Lecture 4: Menstrual Disorders Flashcards
What is menarche?
How long after 1st menarches is first ovulation?
onset of menses (period)
1st ovulation = 6-9 months after 1st menses
What 2 hormones dominate the follicular phase (day 0-14)?
which is more dominant day 0-5?
What causes ovulation on day 14?
What hormone predominates during luteal/secretory phase (day 14-28)
follicular = Estrogen and FSH
Estrogen = day 0-5
ovulation: d/t LH surge
luteal phase = progesterone
3 possible definitions of primary amenorrhea:
What is a marker of ovarian fxn?
Absence of menses:
1. before age 16 in presence of norm pubertal development
- before age 14 in ABSENCE of norm pub. development
- 2 yrs after sexual maturity
breast exam = marker of ovarian fxn
pt has low/normal FSH, what type of problem do they have? Where is problem if FSH is high?
low FSH –> hypothal or pituitary problem
high FSH –> ovarian problem
3 major classification of primary amenorrhea
- Ovarian failure
- Outflow Tract (Uterus problem)
- Obstruction
Ovarian Failure:
- what labs seen?
- what is present/absent?
- What is MC cause of ovarian failure?
Ovarian Failure:
- Labs - high FSH/LH, LOW estradiol
- what is present/absent?
- no breasts but + uterus - What is MC cause of ovarian failure?
- Gonadal Dysgenesis
Infertile patient presents w/webbed neck, short stature, heart defects and learning disabilities…Dx?
What is this d/o assoc w/?
Turner Syndrome (45, X0)
Congenital cause of Gonadal Dysgenesis
Turner Syndrome:
- What is it?
- What does no ovaries lead to?
- How to Dx?
- Tx ?
- partial or complete loss of X chrom
- no ovaries –> “gonadal streak” (fibrous tissue)
- Dx = karotype
- replace estrogen + give progesterone to induce menses/shed lining
Outflow tract problem:
What is Mullerian agenesis? Result of this?
Mullerian agenesis = congenital malformation of mullerian duct (forms vagina, uterus, etc) –> NO uterus + shortened vagina
How does Mullerian Agenesis differ from Turner’s?
what is the Tx for Mullerian Agenesis
Mullerian Agenesis
- breasts present
- NO uterus
- normal karyotype
- norm hormone levels
- Tx = surgical reconstruction of vag
Turner’s
- NO breasts
- Uterus present
- abn karyotype
- abn hormone levels
2 types of obstruction for primary amenorrhea?
are breasts and a uterus present? hormone levels?
What are the Sxs?
Tx?
- Imperforate Hymen
- Transverse vaginal septum
both breasts and uterus are present; hormone levels normal
Sxs = retention –> cyclic abd pain, bloating/ distended abd
Tx = surgery
How does imperforate hymen and transverse vaginal septum cause obstruction?
imperforate hymen
- hymen doest perf during dev –> blocks vagina
transverse vaginal septum
- wall of tissue blocking the vagina
definition of secondary amenorrhea?
MC cause?
absence of menstruation:
- > 3 months (cycles) in pts w/prev prior reg cycles or..
- 6 mo in pts w/irreg cycles
MC cause = preg
Pt presents w/ body habitus (thin), hirustism/acne, galactorrhea, dry/atrophic vagina and dyspareunia. But uterus present/normal size.
What type of d/o does she have?
secondary amenorrhea
Progestin Withdrawal test:
- what does it determine?
- how performed?
What is a + withdrawal bleed
- what does this indicate
- Tx?
What 2 things are a/w (-) withdrawal bleed
- determine if estrogen defic or ovulation prob
- Give pt Provera (medroxyprogesterone) for 10 days–> look for withdrawal bleed
+ withdrawal bleed = bleeding 2-7 days after complete provera
- ovarian problem –> pt not ovulating
- Tx = OCPs
(-) withdrawal bleed = estrogen defic or outflow problem
What is the hypothalamus d/o related to 2ndary amenorrhea?
Functional Hypothalmic Amenorrhea
Pt has low FSH, LH, and estradiol; norm PRL. She has admitted to wt loss d/t excessive exercising lately. You find out she has already been Dx w/AN. What is Tx?
Tx = nutrition, OCPs (estrogen)
Dx = Functional Hypothalmic Amenorrhea
What is the female athlete triad?
- eating d/o (AN)
- amenorrhea
- Osteopenia
What are the 2 pituitary d/o related to 2ndary amenorrhea?
Labs seen? (what is incr/result)
- Sheehan Syndrome
- Pituitary adenoma
decr FSH, LH and estradiol
INCR PRL –> galactorrhea
What is Sheehan syndrome d/t, who occur in and result?
How to Dx/Tx?
Hemorrhage in postpartum pt –> HotN and infarct/necrosis of pituitary gland
Dx = MRI
Tx = replace pituitary hormones
What are the 2 ovary d/o related to 2ndary amenorrhea?
- Premature Ovarian failure
2. PCOS (polycystic ovarian syndrome)
Premature Ovarian failure:
- what is it? age?
- Presentation (what are Sxs similar to)
- Hallmark?
- how to Tx?
early menopause (< 40)
- Sxs = similar to menopause (hot flashes, atrophic/dry vag, etc)
- hallmark = incr FSH
- Tx = HRT (estro + progest), Vit D and Ca
What are the 4 main signs of PCOS?
- hyperandrogenism
- obesity
- Irreg pds (oligo/amenorrhea)
- Anovulatary bleeding
How to Dx/what seen and how to Tx PCOS?
US –> polycystic ovaries
Tx = OCPs, metformin
Main uterine d/o a/w 2ndary amenorrhea?
Ashermann Syndrome
What is Ashermann Syndrome?
- MC cause?
intrauterine adhesions/fibroids
MC caused by D&Cs
What can be used to Dx AND Tx of Ashermann Syn?
- what see on Pelvic US
other Tx?
Dx + Tx = Hysteroscopy
- can use it to remove adhesions
- pelvis US –> no norm uterine stripe
Other Tx = estrogen –> endometrial regen
Definition of dysmenorrhea?
pain w/menstrual cycle (cyclic)
Difference b/t primary dysmenorrhea and secondary?
what are each d/t?
Primary
- no pelvic pathology (d/t incr PGs)
- pain is during 1st 2-3 days of cycle
Secondary
- pathology (MC
= endometriosis)
- new onset pain
Mainstay of Tx for dysmenorrhea?
Other 2 Tx options?
- what no given?
other 2 supportive Tx options?
- NSAIDs + OCPs
Others
- IUDs (NOT COPPER–> more pain)
- Depo Provera
Supportive Tx
- heat, Vit E
What NSAIDs given for dysmenorrhea?
When should they be given?
How do they work to decr pain a/w dysmenorrhea?
- Ibuprofen
- Naproxen Sodium
Start 1-2 days before menses and continue for 2-3 days
decr PGs –> less inflam–> less pain
Definition of endometriosis? result?
MC sites?
Theory for pathogenesis?
growth of endometrial tissue outside the uterine cavity (ectopic) –> inflammatory response (pain)
MC = ovary (and ant/post cul-de-sac)
retrograde menstruation –> backflow of cells thru fallopian tubes to peritoneal cavity
Classic triad a/w endometriosis?
3 other signs:
“PAIN”
- Cyclic pelvic pain
- Dysmenorrhea
- Dyspareunia
others
- dyschezia
- infertility
- urinary Sxs
2 Signs on PE indicating endometriosis?
Gold std = for Dx?
- see raised patches of thickened, discolored, scarred or powder burned implants of tissue
- Tender nodularity (cul-de sace and uterine ligaments)
- Fixed/immobile uterus
gold std for dx = laparascopy
Mainstays of Tx for endometriosis?
Why?
- NSAIDs + continous hormonal therapy
- continous hormonal therapy–> decr ovulation –> less pain
What are the 3 infreq used methods for Tx endometriosis?
- GnRH agonists (leuprolide)
- Danazol
- Aromatase inhib
Definition of PMS (premenstrual syndrome)
When does it resolve?
Physical, behav and mood changes that occur repetitively in 2n half of menstrual cycle (luteal phase) & 1st few days of menses
resolves w/onset of menses (criteria discussed later is more spp)
What is PMS possibly d/t?
ovarian hormonal fluctuations and NT disturbances (serotonin)
2 mai requirements for Dx of PMS?
- 1 or more behavioral/emot or somatic Sxs 5 days before menses in last 3 menstrual cycles
- Sxs relieved w/in 4 days of menses –> cant recur til at least day 13 (7 days of no sxs in follicular phase)
How does PMDD differ from PMS?
PMDD = more severe
Dx criteria for PMDD requires 5+ Sxs during most cycles in last year AND 1 of Sx must be (4 options)
- Depressed mood
- Anxiety/tension
- Lability
- Angry/irritable
what 3 other things must be present to make Dx of PMDD?
- Markedly interferes w/life
- Not exacerbation of another d/o
- Confirmed by prospective daily ratings in 2 consec cycles w/Sxs
Tx for PMS AND PMDD:
- what is tx for mild Sxs?
- what is tx for mod-severe Sxs?
- Mild Sxs –> lifestyle modifications
2. mod-severe Sxs –> SSRIs
What 2 SSRIs used for PMS and PMDD
- Fluoextine
2. Sertraline
