Menstrual and Uterine Disorders Flashcards
1
Q
Amenorrhea
A
Absence of menstrual bleeding
* Can be transient, intermittent, or permanent.
* Caused by dysfunction of the hypothalamic-pituitary-ovarian axis, the
ovaries, uterus, or the vagina.
2
Q
Primary vs. secondary amenorrhea
A
- Primary: Menses and secondary sexual characteristics never begin.
- Secondary: Menses stops (for at least 3 mos) after it has already occurred.
3
Q
Primary Amenorrhea
A
- Absence of menses by age 15
or - Both menses and secondary sexual
characteristics missing by age 13
4
Q
Etiology of primary amenorrhea
A
- Ovarian (Gonadal) dysgenesis (impaired development of the ovaries)
- Turner Syndrome
- Müllerian agenesis (absence of vagina and sometimes uterus)
- Delay of puberty due to genetics or other illness
- Polycystic ovary syndrome (PCOS)
5
Q
Secondary Amenorrhea
A
- Absence of menses for > 3 months in females who previously had regular
cycles or > 6 months in females who had irregular cycles
6
Q
Oligomenorrhea
A
fewer than 9 menstrual cycles per year or > 35 day cycles
* Same etiology, workup, treatment as secondary amenorrhea
7
Q
Etiologies of secondary amenorrhea
A
- Pregnancy is the most common cause of secondary amenorrhea
- Ovarian causes: PCOS, ovarian insufficiency
- Hypothalamic causes: Functional GnRH deficiency, anorexia
- Pituitary causes: Hyperprolactinemia, Cushing syndrome
- Uterine causes: Intrauterine adhesions
- Hypothyroidism
8
Q
Amenorrhea pathophysiology
A
- Hypothalamic-pituitary dysfunction: A result of interference with GnRH transport, GnRH
discharge, or congenital absence of GnRH - Hyperprolactinemia (galactorrhea often present)
- Ovarian Dysfunction
- Dysgenesis: Ovaries fail to develop (often due to Turner Syndrome)
- Premature ovarian failure: Depletion of ova before age 40
- PCOS: Exact mechanism unknown, but related to androgen sensitivity
- Pituitary Dysfunction
- Radiation, Sheehan syndrome, pituitary adenomas/prolactinomas
9
Q
Dysgenesis of the ovaries
A
Ovaries fail to develop (often due to Turner Syndrome)
10
Q
Hypothalamic-pituitary dysfunction
A
- A result of interference with GnRH transport, GnRH
discharge, or congenital absence of GnRH - Hyperprolactinemia (galactorrhea often present)
11
Q
History taking for amenorrhea
A
- Determine if menstruation has occurred previously
- Cycle, duration, and flow of menses. Date of last menstrual period (LMP)
- Determine if sexually active, use of contraception
- Headaches and visual field deficit (tumors)
- Environmental factors, stress, exercise, nutrition status/eating disorders
- Symptoms of estrogen deficiency: hot flashes, vaginal dryness, poor sleep
- Galactorrhea (hyperprolactinemia)
- Current Medications: Birth control, metoclopramide, antipsychotics, opioids
12
Q
Amenorrhea PE
A
- Breast development, pubertal growth spurt are delayed or absent in girls
with hypothalamic-pituitary failure - Hirsutism
- BMI (elevated in >50% of PCOS)
- Yellow skin, dental erosion, reduced gag reflex (Eating Disorders)
- Short stature, webbed neck, low-set hairline and/or ears (Turner Syndrome)
- Examine the breasts and perform a pelvic exam
13
Q
Amenorrhea diagnosis and testing
A
- Urine or serum HCG (Always!)
- TSH, FSH, (+ or - LH), estradiol, prolactin
- Androgen testing (testosterone, dehydroepiandrosterone sulfate) if signs of
hyperandrogenism - Pelvic ultrasound for primary amenorrhea (if normal vagina/uterus are not
obviously present) - Pituitary MRI if prolactin high and no obvious cause.
- Progestin challenge: medroxyprogesterone acetate 10 mg daily for 10 days
14
Q
Amenorrhea treatment
A
- Based on the underlying cause
- PCOS, thyroid dysfunction, hypothalamic, hyperprolactinemia,
ovarian failure…
15
Q
Goals of Amenorrhea treatment
A
- Goals: Correct pathology, achieve fertility, prevent complications.
- Education
- Referral
- Outflow tract abnormalities may require surgery
- Hormone replacement therapy
- Cognitive behavioral therapy
16
Q
Dysmenorrhea
A
Defined as: Painful menstruation, usually crampy lower abdominal pain
* Common in the first few years of menstruation
* Up to 85% of adolescent girls
* Prevalence higher among smokers
17
Q
Dysmenorrhea etiology
A
- Primary: occurs in the absence of pelvic pathology
- Secondary: Occurs due pelvic pathology
- Causes include anatomic abnormalities (like fibroids), endometriosis, ovarian cysts, psychogenic contributors, infection (Pelvic inflammatory disease)
18
Q
Dysmenorrhea pathophysiology
A
- Prostaglandin F2⍺ (PF2⍺)
- Myometrial stimulant
- Causes dysrhythmic uterine contractions,
hypercontractility, and increased uterine
muscle tone leading to uterine ischemia. - Also stimulates GI tract, leading to
nausea, vomiting, and diarrhea - Elevated levels in the endometrium
correspond to degree of pain
19
Q
Clinical presentation of dysmenorrhea (primary)
A
- Begins once menstrual cycles establish as ovulatory. Usually first presents
within 4-5 years of menarche. - Symptoms begin several hours prior to the onset of menstruation
- Durations is 1-3 days
- Labor-like, lower abdominal cramping/pain
- Can include nausea, vomiting, diarrhea, back pain, dizziness, fatigue, and
headache - Physical exam usually normal,
