Menstrual cycle abnormalities Flashcards
Dysmenorrhea
Menstrual pain / cramping interfering with normal activities
Treatment for primary dysmenorrhea (idiopathic)
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
Treatment for secondary dysmenorrhea
Cervical stenosis: dilate (surgical or laminaria) Pelvic adhesions (Crohn’s, appendicitis, myomectomy, other surgeries) can’t see on imaging. Rx NSAIDs, laparoscopy if recalcitrant
PMS/PMDD symptoms
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.
PMS/PMDD treatment
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)
Menorrhagia
Excessive flow duration (>7d) or volume (>80 mL/cycle)
Menorrhagia etiology
Fibroids, adenomyosis, polyps, endometrial hyperplasia.
If in young pt, check for bleeding disorders (F5L, vWB dz, ITP, plt dysfxn, malignancy)
Hypomenorrhea
Regularly timed, light flow.
Hypomenorrhea etiologies
Think A: athletes & anorexics (hypothalamic) or Asherman’s / anatomical.
Could also be 2/2 Depo / Mirena / OCP
Metrorrhagia
Bleeding between periods.
Metrorrhagia etiologies
Think cervical lesions (polyp, eversion, carcinoma) or endometrial (polyps or carcinoma)
Menometrorrhagia:
Heavy bleeding & between periods.
Similar ddx to menorrhagia.
Oligomenorrhea
> 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
Polymenorrhea:
< 21d between cycles
Often caused by anovulation
Dysfunctional uterine bleeding (DUB):
Diagnosis of exclusion (abnormal bleeding & no other etiology)
Dysfunctional uterine bleeding etiology
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.
Work up for dysfunctional uterine bleeding
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
Postmenopausal bleeding:
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
Postmenopausal bleeding work up
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.
