E1: Menstrual Disorders Flashcards
What is the average age of menarche?
Average age of menopause?
Menarche: 12-13
Menopause: 51
What are the 3 things that regular and spontaneous menstruation requires?
1) a functional hypothalamic-pituitary-ovarian axis
2) an endometrium competent to response to steroid hormone stimulation
3) an intact outflow tract from internal to external genitalia
What is primary amenorrhea?
Failure to reach menarche
-absence of messes by age 15 with normal growth and secondary sexual characteristics OR absence of menses by age 13 without secondary sexual characteristics
What is secondary amenorrhea?
- Cessation of menses
- absence of menses for more than 3 cycle intervals or 6 consecutive months in women who were previously menstruating
What are the etiologies of primary amenorrhea and which is most common?
- Ovarian dysfunction (gonadal dysgenesis and PCOS) is MOST COMMON
- Disruption of hypothalamic or pituitary function
- anatomic defects in outflow tract
- receptor abnormality or enzyme deficiency
What are the two conditions that gonadal dysgenesis can cause that are associated with primary amenorrhea?
- Turner syndrome
- 46 XY gonadal dysgenesis
What happens in Turner syndrome?
- 46, XO
- ovaries are unable to response to gonadotropins
- results in premature depletion of oocytes and follicles
Patient presents with have a short stature, shield chest, and widely spaced nipples. Patient also has streaked ovaries and sexual infantilism. What condition do they most likely have?
Turner syndrome
What happens in 46, XY gonadal dysgenesis?
- Mutation of the SRY gene
- fibrous streak gonad cannot secrete AMH or testosterone, resulting in indifferent gonads failing to differentiate into testes
- Lack of AMH, testosterone, and DHT results in female internal and external genitalia
What is PCOS?
- Ovulatary dysfunction resulting in anovulation (rarely a cause of primary amenorrhea)
- androgen excess
- symptoms of hyperandrogenism
- String of pearls appearance on US
What is functional hypothalamic amenorrhea?
- primary amenorrhea from the HPO axis being suppressed due to an a energy deficit stemming from stress, weight loos, excessive exercise or disordered eating (female athlete triad)
- leads to abnormal GnRH secretion, absent follicular development and ovulation, and low estradiol secretion
- FSH levels are often normal, with low LH
What is the female athlete triad?
Insufficient calorie intake with or without eating disorder, amenorrhea, and low bone density/osteoporosis
What is idiopathic hypogonadotropic hypogonadism?
- Congenital GnRH deficiency, Kallmann syndrome if anosmia is present
- cause of primary amenorrhea
What are the two pituitary causes of primary amenorrhea?
- Micro/macroadenomas (cushings, prolactinoma, etc)
- Hyperprolactinemia (though more commonly causes secondary amenorrhea)
What are the outflow tract disorders that can cause primary amenorrhea?
- Mullerian agenesis
- imperforate hymen or transverse vaginal septum
**these are common causes of primary amenorrhea
What is mullerian agenesis?
- 46 XX with congenital absence of the oviducts, uterus, and upper vagina
- normal gonadal function (estrogen= breast development)
What are the symptoms associated with imperforate hymen and transverse vaginal septum?
Cyclic pelvic pain and perirectal mass from sequestration of blood in the vagina
What are the receptor/enzyme abnormalities than can result in primary amenorrhea?
- Androgen insensitivity syndrome
- 5-alpha-reductase deficiency
- 17-alpha-hydroxylase deficiency
What is Androgen Insensitivity syndrome (AIS)?
- 46 XY with female phenotype and high serum testosterone
- Testes make testosterone and AMH but the body is not response to testosterone or DHT due to complete or partial androgen receptor insensitivity
What is the clinical presentation of AIS?
- Presents with breast development, absence of acne/voice changes at puberty, absent/sparse axillary and pubic hair
- Absent upper vagina, uterus, and Fallopian tubes on pelvic US
- testes remain intra-abdominal or partially descended and should be removed due to increased risk of testicular cancer
What is 5-alpha-reductase deficiency?
- 46 XY unable to convert testosterone to DHT, resulting in no differentiation of male genitalia during fetal development and ambitious genitalia at birth
- Undergoes virtualization at puberty, but no enlargement of external genitalia or prostate
What is is 17-alpha-hydroxylase deficiency?
- decreased cortisol synthesis and lack of sex steroids
- high ACTH leads to overproduction of aldosterone
- Results in a phenotypic female or male with HTN and lack of pubertal development
What conditions that cause primary amenorrhea have high FSG?
Hypergonadotropic Hypogonadism (turner, 46 XY gonadal dysgenesis, and primary ovarian insuffiency
What are the possible etiologies of secondary amenorrhea and what is the most common?
- Pregnancy is MOST COMMON
- ovarian dysfunction
- hypothalamic dysfunction
- pituitary dysfunction
- uterine dysfunction
What are the three types of ovarian dysfunction that cause secondary amenorrhea?
PCOS, primary ovarian insufficiency, and hyperandrogenism
What is primary ovarian insufficiency and what causes it?
- Depletion of oocytes before age 40, resulting in clinical menopause
- caused by Turner syndrome, FMR1 gene mutation (Fragile X), autoimmune ovarian destruction, radiation, or chemo
What are the potential pituitary causes of secondary amenorrhea?
- Hyperprolactinemia (due to prolactinoma or medication induced)
- Sheehan syndrome
- iron deposition (hemochromotosis)
- primary hypothyroidism
What is Sheehan syndrome?
Hypopituitarism caused by ischemic necrosis due to severe hemorrhage and hypotension during and after childbirth
What is Asherman syndrome?
- Acquired scarring of the endometrial lining caused by uterine instrumentation during GYN or OB procedures
- May cause secondary amenorrhea
When should you initiate evaluation for primary amenorrhea?
- Age 15 if no uterine bleeding has occurred
- Age 13 if no menses and no evidence of thelarche
- No menarche within 3 years of thelarche
What should be included in the initial work up of amenorrhea?
- Urine or serum HCG
- FSH
- TSH
- Prolactin
- possible pelvic US
If a patient presents with primary amenorrhea, has low/normal FSH, breast development and an absent uterus, what should you suspect and what should you order to test for it?
Mullerian agenesis
-order karyotype and total testosterone to rule out AIS
If a patient presents with primary amenorrhea, has low/normal FSH, breast development, and a uterus is present, what should you suspect and what should you order to test for it?
Endocrine disorder (PCOS, thyroid, etc) -If there is evidence of hyperandrogenism, order a total T and DHEA
What imaging can you order for secondary amoenorrhea?
- Pelvic US
- Pituitary MRI if suspect pituitary pathology
- Adrenal CT if significant virulization and elevated testosterone
What vaginal bleeding is considered abnormal?
- Bleeding or spotting between periods or after sex.
- Heavy menstrual bleeding
- Menstrual cycles that are >38 days or < 24 days
- Bleeding after menopause
What are the most common etiologies of abnormal uterine bleeding?
-Anovulation, structural uterine pathology, bleeding disorders and uterine neoplasm
What does PALM-COEIN stand for?
Polyp
- adenomyosis
- Leiomyoma
- Malignancy
- coagulopathy
- ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not otherwise classified
What is the most common cause of abnormal uterine bleeding in 13-18 year olds?
Persistent anovulation due to immature HPO axis
What are the most common causes of abnormal uterine bleeding in 19-39 year olds?
- Pregnancy
- Structural lesions (leiomyoma, polyps)
What is the most common cause of abnormal uterine bleeding in 40+?
- Anovulatory bleeding
- endometrial hyperplasia and carcinomas
What is anovulatory AUD?
- Unpredictable bleeding, varying in amounts and intervals
- related to hypothalamic abnormalities or PCOS
What is ovulatory AUB?
- Regular cycle and length with molimina symptoms
- menorrhagia and intermenstrual bleeding
What is menorrhagia commonly associated with?
Structural lesions, coagulation disorders, liver or chronic renal failure
What is intermenstrual bleeding commonly due to?
Cervical pathology (infection do dysplasia) or an IUD
What is perimenopause?
Abnormal bleeding in the 5-10 years prior to menopause
What is the most common pathology of perimenopause AUB?
Anovulation due to declining numbers of ovarian follicles
Bleeding that is frequent, heavy, or prolonged should be evaluated with *** to exclude **.
Endometrial biopsy
Endometrial hyperplasia or cancer
What is postmenopausal bleeding concerning for?
Endometrial carcinoma
Who should undergo endometrial biopsy sampling?
- Age >45 with AUB and postmenopausal women with ANY uterine bleeding
- Age <45 with AUB and risk factors for unopposed estrogen exposure, persistent bleeding, or failed medical management for AUB
What is the inpatient management of acute AUB?
- Admit with heavy bleeding and signs or symptoms of hemodynamics instability
- treat with IV estrogen or possible D&C
What is the outpatient management of acute AUB?
- Combined oral contraceptives (Monophysite pill with 35mcg ethinyl estradiol, 3 pills qd x7 days) OR
- Medoxyprogesterone orally OR
- high dose Estrogen
- tranexamic acid IV or oral
What is the medical treatment of chronic AUB?
- Hormone therapy of either levonorgestrel IUD, Depo, or estrogen/progestin OCP
- tranexamic acid
- NSAIDs
What are the surgical options for chronic AUB?
- Endometrial ablation
- Hysterecomty (extreme cases)
What is primary dysmenorrhea?
Painful menstruation in the absence of disease
What is secondary dysmenorrhea?
Painful menstruation due to organic pelvic disease, more common as the women ages
Why does primary dysmenorrhea occur?
The corpus luteum causes a peak in progesterone, which in turn increases PG production in the uterus. If the ovum is not fertilized, menstruation occurs. PGs are released from the endometrium during cell lysis causes uterine contractions and ischemia
How is primary dysmenorrhea diagnosed?
Clinically
What is the first line therapy for primary dysmenorrhea?
NSAIDs
When should you refer for primary dysmenorrhea?
- pain worsening with each menses
- pain lasts longer than the first 2 days of menses
- medication is no longer controlling the pain
- menstrual bleeding becomes increasingly heavy
- pain accompanied by fever
- pain occurs at times unrelated to menses
What other symptoms are commonly associated with secondary dysmenorrhea?
Dyspareunia, infertility, or AUB
What are the common causes of secondary dysmenorrhea?
- endometriosis
- adenomyosis
- adhesions
- PID
- Leiomyomas (uterine fibroid)
What is the treatment of secondary dysmenorrhea?
- Treat the underlying cause
- Hormone therapy with COGs
- Complicated cases may require surgery
What is pre-menstrual syndrome (PMS)?
A group of physical and behavioral changes that occur in a regular, cyclic relationship to the luteal phase that interfere with some aspect of the patients life
What is premenstrual dysphoric disorder (PMDD)?
PMS with more severe emotional symptoms
What is the diagnostic criteria for PMS?
- 1-4 symptoms that are physical, behavioral, or psychological in nature, OR >5 symptoms that are physical or behavioral
- presence of at least one symptom occurring the luteal phase
- leads to impairment in functioning
- symptoms remit at menses
What is the diagnostic criteria for PMDD?
One or more of the following must be present:
-mood swings
-sense of hopelessness
-anger, irritability
-tension, anxiety
AND one or most of the following:
-Difficulty concentrating, change in appetite, diminished interest, fatigue, feeling overwhelmed, sleep changes, breast tenderness/bloating/weight gain
**at least 5 total must be present
What is the first line therapy for PMDD?
SSRIs
