Menstrual Cycle and associated Disorders Flashcards
Menstrual Cylcle
- The cycle lasts 21–35 days on average.
- The cycle consists of two phases:
- Follicular phase : First day of menses to the day before the LH surge
- Luteal phase : lasts 14–15 days. Day of the LH surge to the beginning of the next menses
- Menses last an average of 3–7 days
- First few years following menarche → irregular menstrual cycles (caused by immaturity of the hypothalamic-pituitary-gonadal axis)
- Menstrual cycles are longest at 25–30 years of age, with younger and older women having shorter cycles
Primary Dysmenorrhea
recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings that could account for those symptoms)
Primarry Dysmenorrhea
Etiology
- Etiology: unknown;
- Risk factors
- early menarche
- nulliparity
- smoking
- obesity
- positive family history
Primary Dysmenorrhea
Pathophysiology
- increased endometrial prostaglandin (PGF2 alpha) production →
- vasoconstriction/ischemia and stronger, sustained uterine contractions
Primary dysmenorrhea
clinical features
- Spasmodic, crampy pain in the lower abdominal and/or pelvic midline
- radiating to the back or thighs
- Usually occurs during the first 1–3 days of menstruation
Primary Dysmenorrhea
Tx
- Symptomatic treatment: pain relief (e.g., NSAIDs), topical application of heat
- Hormonal contraceptives (e.g., combined oral contraceptive pill, IUD with progestogen)
Secondary Dysmenorrhea
recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition
Most common cases:
- Endometriosis
- Pelvic inflammatory disease (PID)
Other causes:
- Intrauterine device (IUD)
- Uterine leiomyoma
- Adenomyosis
- Psychological factors
Primarry Amenorhea
- the absence of menarche at age 15 years despite normal development of secondary sexual characteristics
- bsence of menses in girls aged 13 yearswith no secondary sexual characteristics
Primary amenorrhea with normal puberty
Etiology
- Anatomic anomalies:
- hymenal atresia,
- vaginal septum,
- Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome
- Competitive sports (low body mass index suppress the hypothalamic-pituitary-gonadal axis)
Mayer-Rokitansky-Küster-Hauser (MRKH)
aka: Müllerian aplasia
are, congenital defect in which the Müllerian ducts fail to fuse, which results in an atretic uterus, cervix, and upper-third of the vagin
Hypergonadotropic Hypogonadism
insufficient sex steroid production in the gonads that leads to low serum concentrations of sex hormones and compensatory increase in the concentrations of pituitary gonadotropins
Hypogonadotropic hypogonadism
decreased gonadal function due to a disease that primarily affects the pituitary gland and/or hypothalamus. Characterized by low concentrations of pituitary gonadotropins
Primary amenorrhea with development retardation
Etiology
Hypogonadism
- Hypergonadotropic hypogonadism
- Hypogonadotropic hypogonadism
Seoncdary Amenorrhea
absence of menses for more than 3 months (in women with previously regular cycles) or 6 months (in women with previously irregular cycles)
Secondary amenorrhea
etiology
- pregnancy most common cause
- Ovarian disease (PCOS)
- Hypogandism
- hypergonadotropic hypogonadism
- hypogonadotropic hypohonadism
- Hypothyroidism
Functional Hypothalamic amenorrhea
Hypogonadotropic Hypogonadism
Etiology: excessive exercise, reduced calorie intake (e.g., in eating disorders like anorexia nervosa), stress
Functional hypothalamic amenorrhea
pathophysiology
- states of decreased energy availability →
- body regulates reproductive potential down by decreasing GnRH release from the hypothalamus →
- decreased secretion of FSH and LH →
- anovulation and secondary amenorrhea →
- infertility
Functional hypothalmic amenorrhea
Tx
- Lifestyle changes: reduce stress, improve nutrition, increase body weight BMI > 19 kg/m2
- Offer pulsatile GnRH therapy or gonadotropin therapy to induce ovulation
- Should only be offered in patients with BMI> 18.5 kg/m2
Premensstrual Syndrome (PMS)
- onset of severe discomfort or functional impairment prior to menstruation
- 5 days before menstruation; symptoms end within 4 days of start of menstruation
- occurs in ∼ 5–10% of women
- majority of women (∼ 75%) of reproductive age experience discomfort for 1–2 days prior to menstruation. These symptoms are usually mild and not considered premenstrual syndrome (PMS).
PMS Clinical Features
- Pain: dyspareunia, breast tenderness, headache, back pain, abdominal pain
- Gastrointestinal: nausea, diarrhea, changes in appetite
- Tendency to edema formation
- Neurological: migraine, increased sensitivity to stimuli
- Psychiatric: mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness
- Premenstrual dysphoric disorder (PMDD)
Premenstrual Dysphoric Disorder (PMDD)
- Psychiatric symptoms in pms: mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness
- Premenstrual dysphoric disorder (PMDD): severe form of affective symptoms that interferes with daily life, including having abnormal disagreements with family, friends, and colleagues
PMS tx
- Lifestyle changes can be beneficial
- exercise, healthy diet,
- avoiding individual triggers like alcohol or nicotine
- NSAIDs
- Oral contraceptives
- If PMDD: SSRIs (e.g., fluoxetine)
MIttelschmerz
- Recurrent, unilateral, lower abdominal pain in women of reproductive age caused by the transient peritoneal irritation following enlargement and rupture of the follicular cyst during ovulation
- Mittelschmerz is benign and occurs midcycle (immediately before or at the time of ovulation)
Mittelschmerz
clincal features and Tx
- Clinical features: recurrent, unilateral, lower abdominal pain
- Management: symptomatic treatment with NSAIDs as needed
Abnormal Uterine Bleed
Abnormal uterine bleeding is defined as menstrual bleeding that is abnormal and/or irregular in frequency, duration, and/or intensity. It may or may not be accompanied by dysmenorrhea.
two types
- strauctural causes
- non structural causes
PALM- COEIN system
- (PALM) Structural Causes: Polyps, Adenomyosis, Leiomyomas, Malignancy/Hyperplasia
- (COEIN) Non-structural causes: Coagulaopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified
Polymenorrhea
cycles with intervals <21 days
Causes:
- Menarche, menopause
- Psychological stress
Oligomenorrhea
cycles with intervals of 35-90 days
Causes:
- Pregnancy (including ectopic pregnancy)
- PCOS
- Insufficient caloric intake
Hypermenorrhea
Heavy Menstruation with bleeding volume >150ml
Causes:
- Endometrial cancer/hyperplasia
- Endometriosis
Menorrhagia
Increased Bleeding; volume > 80 mL and/or length of menstruation > 7 days
Common Causes:
- Endometrial cancer/hyperplasia
- Endometriosis
Hypomenorrhea
Very low bleeding volume (< 25 ml)
Common Causes:
- Endometrial atrophy
- Eating disorders (e.g., anorexia nervosa)
- Chronic endometritis
- Oral contraceptive use
meTROrrahagia
Bleeding between perios
common causes:
- Ovarian insufficiency
- Myoma, endometrial cancer/hyperplasia, cervical cancer
- Oral contraceptive use
menometrorrhagia
Heavy irregular bleeding
Common causes:
- Ovarian insufficiency
- Myoma, endometrial cancer/hyperplasia, cervical cancer
- Oral contraceptive use
Spotting
minimal bleeding seen in sevral condittions
Common causes:
- After ovulation
- Breakthrough bleeding: mid-cycle bleeding caused by hormoneimbalances (usually after starting new OCP therapy)
- Endometriosis
- Myomas, polyps, carcinomas, contact bleeding
- During pregnancy: may indicate imminent abortion
Types of estrogen
estradiol, estrone, estriol
- Potency: estradiol > estrone > estriol
- During pregnancy:
- 100-fold increase in estradiol and estrone
- 1000-fold increase in estriol
- Estriol is secreted by the placenta as unconjugated estriol (free or uE3)
- Decreased levels are associated with Down syndrome, Edward syndrome, molar pregnancy, and fetal demise.
Estrogen Synthesis in the Ovaries
Primarily takes place in the ovarian granulosa cells
- LH stimulates androgen synthesis in ovarian theca cells
- FSH stimulates conversion of androgens to estrogens
- catalyzed by the aromatase enzyme
Exogenous Estrogen synthesis
Aromatase containing tissues:
- Adrenal glands
- Fatty tissue
- Placenta
- Testicles
Effects of Estrogen on sex characteristics
- Uterus: endometrial proliferation
- Cervix: increased production of cervical mucus → facilitates passage of sperm
- Vagina: proliferation of epithelium
- Pubis: hair growth
- Breast: breast growth
effects of estrogen on extragenital
- Bones: promotes bone formation by inhibiting bone resorption (induces osteoclast apoptosis)
- Blood vessels: protective effect against atherosclerosis
- Blood clotting: increased risk of thrombosis
- Kidneys: increased water and sodium retention → may contribute to edema
- Liver: decreased bilirubin excretion
Adverse effects of estrogen
- Weight gain (edema)
- Liver toxicity
- Breast hypertrophy, gynecomastia (in men)
- Thrombosis
- Spider nevi, gynecomastia, and testicular atrophy in individuals with cirrhosis
Estrogen and Cancer
Increased cancer risk
- Endometrial cancer
- Breast cancer
Reduces the risk
- colon cancer
Hyperestrogenism
a condition of increases circulating estrogen
Hyperestrogenism Etiology
- Increased estrogen production (e.g., due to ovarian tumors, obesity)
- Excess estrogen supplementation (e.g., due to hormone replacement therapy)
- Decreased metabolism and excretion of estrogens (e.g., due to chronic liver disease)
Hyperestrogenism Clinical Features in WOMEN
Women:
- menstrual irregularities
- enlargement of the breast and uterus
- infertility
- increased cancer risk (e.g., endometrial cancer)
Both sexes:
- palmar erythema, spider telangiectasias
Hyperestrogenism Clinical Features in MEN
Men:
- gynecomastia
- testicular atrophy,
- reduced libido
- erectile dysfunction
- infertility
- decreased body hair (e.g., loss of chest hair, female pattern of pubic hair distribution)
Both sexes:
- palmar erythema
- spider telangiectasias
Hypoestrogenism
a condition of decreased circulating estrogen
Hypoestrogenism Etiologies
- Menopause
- Ovarian insufficiency: idiopathic or secondary to an underlying conditions (e.g., Turner syndrome, polycystic ovary syndrome)
- Congenital aromatase deficiency (↓ aromatase → ↑ androgens and ↓ estrogen)
- Hyperprolactinemia (e.g., in pituitary adenomas, hypothyroidism)
- GnRH agonists