Lecture 4 - Menstrual Probs Flashcards
Amenorrhea
absence of menses
this is a symptom, not a dz
What are the stages of puberty?
Thelarche (breast development)
Pubarche (axillary and pubic hair growth)
Accelerated Growth
Menarche (first menses)
Primary Amenorrhea
absence of menarche by age 16 in presence of normal pubertal development
OR
absence of menarche by age 14 years in absence of normal pubertal development
OR
absence of menarche 2 years after completion of sexual maturation
When does typical menarche start?
11-13 years old
estrogen dependent
How much blood is loss during menstruation?
<80mL
What 3 three questions are you aiming to answer when examining a pt with primary amenorrhea?
1) Do they have secondary sexual characteristics?
2) Are all reproductive organs present?
3) Is there an obstruction to menstrual flow?
What history is important to ask about in regards to primary amenorrhea?
Childhood chemotherapy or radiation exposure
pubertal development
sexual activity
contraceptive use
athletic training
weight change
family hx - when family members started their menarche
autoimmune dz
Which labs should you run for pts with primary amenorrhea?
B-hCG FSH (high indicates ovarian failure, low indicates hypothalamus/pituitary disorders) Prolactin TSH Karyotype
What is the most important step in evaluation of amenorrhea?
determine by PE or US if uterus is present
Poll everywhere questions
go back and panopto
What can cause ovarian failure?
Gonadal dysgenesis
Turner’s syndrome
What is the MC cause of primary amenorrhea?
Gonadal dysgenesis
decrease in estrogen
increase in LH and FSH
Gonadal Dysgenesis
MC cause of primary amenorrhea decrease in estrogen increase in LH and FSH underdeveloped ovaries normal internal and external female genitalia
Congenital - Turner’s Syndrome (45 XO)
Acquired - chemo/radiation
Turner’s Syndrome
45XO
partial/complete absence of X chromosome
no ovaries-fibrous band of tissues “gonadal streak”
Poor breast development
Primary amenorrhea
short stature, webbed neck, infertility, hear defects (coart of aorta), learning disabilities
dx: karyotype
management: estrogen replacement
cyclic progesterone to induce menses
How do you dx Turner’s syndrome?
Karyotype
How do you manage Turner’s syndrome?
estrogen replacement
cyclic progesterone to induce menses
Mullerian Ageneiss
Congenital malformation of genital tract normal XX karyotype no uterus shortened vagina ovulation occurs normal hormone levels
management: surgical reconstruction of vagina
AIS
androgen insensitivity syndrome
genetically male
testosterone is secreted - target cells lack receptors - no masculizing effects occur
46XY - X linked recessive
lack of androgen receptors
primary amenorrhea with normal breast development
absent uterus, short vagina, +testes present
complete (female external genitalia) vs partial
increase testosterone (to male levels)
tx: remove testes after puberty
estrogen replacement after puberty
gender assignment
What is the treatment for AIS?
remove testes after puberty
estrogen replacement after puberty
gender assignment
Secondary Amenorrhea
Absence of menstruation for at least 3 cycles in pts who previously had regular menstrual cycles
or 6 months in females with irregular cycles
What is the MC cause of secondary amenorrhea?
PREGNANCY
ovary (40%) hypothalamus (35%) pituitary (7%) uterus (7%) other (1%)
12 x 28 x 6
an example of how you document
12 years age of menarche
28 day cycles
6 days of bleeding
What drugs of abuse can decrease GnRH?
heroin and methadone
What are the initial labs you order for secondary amenorrhea?
urine pregnancy test TSH prolactin FSH LH serum estradiol testosterone/DHEA-S (r/o PCOS) Pelvic US
Progestin withdrawal test
Rx Provera 10mg daily for 10 days
estrogen vs ovulation problem –confirms the presence of estrogen
withdrawal bleeding occurs within 2-7 days after completion of meds
you are doing this test for pts with a hx of amenorrhea to determine cause
What are the possible results of the progestin challenge?
you are doing this test for pts with a hx of amenorrhea
if they bleed after this test then they have normal estrogen levels, normal outflow tract, they are NOT ovulating right
if they don’t have withdrawal bleeding its because they dont have endometrial proliferation d/t estrogen deficiency or outflow tract abnormality
Functional hypothalamic amenorrhea
no pathology
associated with: weight loss excessive exercise anorexia stress
Female athlete triad: anorexia, amenorrhea, osteoporosis
tx: manage nutritional status
OCPs
What is the treatment for functional hypothalamic amenorrhea?
manage nutritional status
OCPS
Sheehan Syndrome
post partum pituitary necrosis
pituitary cell destruction
severe HTN secondary to massive hemorrhage
pituitary hormones GH, TSH, LH, FSH, ACTH
dx: MRI
Tx: replace pituitary hormones
Premature ovarian failure
depletion of oocytes <40 y/o
high FST and LH
low estradiol
sx: hot flashes, vaginal dryness
concerns: ischemic heart dz, osteoporosis
tx: HRT
estrogen + progesterone
weight -bearing exercise
calcium and vitamin D supplement
Polycystic ovaries
hyperandrogenism obese; hirsute dx: polycystic ovaries on US signs of androgen excess (acne, hirsuitism) oligomenorrhea/amenorrhea
tx: OCPs
metformin
Asherman Syndrome
intrauterine adhesions or fibrosis
most commonly secondary to scarring from pregnancy related D and Cs
dx: hysteroscopy
tx: hysteroscopic lysis of adhesions
Dysmenorrhea
painful menstruation, normally occurring with ovulatory cycles
What is the most commonly reported menstrual disorder?
dysmenorrhe
Primary vs Secondary dymenorrhea
Primary: prostaglandin -mediated pain during first 1-2 days of menses assoc with N/V/D no identifiable pathology
Secondary:
new onset of pain in older women
endometriosis is MC cause of secondary dysmenorrhea
+ pathology
What is the MC cause of secondary dysmenorrhea?
endometriosis
What is the Ddx of secondary dysmenorrhea?
endometriosis leiomyoma (fibroids) Adenomyosis PID UTI ectopic pregnancy
What is the treatment for dysmenorrhea?
NSAIDs and OCPs
What is the function of OCPs?
estrogen -progestin combo
prevents ovulation
reduces endometrial growth
decreases PG production
Endometriosis
MC cause of secondary dysmenorrhea
aberrant growth of endometrium outside the uterine cavity –pelvis and ovary MC locations
nulliparous women 20s-30s
infertility common
What are the symptoms of endometriosis?
3Ds Dysmenorrhea Dyspareunia Dyschezia Pelvic Pain
Signs:
tender nodularity of cul-de-sac and uterine ligaments
fixed uterus
What is the gold standard dx for endometriosis?
laparoscopy
What is the treatment for endometriosis?
based on severity of sx and desire for fertility
pain management
hormonal treatment
surgery
What are the different behavior and somatic sxs seen with PMS?
Behavioral: labile mood irritability anxiety/tension sad or depressed mood increased appetite/food cravings diminished interest in activities
Somatic: abdominal bloating fatigue breast tenderness HA hot flashes dizziness
to dx: they must have 1 or more of these sxs 5 days before menses for at least 3 prior menstrual cycles
PMDD
Premenstrual dysphoric disorder
How do you dx PMDD?
5 of the 11 sxs occurring during the majority of cycles over the past year (must have 1 of the first 4 sxs)
1) depressed mood
2) anxiety, tension
3) affective lability
4) anger or irritability
5) decreased interest in usual activities
6) difficulty concentrating
7) lack of energy, fatigue
8) change in appetite, specific food cravings
9) hypersomnia or insomnia
10) overwhelmed or feeling “out of control”
11) physical sxs such as breast tenderness, HA, weight gain
What is the treatment of PMDD?
mild:
lifestyle modifications - exercise, relaxation
moderate:
OCPS
severe:
SSRIs (fluozetine, sertraline)
