Menses Flashcards
Hormone responsible for follicle formation and beginning of follicle maturation
FSH
Hormone responsible for follicle maturation and triggering ovulation
LH
Role of the hypothalamus in the menstrual cycle
produces and releases GnRH to anterior pituitary
In response to GnRH, the anterior pituitray releases
TSH, GH, ACTH, Prolactin, FSH, LH
Hormone produced primarily by developing follicles in the ovary and stimulates endometrial cell growth
estrogen
Hormone produced by the corpus luteum and prepares the uterus for implantation [Pro-Gestation] → converts proliferative endometrium to secretory endometrium
Progesterone
Hormone produced by the ovaries, placenta, and corpus luteum → inhibits FSH release
Inhibin
Average duration of the menstrual cycle
28 days
Average duration of menses
3-8 days
what day in the cycle does ovulation occur?
day 14
Average age of menarche
Average age of menopause
- 7
51. 4
What is the first day of the menstrual cycle?
first day of menses
Two phases of the menstural cycle
follicular and luteal
This phase begins with the onset of menses and ends on the day of LH surge → average duration is 14 days [can vary → 14-21 days]
follicular phase
This phase begins on the day of LH surge and ends at onset of next menses → duration is 14 days
luteal phase
what hormones are doing their thing in the follicular phase?
estrogen levels low → increse in FSH and LH secretion → follicle develops in the ovaries → follicle produces estrogen and progesterone → increases estrogen turns off the GnRH release from hypothalamus → inhibin also released to decrease FSH release
what anatomy changes in follicular phase?
uterus lining thickens
where does fertilization occur?
fallopian tube
what occurs hormone wise during ovulation?
increase in estrogen → LH surge and FSH spike
Increasing levels of estrogen have been suppressing GnRH, LH, FSH until day 14 when ____ occurs and the process switches from negative feedback control to positive feedback
neuroendocrine phenomenon
what is occuring in the luteal phase?
empty follicle becomes the corpus luteum → secretes more progesterone → further develops uterus lining → makes it more favorable for implantation
what are somy symptoms that may indicate your patient is in the luteal phase of her menstural cycle?
raised basal body temperature, bloating and breast tenderness (dur to water retention)
what causes the eventual decrease in progesterone and estradiol?
decrease in LH
If an oocyte Is fertilized what hormone will then be released?
hCG (human chorionic gondaotropin)
what causes onset of menses?
corpus luteum begins to disintigrate → progesterone levels drop
If embryo develops what prevents menses from occuring?
maintained increased progesterone, estrogen, and inhibin levels
Time frame for follicular phase
what develops in this phase?
Dominant hormone?
first day of menses to ovulation
follicle develops
estrogen > progesterone
what happens on day 14 that correlates with ovulation?
LH surge
Time frame for luteal phase
Dominant hormone?
ovulation to menses
Progesterone > estrogen
what syptoms can you see in the proliferative phase?
hormones are rising → menstrual symptoms are subsiding → increased libido
Term for pain sometimes felt when a woman ovulates
mettelschmerz
Describe vaginal mucus during the ovulation phase
high volume and elasticity, thin, clear
Symptoms of the ovulation phase
low temperature, nausea, sharp or dull pain, spotting, high libido
Describe the vaginal mucus during the secretory phase
low in volume and elasticity, thick, cloudy
Symptoms of the secretory phase
temperature spikes, weight gain, bloating, swelling, breast tenderness, anxiety, depression, headache, spotting, constipation, acne
How does primary differ from secondary amenorrhea?
primary is complete absence/never have it
secondary is due to some cause (absense for 3+ months)
How long must a woman have amenorrhea to be diagnosed with menopause? What type of diagnosis is this?
1 year
retrospective diagnosis
Causes of Primary Amenorrhea
anatomic, primary ovarian insufficiency, hypothalamic causes, pituitary causes, physiologic causes, Iatrogenic
term for congenital absense of uterus
Mullerian agenesis
Anatomic causes of primary amenorrhea
Mullerian agenesis, imperforate hymen, transverse vaginal septum, vagina or cervical agenesis
Congenital causes of primary ovarian insufficiency
Turner syndrome, Condala dysgenesis, Ovarian agenesis
Acquired types of primary ovarian insufficiency
chemo/radiation, mumps or autoimmune oophoritis
How can the hypothalamus cause primary amenorrhea?
reduction in GnRH → reduction in FSH, LH
What can cause the hypothalamus to decrease its production of GnRH?
psychotic stress, excessive exercise, malnourishment, rapid weight loss, eating disorder
What are pituitary causes of primary amenorrhea?
pituitary tumors, empty sella syndrome, medications (antidepressants, antipsychotics)
what are somy symptoms of primary amenorrhea?
headache or visual field abonormalities, pregnancy symptoms, elevated BP, acne, hirsutism, short stature
If a patient hasn’t had a period and complains of headahce and visual field abnormalites, what may you want to assess first?
pituitary or hypothalamic tumor
what labs do you want to order for patient with primary amenorrhea?
FSH, LH, PRL, testosterone, thyroid studies, pregnancy test
If the prolactin levels are high and the patient is complaining of headache and vision abnormalities what would you want to order?
MRI of hypothalamuc and pituitary
common causes of secondary amenorrhea
pregnancy, hypothalamic/pituitary, androgen disroders (PCOS)
Most common cause of amenorrhea
pregnancy
What will be pertinent in the patient history that may lead you to pregnancy
breast fullness, weight gain, nausea
How can you confirm pregnancy?
hCG assay (urine or serum)
Post partum pituitary necrosis secondary to severe hemorrhage and hypotension
Sheehan Syndrome
Most common cause of ovulatory dysfunction in reprodutive age women
PCOS
What occurs in PCOS?
high insulin → increase GnRH pulse frequency → increased LH and FSH → increase in ovarian androgen production and decrease follicular maturation
Early vs Premature Menopause
Early → primary ovarian failure before 45
Premature → primary ovarian failure before 40
what is going on hormone wise in ovarian failure?
FSH and LH increase to stimulate follicle maturation → decrease estrogen and progesterone → no follicle response
Signs and symptoms of ovarian failure
estrogen deficiency → abnormal hair growth, hot flashes, mood swings, insomnia, vaginal atrophy
what are some causes of ovarian failure?
autoimmunity against ovaries, chromosomal abnormalities, surgical bilateral oophrectomy, radiation to pelvic area, chemo
What is bad about ovarian failure?
irreversible
why is it important to catch ovarian failure early?
save eggs for futre IVF with surrogate
intrauterine synechiase → scaring of the uterine cavity → may be secondary to d&c or C-section
Asherman Syndrome
post partum pituitary necrosis secondary to severe hemorrhage and hypotension
Sheehan Syndrome
Symptoms of menopause
vasomotor symptoms, sleep disturbances, fatigue, headache, diminished libido, depression, irritability, vaginal dryness and atrophy
Symptoms of pregnancy
fatigue, sore, swollen, tender breast, bloating, weight gain
Symptoms of PCOS
hisutism and masculine features
Diagnostic tests for secondary amenorrhea
pregnancy test, TSH, prolactin, FSH and LH, estradiol, serum testosterone
While you do not have to do labs in a patient you suspect is in menopause, what would the levels be if you did order it?
high FSH and low estradiol
what is the progesterone challenge test?
administer progesterone (medroxyprogesterone) 10-14 days during menstrual cycle → withdrawal bleeding should occur within a week
If bleeding occurs in progesterone challenge test then the patient is
anovulatory or oligo-ovulatory → issue with hypothalamic/pituitary axis or abnormal ovaries
If no bleeding occurs in the progesterone challenge test the patient
lacks estrogen or has genital outflow tract disorder
If a patient desires pregnancy, what can induce ovulation?
clomiphene citrate, heman menopausal gonadotropins, pulsatile GnRH, aromatase inhibitors
what do you primarily use in patients with PCOS?
clomiphene citrate
Treatment for premature ovarian failure
HRT
what can be used to suppress prolactin secretion?
bromocriptine
Conservative treatment for menopause
keep cool, medication, exercise, vaginal lubricant
nonhormonal treatment for menopause
escitalopram (SSRI), venlafaxine (SNRI) → help with anxiety or labile mood
meds for osteoarthritis → calcium and vitamin D
If your menopause patient has a uterus what hormone replacement therapy can you give her?
conbined estrogen and progesterone
if your menopause patient lacks a uterus what hormone replacement therapy can you give her?
estrogen only
a woman on HRT is at greater risk for
blood clots
Normal menstrual interval but heavy flow and longer duration
menorrhagia
intermenstrual bleeding (bleeding between period at irregular intervals)
metrorrhagia
prolonged and heavy bleeding at irregular intervals
menometrorrhagia
frequent periods
polymenorrhea
light flow or “spotting”
hypomenorrhea
menstrual periods > 35 days apart
oligomenorrhea
bleeding after intercouse “contact bleeding”
postcoital bleeding
average length of cycle
amount of blood loss
heaviest days
5 days
30 cc
days 1-3
What is considered an abnormal blood loss in menstruation
> 80 cc
what is considered abnormal tampon/pad use?
> 6 full pads/tampons a day [normal is >1 pad/tampon per 3hr]
three golden rules for abnormal uterine bleeding
rule out pregnancy, rule out cancer, assess hemodynamic status
what are structural causes of abnormal uterine bleeding?
PALM → Polyp, Adenomyosis, Lelomyoma, Malignancy/hyperplasia
what the nonstructural causes of abnormal uterine bleeding?
COEIN → Coagulability, Ovulatory dysfunctino, Endometrial, Iatrogenic, Not yet classified
what are signs of ovulation?
cervial mucous becomes stringy/stretchy [Spinnbarkeit], breast tenderness, bloating
What do you what to rule out before performing endometrial biopsy?
pregnancy
In this scan you put water in the uterus and check for any structural abnormalities
sonohysterography or hysteroscopy
what is the goal for treating abnormal uterine bleeding?
control bleeding and treat underlying cause
Can you take NSAID with abnormal uterine bleeding?
yes → helps with pain
what is the goal of hormone manipulation with abnormal uterine bleeding?
restore normal cycle
Treatment for heavier abnormal uterine bleeding
GnRH → shuts down the system by ovarian suppression
OCP → multiple/day
IV progesterone or estrogen
If a patient with heavy abnormal uterine bleeding is resistant to medications what two options can you consider?
surgery or endometrial ablation
Is abnormal uterine bleeding something to be concerned about in adolescent patients?
yes → normal to be irregular when starting out
Most common cause of AUB in adolescents
immaturity of hypothalamic-pituitary-ovarian axis
once regular menses is established in adolescence what is the most common cause of AUB?
ovulatory dyfunction
what do you do in postmenopausal patient with AUB?
endometrial biopsy
