Menstrual Cycle & Abnormalities Flashcards
Three layers of the uterus
1) Peritoneum
2) Myometrium
3) Endometrium
2 layers of the endometrium
Basal layer and functional layer
Function of the endometrium
Responds to hormones, undergoes growth and stabilization changes during the menstrual cycle. It’s the site of implantation for an embryo
Function of the fallopian tube
Passageway where oocytes travel from ovaries to the uterus. Provides nutrients for the embryo and is crucial to its survival and developent
How does cervical mucus change & what cool stuff can it do
It changes in response to hormones (remember it’s CT, not muscle!) When not ovulating, cervical mucous will prevent sperm from reaching the uterus, which prevents fertilization. Also filters out “unfit” sperm
Functions of the ovaries
Storage, maturation and release of oocytes
Formation of corpus luteum
Production and sevretion of hormones (E and P)
Things that absolutely do not impact the rate of declining eggs in a woman over time
Definitely NOT
Age of menarche, # of pregnancies, use of contraceptives, or # of IVF cycles. We have so many eggs that we’re never going to use.
Most basic stage of oocyte/follicle, found in fetus
Primordial follicle w/ primary oocyte
Final follicle form (one that’s actually going to make a proper egg)
Graafian follicle
Function of hypothalamus in cycles (most basic form)
Pituitary serves as the communication system between the nervous/endocrine system
How can the thyroid gland affect a fetus
Impacts the HPO axis. Elevated thyrotropin stimulates the pit to secrete prolactin. Excess prolactin inhibits GnRH, which can cause pregnancy loss and complications in fetal development.
What does it mean if you’re in the secondary phase/secretory phase?
It means you’ve ovulated, marked by elevated progesterone
Menarche
First menstruation. Usually at 12-13. Abnormal if <8 or >15. % of body fat plays a big part in this. Can make it happen abnormally early/late
Thelarche
Breast development
Pubarche
Pubic hair development
Menorrhagia
Abnormally heavy bleeding at regular intervals.
What to keep in mind when working up menstruation pathologies
Find out if the woman has ovulated or not, this changes the WU
All irregular bleeding must be worked up because it can be a sign of cancer
Metrorrhagia
Bleeding at irregular intervals (the metro always runs at weird times)
Menometrorrhaggia
Abnormally heavy bleeding at irregular intervals.
Intermenstrual bleeding
Bleeding in between normal menstrual cycles
Polymenorrhea
<21 day cycle intervals. Happens too much
Oligomenorrhea
> 35 day cycles. Happens toolittle
Hypomenorrhea
Extremely light menstrual flow
Mittelschmerz
Pain mid cycle from ovulating
Overview of menstrual cycle (read only)
1) Begins at hypoT, which sends GnRH to the pit
2) Pit sends LH/FSH to the ovaries
3) Ovaries send signal to uterine endometrium & negative feedback to the hypoT and pit
4) Uterine endometrium thickens and then bleeds (if not pregnant)
What two phases make up the ovarian cycle
1) Follicular phase. Can vary in length
2) Luteal phase. Post ovulation, will always be 14 days.
What three phases make up the uterine cycle?
1) Proliferative
2) Secretory phase
3) Menstruation (or pregnancy)
Ovarian follicular phase corresponds to the _____
Proliferative phase of the uterine cycle
Ovarian luteal phase corresponds to the ________
Secretory phase of the uterine cycle
Uterine Proliferative phase corresponds to the _______
Follicular phase of the ovarian cycle
Uterine Secretory phase corresponds to the ________
Luteal phase of the ovarian cycle
How long is the luteal phase of the ovarian cycle?
14 days
If you don’t ovulate, you don’t have ____ phase of the ovarian cycle
Luteal
What happens to the corpus luteum if unfertilized?
Undergoes apoptosis/macrocytosis and forms the corpus albicans
What day of the cycle does ovulation happen at?
14 days
When does the secretory phase of the uterine cycle begin?
Begins after ovulation! Secretes loads of progesterone to stabilize the endometrium so it can sustain a fetus
What two cells are oocytes surrounded by? What are their function?
Surrounded by granulosa cells and theca cells.
Granulosa- Contain FSH receptors and produce estrogen! Also helps out by converting androgens to estrogen.
Theca- Contains LH receptors and makes estrogen.
What kind of receptors do granulosa cells contain
FSH
What kind of receptors do theca cells contain
LH
What hormone bursts “finish off” maturing the egg and getting it ready for fertilization?
Big burst of LH
What kicks off the HPO (hypothal-pit-ovarian) axis?
Hypo releases GnRH
What does GnRH trigger?
Triggers the ant pit to make LH and FSH
What does FSH and LH do?
Stimulates the ovarian follicle to make estrogen. LH specifically targets the theca cells to make them produce more androgens as well
What suppresses FSH (neg feedback!)
Estrogen produced from the ovary!
What suppresses GnRH (neg feedback!)
Estrogen, progesterone, testosterone. The androgens produced by the theca cells
What do elevated estrogen levels cause?
Triggers the ant pit to release a bunch of LH, which finishes off the egg.
Which hormone gets only positive feedback in the HPO?
LH! Never gets neg feedback
Are the hormones in the HPO axis released constantly or nah
Nah. Pulsatile, be wary of taking levels, you could get a low reading and it’s just a trough
Patient comes in with primary amenorrhea, short, webbed neck and widely spaced nipples. Whatdya thinking
Turner’s syndrome!
Amenorrhea
Absence of menstruation. Can be primary or secondary. Can be transient, intermittent or permanent
> 50% of cases of primary amenorrhea is ____
Gonadal dysfunction
Primary Amenorrhea
Never had menarche
Secondary Amenorrhea
Started menses and then stopped.
Most common cause of secondary amenorrhea
PREGNANCY
Second most common cause of secondary amenorrhea
Hypothalamus dysfunction
Three types of hypothalamic dysfunction
1) Constitutional delay of puberty
2) Isolated GnRH deficiency
3) Functional hypothalamic amenorrhea
Constitutional delay of puberty
Everything is normal! They’re just starting a little late. Absolutely primary amenorrhea, wait and watch. However, this is a diagnosis of exclusion, you’ve got to rule out everything else first.
Causes of functional hypothalamic amenorrhea
1) Stress
2) Overexercise
3) Eating disorder
High levels of cortisol shut down GnRH in hypoT. Correct the cortisol and you’ll correct the amenorrhea. Called functional because it is NOT pathologic.
Why would we consider OCP’s for patients with amenorrhea?
Amenorrhea women are not producing enough estrogen so we’d be concerned about bone health
Three main causes of pituitary dysfunction
1) Hyperprolactinemia
2) Prolactinomas (adenomas that secrete prolactin)
3) Other masses/diseases of the pituitary
Causes of hyperprolactinemia
Tumor, anti psych Rx, trauma, stress, alterations in sleep.
Does hyperprolactinemia usually cause primary or secondary amenorrhea
Secondary! Very rarely causes primary
Causes of ovarian dysfunction
Turner Syndrome (X0) Swyer Syndrome-gonadal dysgenesis (XY) Primary Ovarian insufficiency Ovarian tumors (rare) PCOS
What is primary ovarian insufficiency?
Normal karyotype, but undergoes menopausal @ <40yo. Think fragile X, family history is a big part of this
What is Swyer Syndrome (XY gonadal dysgenesis)
Genotypically male but phenotypically female. These patients will have non functional gonads, they’re premalignant and fibrotic, and should be removed.
What is PCOS?
Polycystic ovarian syndrome. Pretty common in reproductive women. Usually oligomenorrhea rather than amenorrhea. Increased androgen decreases ovary function.
Must have 2 out of these three things to be diagnosed with PCOS
1) Hyperandrogenism
2) Polycystic ovaries on US
3) Amenorrhea/oligomenorrhea
Uterine dysfunction & outflow tract disorders that can cause amenorrhea
1) Intrauterine adhesions (Asherman syndrome)
2) MRKH syndrome
3) Imperforate hymen
4) Transverse vaginal septum
What is Asherman syndrome? What type of amenorrhea does it cause?
Ashermans syndrome is adhesions/scarring of endometriurm/uterus. NOT CONGENITAL. Caused by PPH or infection via instrumentation. Causes secondary amenorrhea
What is MRKH?
Defect in development. Absence or defect in vagina/uterus. Pts are born w/o a vagina, may or may not have a uterus or a portion of the uterus. Neovaginal out of bowel. So cool. It’s congenital, so primary amenorrhea.
Hx questions specific to primary amenorrhea (really just read this, not a biggie)
1) Completed other stages of puberty?
2) Family history of delayed/absent puberty?
3) Height in relation to family members?
4) Normal neonatal and childhood health?
Hx questions specific to secondary amenorrhea (really just read this, not a biggie)
1) Are there any symptoms of estrogen deficiency, including hot flashes/vaginal dryness/poor sleep/decreased libido
2) Hx of obstetrical catastrophe, severe bleeding, D&C, endometritis or anything else that may have caused scarring in the endometrial lining (Asherman)?
PE Workup for amenorrhea
Growth
Skin
Breast exam/development
Pelvic exam (check for signs of E deficiency)
Parotid gland swelling or erosion of dental enamel (bullemia)
Lab WU for amenorrhea
HCG FSH TSH PRL (prolactin) T- if indicated
***do an US to make sure there’s a uterus
Dysmenorrhea
Recurrent crampy lower abd pain during menstruation, no other pelvic pathology.
What’s pathognomonic for dysmenorrhea
Crampy pain stops upon menses
Sx of dysmenorrhea
Crampy lower abd/pelvic pain Back pain N/V Diarrhea HA Fatigue Dizziness
First line tx for dysmenorrhea
NSAIDS. Effective for 90% of cases.
Ibuprofen or naproxen. However if these aren’t effective, try mefenamic acid. It’s more specific to the uterus
Second line tx for dysmenorrhea
Hormonal! OCPs prevent dysmenorrhea by suppressing ovulation, so they won’t have those ovulating symptoms
When is hormonal tx first line for dysmenorrhea?
When the patient is sexually active
Premenstrual syndrome (PMS)
Physical and emotional sx that happen recurrently in the 2nd half of menstrual cycle, resolve with menses and interfere with the woman’s life
Premenstrual Dysphoric Disorder (PMDD)
Severe form of PMS marked by anger, irritability and internal tension
Emotional symptoms of PMS/PMDD
Mood swings Angry outbursts Irritability Anxiety Depression Inc appetite or food cravings Sleep disturbances/insomnia Poor concentration
Physical symptoms of PMS/PMDD
Breast tenderness/pain Bloating Constipation HA Fatigue Dizziness Hot flashes
When do the sx of PMS/PMDD occur
Must begin during the luteal phase & end with the onset of menses. ~ 6 days per month
Why are antidepressants first line for severe PMS/PMDD
Because PMDD is associated with an increased risk of suicide ideation/suicide attempts. It’s a hormonal problem, we’re fixing the hormones.
Tx for mild PMS
Exercise and stress reduction
1st line for mod/severe PMDD
SSRI
2nd line for mod/severe PMDD
OCP- maybe augment w/ a benzo
3rd line for mod/severe PMDD
GnRH agonist therapy w/ low dose Estrogen/Progesterone replacement therapy. This will basically induce menopause, this is why it’s second to last line
Last line therapy for PMDD
Surgery
Dysfunctional Uterine Bleeding
Abnormal uterine bleeding unrelated to any kind of lesions/pregnancy/disease/pathology. Usually due to a HPO axis issue
What is key to diagnosing dysfunctional uterine bleeding
Determining whether or not ovulation is occurring
When does dysfunctional uterine bleeding normally occur and why?
Occurs right after menarche and during perimenopause, because these are time periods where we see a lot of menses w/o ovulation.
