnormal
- quantity= more than 80 mL
- schedule= cycle <24 or >38 days
- duration = more than 8 days
cyclic pain/ menstrual cramps
primary amenorrhea
hematometra/ hematocolpos
no uterus
outflow obstruction:
transverse septum (inside vagina)
or
imperforate hymen
premenstural symptoms affects __% of women
PMS affects __% of women
PMDD affects __% of women
premenstural symptoms affects 75% of women
PMS affects 3-8% of women
PMDD affects 2% of women
hematometra
blood sequestered in uterus
AUB and you suspect anovulatory bleeding…
what labs/ screening
CBC
+/- TSH, prolactin, fasting glucose w/ fasting insulin
screen for eating disorder, stress, female athlete triad
leiomyomas =
uterine fibroids
how do you tx a pt w/ chronic AUB
hormone therapy- mirena IUD/ depo/ estrogen-progestin OCP
tranexamic acid- 3x daily up to 5 days during menses
NSAIDs for the entirety of menses
endometrial ablation
hysterectomy (extreme cases)
endometrial artery embolization/ myomectomy (leiomyomas)
how do you treat a stable pt w/ acute AUB
hormonal treatents
- combo oral contraceptives
- monophasic tab w/ 35 mcg ethinyl estradiol (3 tabs Q daily x 7 days)
- medroxyprogesterone PO
- HD estrogen PO w/ anti-emetic
non-hormonal treatment
- tranexamic acid IV or oral
for a pt of reproductive age, what are the etiologies of
intermenstrual bleeding
cervical infection
cervical dysplasia
IUD
what are the common causes of AUB in a 13-18 y/o patient
- immature HPO axis ⇒ anovulation
- oral contraceptives
- pelvic infection
- coagulopathy ⇒ menorrhagia
- tumor
- primary amenorrhea etiologies
what are the pituitary causes of amenorrhea
adenomas (cushings disease/ prolacinomas/ thyrotropinomas)
isolated hyperprolactinemia w/ galactorrhea (more commonly secondary amenorrhea cuased by hypothyroidism/ meds)
infiltrative dz and or tumors that compress the pituitary stalk
when evaluating a pt for AUB, what systemic disease do you need to r/o
anemia
(pallor, weakness, parethesias, bruising, etc)
PMS is related to what phase
luteal
AUB classification
PALM COEIN
AUB stands for
abnormal uterine bleeding
adenomyosis
ectopic endometrial tissue within the myometrium
when does primary dysmenorrhea occur
during ovulatory cycles
age 17-22
for a pt of reproductive age, what are the etiologies of
oligomenorrhea (infrequent)
long follicular phase
for a pt of reproductive age, what are the etiologies of
menorrhagia
structural lesions
coagulopathy
liver failure
renal failure
what are the causes of pituitary disease that lead to amenorrhea
hyperprolactinemia (from prolactinoma/ meds)
sheehans syndrome
iron deposition
primary hypothyroidism
how would PCOS present
amenorrhea
hyperandrogenism
acne
what are the common causes of AUB in a 19-38 y/o patient
pregnancy
structural lesions (leiomyoma, polyp)
anovulatory cycles (PCOS)
oral contraceptives
endometrial hyperplasia
endometrial CA
at what age and under what circumstances do you need to evaluate primary amenorrhea
under 15 with no menarche
or
no menarche w/in 3 years of thelarche
or
under 13 with no menarche/ thelarche
how would 17 alpha reductase deficiency present
46 XX F
female w/ HTN and primary amenorrhea
46 XY M
ambiguous genitalia at birth
at puberty ⇒ virilization (male hair growth, acne, increased muscle mass, deeper voice) but no genital enlargement
+
treatment?
5 alpha reductase deficiency
can’t change T ⇒ DHT
don’t undergo DHT dependent masculinization as a fetus
- treatment: counseling to decide on gender identity
- male ⇒ DHT therapy
- female ⇒ estrogen therapy
PALM COIEN:
What does PALM stand for?
(AUB classification)
- Structural causes of AUB
- Polyp
- Adenomyosis- endometrial tissue grows into uterine wall
- Leio-myoma- non cancer uterine growth
- Malignancy and endometrial hyperplasia
amenorrhea
+
hyperandrogenism
what’s next?
US ⇒ PCOS
what specific history questions should you ask when evaluating secondary amenorrhea
- exercise habits/ weight change
- skin abnormalities/ changes
- sxs of estrogen deficiency
- vag dryness, hot flashes, poor sleep, decreased libido
- galactorrhea
- HA/ visual field defects
first line tx for PMDD
SSRIs
for a pt of reproductive age, what are the etiologies of
polymenorrhea (short intervals)
luteal phase disorder
short follicular phase
how would Tuners Syndrome present
45 XO
primary amenorrhea
streak ovaries
sexual infantilism
shield chest
broad webbed neck
short
hypergonadotropic (high FSH) hypogonadism
hematocolpos
blood sequestered in vagina
patient presents with primary amenorrhea
+
secondary sexual characteristics
…. what do you do next?
Ultrasound!
- uterus present ⇒
- imperforate hyman and transverse septum (outflow obstruction)
- no uterus ⇒ karyotype
- 46XX = muellerian agenesis (no upper vagina/ oviducts/ uterus)
- 46 XY = androgen insensitivity syndrome (boobs + internal testes)
ovaries don’t respond to gonadotropins ⇒ premature depletion of ooctyes and follicles
streak ovaries
sexual infantilism
hypergonadotropic (high FSH) hypogonadism
Turners
what are the common causes of AUB in a 40+ y/o patient
anovulatory bleeding
endometrial hyperplasia/ carcinomas
endometrial atrophy
leiomyoma
46 XX F
female w/ HTN and primary amenorrhea
+
treatment?
17 alpha hydroxylase deficiency
no adrenal or sex hormone synthesis so all the precursors get shunted to making mineralocorticoids (aldosterone precursors) ⇒ hypernatremia + hypokalemia + HTN
- hydrocortisone/dexamethosone (normalize BP)
- spironolactone (to counter excess aldosterone precursors)
- LD estrogen (induce development of secondary sex characteristics)
1st day of period onset and lasts 12-72 hours:
cramp like, intermittent, lower abdominal pain, radiates to lower back/upper thighs
N/V/D
HA
hypotension
fatigue
primary dysmenorrhea
(clinical diagnosis)
for a pt of perimenopausal age, what are the etiologies of AUB
very common
declining number of ovarian follicles ⇒ anovulation
⇒ longer intermenstrual periods, skipped cycles, and episodes of amenorrhea
postpartum amenorrhea
severe hemorrhage
hypotension
sheehans syndrome
(secondary amenorrhea)
46 XX
w/ no fallopian tubes/ uterus/ upper vagina (short vagina)
ovaries develop normally ⇒ normal estrogen and progesterone ⇒ normal breast development and FSH
what’s the treatment?
muellerian agenesis
- treatment
- counseling
- sx to create vagina + vaginal dilation
- Assisted Reproduction Techniques
- egg harvesting
- IVF
- surrogate pregnancy
- uterine transplant
how do transverse septum/ imperforate hymen present
cyclic pain/ menstrual cramps
primary amenorrhea
hematometra/ hematocolpos
no uterus
46XY M
SRY gene is mutated ⇒ gonads don’t differentiate into testes ⇒ no testosterone/ DHT/ AMH = no secondary sex characteristics
female internal and external genitalia
hypergonadotrophic hypogonadism
swyer syndrome
how would Swyer Syndrome present
46 XY male with
female internal and external genitalia
primary amenorrhea initial lab workup
urine/ serum HCG
serum FSH
prolactin
TSH
pelvic US
postpartum pituitary necrosis ⇒ secondary amenorrhea
leads to
severe hemorrhage
hypotension
sheehans syndrome
when do you need to evaluate perimenopausal AUB further
if the bleeding is frequent, heavy, or prolonged
⇒ endometrial biopsy (EMB) to r/o hyperplasia and CA
how would hypothalamic amenorrhea present
amenorrhea (primary or secondary)
hypogonadotropic hypogonadism
hx of eating disorder, WL, stress, female athletes triad
low GNRH ⇒ low/ no FSH and LH ⇒ low follicular development and estradiol
mullerian agenesis
46 XX w/ no fallopian tubes/ uterus/ upper vagina (short vagina)
ovaries develop normally ⇒ normal estrogen and progesterone ⇒ normal breast development and FSH
patient presents with primary amenorrhea
but
NO secondary sexual characteristics
…. what do you do next?
check FSH
- low ⇒ hypogonadotropic hypogonadism
- hypothalamic
- pituitary
- high ⇒ hypergonadotropic hypogonadism ⇒ karyotype
- 46 XY = Swyer
- 45 XO = Turners
- 46 XX = Premature Ovarian Insufficiency
who should get an endometrial biopsy
all postmenopausal women w/ any uterine bleeding
pts > 45 w/ ovulatory AUB or bleeding is frequent/heavy/lasts more than 5 days
pts < 45 w/ AUB plus obese/ chronic anovulation/ PCOS/ persistent bleeding/ refractory
how would Primary Ovarian Insufficiency present
46 XX
+
menopause before 40
common causes of secondary dysmenorrhea
endometriosis
adenomyosis
adhesions
PID
leiomyomas
inflammation/ infection
IUD
when evaluating primary amenorrhea, what are you looking for in the skin exam
acne
virilization/ hirsuitism (male hair pattern)
axillary hair growth
pubic hair growth
when evaluating primary amenorrhea, make sure to look at the development of
breasts
external genitalia
presence/ absence of uterus
what are the most common etiologies of AUB
(AUB accounts for 1/3 GYN visits)
anovulation
structural uterine pathology
hemostasis disorders
neoplasia
endometriosis
endometrial glands outside the uterus
No secondary sex characteristics and low FSH
hypogonadotropic hypogonadism
- hypothalamic problem
- female triad
- Kallmans
- pituitary problem
- tumor
what specific history questions should you ask when evaluating primary amenorrhea
- timeline of other stages of puberty
- neonatal and childhood health
- time of menarche in mother/ sisters
- height compared to other family members
- sex activity/ stress/ WL/ diet/ exercise/ illness
- sxs of virilization (male development)
- galactorrhea
- HA/ visual field defects
- anosmia
- hx of head trauma
PALM COIEN:
What does COIEN stand for?
(AUB classification)
- Non-structural causes of AUB
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic (anticoags, hormonal contraceptives)
- Not otherwise classified
for a pt of POSTmenopausal age, what are the etiologies of postmenopausal bleeding
ABNORMAL!!!
endometrial carcinoma
assess w/ pelvic US or endometrial biopsy (EMB)
intermenstrual bleeding, what extra diagnostic tests?
pap smear
cervical cx
how would androgen insensitivity syndrome present
46 XY F
female external genitalia + breasts + no acne + amenorrhea + elevated T
US ⇒ no upper vagina/ uterus/ fallopian tubes BUT has un/partially descended testes
primary dysmenorrhea treatment options
heat, massage, exercise, yoga, increase dairy and vit B, smoking cessation
NSAIDs (ibuprofen 400 mg, 1 tab PO Q 4-6 hours x 3-4 days)
hormonal contraceptives
laparoscopy/ GnRH analogue (refractory)
what drugs can cause secondary amenorrhea
antipsychotics (risperidone)
antidepressants
cimetidine (H2 blocker)
anti-HTN (methyldopa, verapamil)
metoclopropamide (reglan)
(cause hyperprolactinemia)
how would Kallmans syndrome present
ansomia
primary amenorrhea
hypogonadotropic hypogonadism
46 XY F
female external genitalia + breasts + no acne + amenorrhea + elevated T
US ⇒ no upper vagina/ uterus/ fallopian tubes BUT has un/partially descended testes
+
treatment?
androgen insensitivity syndrome
problem w/ androgen receptor ⇒ testes make testosterone and AMH but body doesn’t respond to it
- treatment
- surgical removal of testes (CA risk)
- counseling
- vag surgery
- vag dilation
what are some non-pharmacologic things that patients can do to manage menstrual cycle sxs
decrease salt, caffeine, ETOH
aerobi exercise
Mg and Ca supplements
acupuncture, yoga
menorrhagia and you suspect ovulatory bleeding…
what labs/ screening
CBC
pelvic US (to r/o uterine fibroids)
+/- LFTs, BUN/creatinine, coags
+/- EMB (to r/o endometrial hyperplasia)
