Menstrual and Uterine disorders Flashcards
what 3 processes do we need to have normal menses?
- intact HPO axis
- endometrium responsive to hormal stimulation
- intact outflow tract from internal to external genitalia
what is Primary Amenorrhea
Absence of menses…
- By age 13 (if sexual development also impaired)
- By age 15 (if normal sexual development)
MCC of primary amenorrhea? other causes?
genetic or anatomic abnormality
- 50% - abnml chromosomes → gonadal dysgenesis - ovarian insufficiency due to premature depletion of oocytes
- 20% - Hypothalamic hypogonadism
- Other:
- GU - absent genitalia; transverse vaginal septum; imperforate hymen
- Endo - pituitary disease; androgen insensitivity
definition of Secondary Amenorrhea
Absence of menses for >3 cycles or 6 consecutive months in a previously menstruating pt
MCC of secondary amenorrhea?
other causes?
- pregnancy
- Other common causes - galactorrhea, PCOS, hypothalamic or pituitary disease, adrenal hyperplasia
- Less common - premature ovarian failure, drug-induced
- Rare - Other endocrine disease (DM, thyroid, adrenal), cirrhosis, renal failure, malnutrition
3 main categories of causes of amenorrhea?
- Hypothalamic-Pituitary Dysfunction
- Ovarian causes
- Anatomic Causes
what can cause Hypothalamic-Pituitary Dysfunction that ultimately causes amenorrhea?
- GnRH deficiency
- Pituitary dysfunction
- Hyperprolactinemia
- Sheehan’s syndrome - postpartum
pituitary necrosis due to hypovolemia - Surgical destruction
- Infiltrative diseases
ovarian causes that causes amenorrhea
- Gonadal dysgenesis
- Ovarian failure
- Abnormal steroid enzymes - Unable to produce hormones
- Ovarian resistance - Follicles do not respond to gonadotropins
- Polycystic Ovarian Syndrome (PCOS)
3 types of ovarian failure?
- Primary - directly due to ovaries
- Secondary - due to hypothalamic or pituitary disease
- Premature - onset of menopause in women <40 y/o
anatomic causes that causes amenorrhea?
- Mullerian Dysgenesis - congenital absence of uterus and upper ⅔ of vagina; May ovulate and have normal secondary sex characteristics
- Vaginal agenesis
- Transverse vaginal septum
- Imperforate hymen
- Asherman’s syndrome - uterine synechiae (adhesions); Often due to dilation and curettage
w/u for primary amenorrhea if (+) 2o sex characteristics
- Evaluate anatomy → PE, US; check karyotype
- Pregnancy test
Ovaries are producing estrogen
w/u for primary amenorrhea if (-) 2o sex characteristics
- Evaluate anatomy
- Check prolactin and TSH
- Check LH and FSH
- Low → hypothalamic/pituitary disease, stress, low weight/malnutrition = MRI
- High → ovarian failure = Check karyotype
Ovaries aren’t producing estrogen
w/u for secondary amenorrhea
- Physical exam +/- imaging
- Pregnancy test
- TSH and Prolactin
- If abnormal TSH → thyroid disease
- If abnormal prolactin → pituitary imaging - Progesterone Challenge Test
- If bleeding occurs, endometrium is intact but progesterone is lacking
- Anovulation - no production of progesterone by corpus luteum - Estrogen + Progesterone Challenge Test
- No bleed → unresponsive endometrium or blockage of outflow
- If bleeding occurs, suspect hypogonadism - FSH and LH
- If high → primary/premature ovarian failure
- If low → secondary ovarian failure
complications of amenorrhea
- Infertility
- Lack of normal physical sexual development
- Osteoporosis and fractures
- Endometrial hyperplasia and carcinoma
tx for amenorrhea
- Correction of underlying disease
- If desiring pregnancy - ovulation induction
- Letrozole (Femara), clomiphene (Clomid)
- Less common - dopamine agonist, gonadotropins - If not desiring pregnancy - estrogen/ progesterone
- Maintain bone density, reduce genital atrophy or other menopausal s/s
- Many women do well on COC
Painful menstruation that inhibits normal activity and requires medication
Dysmenorrhea
3 types of Dysmenorrhea
- Primary - no organic, demonstrable cause
- Secondary - presence of another disorder that could cause s/s (endometriosis, adenomyosis, PID, cervical stenosis, fibroids, endometrial polyps)
- Membranous - due to passage of a cast of the endometrium through an undilated cervix (rare)
Dysmenorrhea is associated with _____ activity during ovulatory cycle
Abnormal uterine contractions → dec blood flow to uterus → uterine hypoxia
Leukotrienes also contribute
Psych factors may also be involved
prostaglandin
clinical findings of Dysmenorrhea
Pain - hallmark characteristic
- intermittent intense cramps or dull, continuous ache
- at menses or up to 1-2 d prior; Subsides 12-72 hrs after menses begins
- MC recurs
- lower abdomen and suprapubic region; lower back and/or thighs possible
- Impact on ADLs
- N/V/D, malaise, and/or HA
- No significant pelvic disease on PE - pelvic tenderness possible
tx of dysmenorrhea
- NSAIDs; acetaminophen, consider short-term codeine/opioid if severe
- Continuous heat to abdomen - as effective as ibuprofen, more than acetaminophen
- Hormonal Contraceptives - if no relief from NSAIDs
- Other - Exercise, TENS unit, Ca, Mg
- refractory - surgery
what is Psychoneuroendocrine disorder
- Restricted to luteal phase of menstrual cycle
- Biologic, psychological, and social parameters
- Poorly understood; not associated with pathologic hormone levels - Serotonergic dysfunction and decreased GABA levels found
PMs and PMDD MC at what age?
late 20s to early 30s
Up to 75% of women experience
Non-Pharmacologic tx for for mild-moderate PMS/PMDD
- Change in eating habits
- Avoid or limit - caffeine, alc, tobacco, chocolate, sodium
- small freq meals high in complex carbs - Aerobic exercise, stress management and/or CBT
- Chasteberry, Calcium carbonate (bloating, food cravings, pain), Mg (water retention), Vitamin B6 and vitamin E
medications for mild-moderate PMS/PMDD
- NSAIDs - headache, breast or abdominopelvic pain
- Spironolactone - cyclic edema
- Bromocriptine (dopamine agonist) - breast pain
tx for severe PMS/PMDD
- SSRIs - first-line
- Hormonal contraception - Often use contraceptives with drospirenone ( Yaz, Yasmin, Beyaz)
- consider alprazolam
- Refractory - GnRH agonists - Can induce “medical menopause”
- Definitive - BL oophorectomy +/- hysterectomy
Encompasses both abnormal menstrual bleeding and bleeding due to underlying causes or diseases
Pregnancy, GU disease, systemic disease, cancer
Dysfunctional Uterine Bleeding
first eval of DUB
- bleeding hx
- PE
- lab test - CBC, hCG, TSH
- cervical cytology - can help screen for invasive cervical lesions
- Endometrial cells in postmenopausal pt - abnormal unless on MHT
further w/u for DUB
-
Pelvic US
- Transvaginal - empty bladder - pelvic organs
- Transabdominal - full bladder - less detail, wider visualization
- Sonohysterography - saline injected in intrauterine cavity - increased sensitivity - Endometrial Bx
- D&C
- Hysteroscopy - Gold standard for eval pathology in uterine cavity
when can observation be the mgmt for DUB?
premenopausal - if serious pathology ruled out and not impacting patient functioning or quality of life
tx for premenopausal DUB
- observation
- hormones - COC, estrogen
- acute hemorrhage - IV estrogen
- refractory - levonorgestrel-releasing IUD, D&C (temporary fix) or endometrial ablation
- Definitive - hysterectomy
causes for postmenopausal DUB
- Exogenous hormones - MCC postmenopausal uterine bleed - Menses usually stop 6-12 months after discontinuing MHT
-
Vaginal Atrophy - MCC lower GU tract postmenopausal bleed
- lubricants, topical or systemic estrogen; avoidance of trauma - Tumors of Reproductive Tract - surgery possible
Hysteroscopic procedures - destroy or resect endometrium → eumenorrhea
Similar outcomes with bleeding and patient satisfaction between first and second generation procedures
Endometrial Ablations
what are the 1st gen Endometrial Ablations
- Endometrial vaporization (Nd-YAG)
- Rollerball electrosurgical desiccation
- Endometrial resection (electrosurgery)
- Direct hysteroscopic guidance
- Advanced skills and training
- Longer operating times; More complications
what are the 2nd gen endometrial ablations?
- Do not require direct hysteroscopic guidance to perform
- Quicker and less complicated
- Thermal energy
- Cryosurgery
- Radiofrequency electrosurgery
- Microwave
MC sign from endometrial ablations?
- Decreased menstrual flow - 70-80% of patients
- Amenorrhea - 15-35%
endometrial ablations are CI if patients want what?
What happens if the CI happens?
- who desire future fertility
- Patient will still need adequate post-op contraception
- If pregnancy occurs - miscarriage, prematurity, abnormal placentation, perinatal ablation
T/F: patients need to be treated prophylactically with abx for endometrial ablation
F: not needed MC
pts may premedicate for 1-2 mo with tx that cause endometrial atrophy, what are they?
- GnRH agonist, combination oral contraceptives, progestins
- Alternatively may consider curettage before procedure
CIs for endometrial ablations
- Obstetric - Pregnancy, Women wishing to preserve fertility
- Endometrial hyperplasia or genital tract cancer
- Postmenopausal women
- Acute pelvic infection
- Expectation of amenorrhea
- IUD in place
concerns if endometrial ablation is done
not CIs
- Patients at high risk for endometrial cancer
- Large or distorted endometrial cavity
- Prior uterine surgery
- First tool for endometrial ablation
- Uterus is distended with saline
- laser fiber touches endometrium and is dragged across endometrial surface - Creates 5-6mm deep furrows in endometrium
Vaporization (Nd-YAG Laser) - 1st gen
2-4 mm ball or barrel shaped electrode
Shorter operating time, less perforation than other first gen methods
Does not work for intracavitary lesions
Rollerball Ablation - 1st gen
- Less expensive and larger loop diameter than laser ablation
- Resectoscope with electrical current used to excise strips of endometrium
- Higher rates of perforation
Endometrial Resection - 1st gen
- Uncontained saline solution heated and recirculated for 10 minutes
- Low pressure to avoid opening fallopian tubes to peritoneal cavity
- Water seal to avoid leakage into vagina - Allows direct observation of endometrium as it is being destroyed
- Higher burn risk than other 2nd-gen methods
- Can use with anatomically abnormal uterus
Hysteroscopic Thermal Ablation - 2nd gen
- Fan-shaped mesh device contours to shape of endometrial cavity
- Uses suction to improve contact with mesh and remove vapor
- Radiofrequency run through mesh fan to desiccate endometrium - Does not require endometrial preparation
- Has been used in patients with small submucosal leiomyomas and polyps
Radiofrequency Thermal Ablation - 2nd gen
- Silicone device contours to shape of endometrial cavity
- Filled with RF-heated argon gas
- Liquid produced during procedure is also heated, providing hot liquid thermal ablation - Does not require endometrial preparation
- Has not been studied in patients with fibroids
- Higher rates of normal or no menstrual flow after the procedure
Thermal + RF Thermal Ablation - 2nd gen
- Uterus is sealed off with balloons
- Uterine cavity then filled with high-temperature water vapor
- Thermal injury causes scarring to endometrium - Does not require endometrial preparation
- May be used in patients with irregular uterine cavity contour
Water Vapor Thermal Ablation - 2nd gen
- Generates temperatures -100 to -120 C to produce an iceball in the endometrial cavity
- Endometrium undergoes cryonecrosis due to low temperatures
- Less pain than thermal energy procedures
Cryoablation - 2nd gen
what are the 2 endometrial ablation that are no longer in the US?
- Thermal Balloon Ablation
- Microwave Ablation
Aberrant growth of endometrium outside uterine cavity
Most common GYN diagnosis responsible for hospitalization in women 15-44
Endometriosis
Endometriosis MC in who?
- 53% of adolescents with severe pelvic pain warranting surgical evaluation
- 25-35% of infertile women
- 6-10% of women in reproductive age group
possible causes of endometriosis
- Retrograde menstruation
- Genetic predisposition
- Altered immunity → inhibited ability to recognize abnormal endometrial implants