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OBGYN rotation review > dysmenorrhea and amenorrhea > Flashcards

dysmenorrhea and amenorrhea Flashcards

1
Q

why are women w/ PMDD emotional

A

decreased serotonin in the progesterone dominant luteal phase

progestone increases MAO ⇒ reduces serotonin availability​

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2
Q

pharmacologic treamtent options for PMDD

A

*** SSRIs ***

oral contraceptives

NSAIDs (helps dysmenorrhea, mastodynia, leg edema)

spironolactone (decreases bloating)

GnRH agonists (refractory)

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3
Q

No secondary sex characteristics and high FSH

A

hyper gonadotropic hypogonadism

  • swyer
  • turners
  • POI
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4
Q

secondary amenorrhea initial lab workup

A

urine/ serum hCG

FSH

prolactin

TSH

total testosterone (if hyperandrogenism)

pevlic US

pituitary MRI (if suspect pituitary etiology)

adrenal CT (if virilization + high T)

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5
Q

when evaluating primary amenorrhea, what are you looking for in the thyroid exam

A

goiter

abnormal DTR’s

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6
Q

molimina symptoms

A

breast tenderness

ovulatory pain

bloating

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7
Q

46 XX F

+

menopause before 40

A

Primary Ovarian Insufficiency

presents as secondary > primary amenorrhea

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8
Q

scarring of the endometrial lining

(secondary to postpartm hemorrhage/ uterine instrumentation such as D and C)

A

Ashermans Syndrome

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9
Q

pain not as much related to the first day of menses, not limited to menses

dyspareunia, infertility, AUB

30-40 y/o

A

secondary dysmenorrhea

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10
Q

how do you tx a hemodynamically unstable pt w/ acute AUB

A

admit

IV estrogen

+/- D and C

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11
Q

AUB is defined as menstrual bleeding of abnormal

  • quantity =
  • schedule=
  • duration =
A

AUB is defined as menstrual bleeding of abnormal

  • quantity= more than 80 mL
  • schedule= cycle <24 or >38 days
  • duration = more than 8 days
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12
Q

cyclic pain/ menstrual cramps

primary amenorrhea

hematometra/ hematocolpos

no uterus

A

outflow obstruction:

transverse septum (inside vagina)

or

imperforate hymen

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13
Q

premenstural symptoms affects __% of women

PMS affects __% of women

PMDD affects __% of women

A

premenstural symptoms affects 75% of women

PMS affects 3-8% of women

PMDD affects 2% of women

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14
Q

hematometra

A

blood sequestered in uterus

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15
Q

AUB and you suspect anovulatory bleeding…

what labs/ screening

A

CBC

+/- TSH, prolactin, fasting glucose w/ fasting insulin

screen for eating disorder, stress, female athlete triad

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16
Q

leiomyomas =

A

uterine fibroids

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17
Q

how do you tx a pt w/ chronic AUB

A

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)

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18
Q

how do you treat a stable pt w/ acute AUB

A

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
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19
Q

for a pt of reproductive age, what are the etiologies of

intermenstrual bleeding

A

cervical infection

cervical dysplasia

IUD

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20
Q

what are the common causes of AUB in a 13-18 y/o patient

A
  • ​immature HPO axis ⇒ anovulation
  • oral contraceptives
  • pelvic infection
  • coagulopathy ⇒ menorrhagia
  • tumor
  • primary amenorrhea etiologies
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21
Q

what are the pituitary causes of amenorrhea

A

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

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22
Q

when evaluating a pt for AUB, what systemic disease do you need to r/o

A

anemia

(pallor, weakness, parethesias, bruising, etc)

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23
Q

PMS is related to what phase

A

luteal

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24
Q

AUB classification

A

PALM COEIN

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25
Q

AUB stands for

A

abnormal uterine bleeding

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26
Q

adenomyosis

A

ectopic endometrial tissue within the myometrium

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27
Q

when does primary dysmenorrhea occur

A

during ovulatory cycles

age 17-22

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28
Q

for a pt of reproductive age, what are the etiologies of

oligomenorrhea (infrequent)

A

long follicular phase

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29
Q

for a pt of reproductive age, what are the etiologies of

menorrhagia

A

structural lesions

coagulopathy

liver failure

renal failure

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30
Q

what are the causes of pituitary disease that lead to amenorrhea

A

hyperprolactinemia (from prolactinoma/ meds)

sheehans syndrome

iron deposition

primary hypothyroidism

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31
Q

how would PCOS present

A

amenorrhea

hyperandrogenism

acne

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32
Q

what are the common causes of AUB in a 19-38 y/o patient

A

pregnancy

structural lesions (leiomyoma, polyp)

anovulatory cycles (PCOS)

oral contraceptives

endometrial hyperplasia

endometrial CA

33
Q

at what age and under what circumstances do you need to evaluate primary amenorrhea

A

under 15 with no menarche

or

no menarche w/in 3 years of thelarche

or

under 13 with no menarche/ thelarche

34
Q

how would 17 alpha reductase deficiency present

A

46 XX F

female w/ HTN and primary amenorrhea

35
Q

46 XY M

ambiguous genitalia at birth

at puberty ⇒ virilization (male hair growth, acne, increased muscle mass, deeper voice) but no genital enlargement

+

treatment?

A

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
36
Q

PALM COIEN:

What does PALM stand for?

(AUB classification)

A
  • Structural causes of AUB
    • Polyp
    • Adenomyosis- endometrial tissue grows into uterine wall
    • Leio-myoma- non cancer uterine growth
    • Malignancy and endometrial hyperplasia
37
Q

amenorrhea

+

hyperandrogenism

what’s next?

A

US ⇒ PCOS

38
Q

what specific history questions should you ask when evaluating secondary amenorrhea

A
  • exercise habits/ weight change
  • skin abnormalities/ changes
  • sxs of estrogen deficiency
    • vag dryness, hot flashes, poor sleep, decreased libido
  • galactorrhea
  • HA/ visual field defects
39
Q

first line tx for PMDD

A

SSRIs

40
Q

for a pt of reproductive age, what are the etiologies of

polymenorrhea (short intervals)

A

luteal phase disorder

short follicular phase

41
Q

how would Tuners Syndrome present

A

45 XO

primary amenorrhea

streak ovaries

sexual infantilism

shield chest

broad webbed neck

short

hypergonadotropic (high FSH) hypogonadism

42
Q

hematocolpos

A

blood sequestered in vagina

43
Q

patient presents with primary amenorrhea

+

secondary sexual characteristics

…. what do you do next?

A

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)
44
Q

ovaries don’t respond to gonadotropins ⇒ premature depletion of ooctyes and follicles

streak ovaries

sexual infantilism

hypergonadotropic (high FSH) hypogonadism

A

Turners

45
Q

what are the common causes of AUB in a 40+ y/o patient

A

anovulatory bleeding

endometrial hyperplasia/ carcinomas

endometrial atrophy

leiomyoma

46
Q

46 XX F

female w/ HTN and primary amenorrhea

+

treatment?

A

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)
47
Q

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

A

primary dysmenorrhea

(clinical diagnosis)

48
Q

for a pt of perimenopausal age, what are the etiologies of AUB

A

very common

declining number of ovarian follicles ⇒ anovulation

⇒ longer intermenstrual periods, skipped cycles, and episodes of amenorrhea

49
Q

postpartum amenorrhea

severe hemorrhage

hypotension

A

sheehans syndrome

(secondary amenorrhea)

50
Q

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?

A

muellerian agenesis

  • treatment
    • counseling
    • sx to create vagina + vaginal dilation
    • Assisted Reproduction Techniques
      • egg harvesting
      • IVF
      • surrogate pregnancy
    • uterine transplant
51
Q

how do transverse septum/ imperforate hymen present

A

cyclic pain/ menstrual cramps

primary amenorrhea

hematometra/ hematocolpos

no uterus

52
Q

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

A

swyer syndrome

53
Q

how would Swyer Syndrome present

A

46 XY male with

female internal and external genitalia

54
Q

primary amenorrhea initial lab workup

A

urine/ serum HCG

serum FSH

prolactin

TSH

pelvic US

55
Q

postpartum pituitary necrosis ⇒ secondary amenorrhea

leads to

severe hemorrhage

hypotension

A

sheehans syndrome

56
Q

when do you need to evaluate perimenopausal AUB further

A

if the bleeding is frequent, heavy, or prolonged

⇒ endometrial biopsy (EMB) to r/o hyperplasia and CA

57
Q

how would hypothalamic amenorrhea present

A

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

58
Q

mullerian agenesis

A

46 XX w/ no fallopian tubes/ uterus/ upper vagina (short vagina)

ovaries develop normally ⇒ normal estrogen and progesterone ⇒ normal breast development and FSH

59
Q

patient presents with primary amenorrhea

but

NO secondary sexual characteristics

…. what do you do next?

A

check FSH

  • low ⇒ hypogonadotropic hypogonadism
    • hypothalamic
    • pituitary
  • high ⇒ hypergonadotropic hypogonadism ⇒ karyotype
    • 46 XY = Swyer
    • 45 XO = Turners
    • 46 XX = Premature Ovarian Insufficiency
60
Q

who should get an endometrial biopsy

A

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

61
Q

how would Primary Ovarian Insufficiency present

A

46 XX

+

menopause before 40

62
Q

common causes of secondary dysmenorrhea

A

endometriosis

adenomyosis

adhesions

PID

leiomyomas

inflammation/ infection

IUD

63
Q

when evaluating primary amenorrhea, what are you looking for in the skin exam

A

acne

virilization/ hirsuitism (male hair pattern)

axillary hair growth

pubic hair growth

64
Q

when evaluating primary amenorrhea, make sure to look at the development of

A

breasts

external genitalia

presence/ absence of uterus

65
Q

what are the most common etiologies of AUB

(AUB accounts for 1/3 GYN visits)

A

anovulation

structural uterine pathology

hemostasis disorders

neoplasia

66
Q

endometriosis

A

endometrial glands outside the uterus

67
Q

No secondary sex characteristics and low FSH

A

hypogonadotropic hypogonadism

  • hypothalamic problem
    • female triad
    • Kallmans
  • pituitary problem
    • tumor
68
Q

what specific history questions should you ask when evaluating primary amenorrhea

A
  • 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
69
Q

PALM COIEN:

What does COIEN stand for?

(AUB classification)

A
  • Non-structural causes of AUB
    • Coagulopathy
    • Ovulatory dysfunction
    • Endometrial
    • Iatrogenic (anticoags, hormonal contraceptives)
    • Not otherwise classified
70
Q

for a pt of POSTmenopausal age, what are the etiologies of postmenopausal bleeding

A

ABNORMAL!!!

endometrial carcinoma

assess w/ pelvic US or endometrial biopsy (EMB)

71
Q

intermenstrual bleeding, what extra diagnostic tests?

A

pap smear

cervical cx

72
Q

how would androgen insensitivity syndrome present

A

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

73
Q

primary dysmenorrhea treatment options

A

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)

74
Q

what drugs can cause secondary amenorrhea

A

antipsychotics (risperidone)

antidepressants

cimetidine (H2 blocker)

anti-HTN (methyldopa, verapamil)

metoclopropamide (reglan)

(cause hyperprolactinemia)

75
Q

how would Kallmans syndrome present

A

ansomia

primary amenorrhea

hypogonadotropic hypogonadism

76
Q

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?

A

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
77
Q

what are some non-pharmacologic things that patients can do to manage menstrual cycle sxs

A

decrease salt, caffeine, ETOH

aerobi exercise

Mg and Ca supplements

acupuncture, yoga

78
Q

menorrhagia and you suspect ovulatory bleeding…

what labs/ screening

A

CBC

pelvic US (to r/o uterine fibroids)

+/- LFTs, BUN/creatinine, coags

+/- EMB (to r/o endometrial hyperplasia)

OBGYN rotation review (14 decks)

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