Menstrual cycle abnormalities

Question 1

Dysmenorrhea

Answer 1

Menstrual pain / cramping interfering with normal activities

Question 2

Treatment for primary dysmenorrhea (idiopathic)

Answer 2

NSAIDs (inhibit endometrial prostaglandin production). Take at onset of menses → continue 1-3d as needed. Can also use COX-2 inhibitors, but worry about side effects.
OCPs are second line.
Can also try heating pads, exercise, massage, etc.
Surgical therapy not helpful

Question 3

Treatment for secondary dysmenorrhea

Answer 3

Cervical stenosis: dilate (surgical or laminaria)
Pelvic adhesions (Crohn’s, appendicitis, myomectomy, other surgeries) can’t see on imaging.  Rx NSAIDs, laparoscopy if recalcitrant

Question 4

PMS/PMDD symptoms

Answer 4

Happens in second half of menstrual cycle (luteal).
Bloating, wt gain, H/A, breast tenderness, moodiness, etc.
Multifactorial.
PMDD = worse sx, interfere with life, etc.

Question 5

PMS/PMDD treatment

Answer 5

Mood diary, try vitamin B6 and stuff like that, then, SSRIs if that treatment fails. OCPs help too (e.g.Yaz, has low dose estrogen + drospirinone, a spironolactone with anti-androgen activity)

Question 6

Menorrhagia

Answer 6

Excessive flow duration (>7d) or volume (>80 mL/cycle)

Question 7

Menorrhagia etiology

Answer 7

Fibroids, adenomyosis, polyps, endometrial hyperplasia.

If in young pt, check for bleeding disorders (F5L, vWB dz, ITP, plt dysfxn, malignancy)

Question 8

Hypomenorrhea

Answer 8

Regularly timed, light flow.

Question 9

Hypomenorrhea etiologies

Answer 9

Think A: athletes & anorexics (hypothalamic) or Asherman’s / anatomical.
Could also be 2/2 Depo / Mirena / OCP

Question 10

Metrorrhagia

Answer 10

Bleeding between periods.

Question 11

Metrorrhagia etiologies

Answer 11

Think cervical lesions (polyp, eversion, carcinoma) or endometrial (polyps or carcinoma)

Question 12

Menometrorrhagia:

Answer 12

Heavy bleeding & between periods.

Similar ddx to menorrhagia.

Question 13

Oligomenorrhea

Answer 13

> 35d between cycles.
Similar to amenorrhea etiologies: PCOS, chronic anovulation, pregnancy, thyroid disorders
If > 6 mo, then secondary amenorrhea
If prolonged & pt is obese / you’re concerned for anovulatory cycles, get endometrial bx even if < 35 y/o

Question 14

Polymenorrhea:

Answer 14

< 21d between cycles

Often caused by anovulation

Question 15

Dysfunctional uterine bleeding (DUB):

Answer 15

Diagnosis of exclusion (abnormal bleeding & no other etiology)

Question 16

Dysfunctional uterine bleeding etiology

Answer 16

Usually 2/2 anovulation → no corpus luteum → no progesterone → no withdrawal; endometrium just grows until blood supply can’t keep up, then breaks down. Tx:○If acutely hemorrhaging, give IV estrogen for quick relief (but risk DVT/PE) or oral estrogens ifhemodynamically stable (lower risk, but takes 24-48h)○For chronic DUB, use NSAIDs to decrease blood loss, regulate periods with OCPs or progestin onlyif estrogen contraindicated○If refractory, consider surgery (D&C is first step → endometrial ablation if done with kids).Hysterectomy is definitive treatment; can leave ovaries too.

Question 17

Work up for dysfunctional uterine bleeding

Answer 17

Hypothyroidism, hyperPRL, hyperandrogenism, PMOF
ANY WOMAN OVER 35 WITH ABNORMAL UTERINE BLEEDING GETS AN ENDOMETRIAL BX
Also true for obese women < 35 with extended oligomenorrhea

Question 18

Postmenopausal bleeding:

Answer 18

Always abnormal!
Atrophy is #1 cause, but rule out cancer
HRT can cause too
Also check for non-GYN causes (hemorrhoids, anal fissures, rectal prolapse, lower GI tumors, urethral caruncles

Question 19

Postmenopausal bleeding work up

Answer 19

CBC, TSH, PRL, FSH; Pap smear, DRE, tumor markers if adnexal mass identified, endometrial biopsy. Image with pelvic U/S, sonohysterogram, MRI to get endometrial stripe thickness. Hysteroscopy for polyps / fibroids, and D&C also useful.