Menstrual Cycle Disorders Flashcards
Premenstrual syndrome (PMS)
Cyclic occurrence of symptoms that are sufficient severity to interfere with some aspects of life that appear with consistent and predictable relationship to menstration
Symptoms include
- mood symptoms (irritability and mood swings or depression or anxiety)
- physical symptoms (bloating, abdominal discomfort, breast tenderness, insomnia, hot flushes, migraines)
- cognitive changes (confusion and poor concentration, social withdrawal)
symptoms MUST occur in the 2nd half of the menstrual cycle (luteal phase)
- *there must be a symptom-free period of at least 7 days in the first half of the cycle, must be relived within 4 days of the onset of menses and not recur until at least day 13 must occur in at least 2 consecutive cycles**
- this is challenging so often need the patient to take carful journal entries for when symptoms come and go
Pathogenesis is believed to be due to physiologic ovarian functions (since it goes away with suppression of the cycle). However the exact mechanism is unknown
- **serotonin is the neurotransmitter relegated to this also.
- *is a diagnosis of exclusion and medical history = rule out thyroid disease and anemia**
- also rule out emergent things for symptoms as well
PMDD = severe PMS with symptoms that actually disrupt every day living and activity
Acute vs chronic uterine bleeding
Acute = immediate bleeding sufficently heavy to require immediate intervention
Chronic = bleeding that has been present very commonly in the last 6 months
Normal menstruate cycle
Normally every 28 days (+/- 7 days)
- average duration si 5 days
Heavy menstrual bleeding (menorrhagia)
Excessive flow that commonly lasts 8 days or longer per period
- blood loss is usually > 80mL
- also commonly has presence of clots
- often have to change pads every 3 hrs and usually pass clots 1 inch or greater
- *90% shows hemoglobin below 12 g/dL**
- 10% is still possible for normal hemoglobin
pictorial blood assessment is used to try to standardize menorrhagia
Asks for daily number of tampons used during the entire period cycle
- 1 pt = for every lightly stained tampon
- 5 pt = for every moderately saturated
- 10 pt = completely soaked
- 1 pt for closes 2 mm in diameter
- 5 pt for large clots (> 3mm)
** total of > 100 pts per menstrual cycle = positive for heavy menstrual bleeding
Amenorrhea
Absence of menstrual bleeding in > 6 months
- 3-5% of women exercise at least 3 months of “secondary amenorrhea” in any specific year
Bleeding is decreased in amount correlated to the association of anovulation
Estrogen secreting tumors often causes this but starts with olgiomenorrhea first
there is no prevalence increase among race or ethnicity
Irregular cycle definition
Cycle lengths vary from cycle-cycle by at least 10 days from each other
Mastodynia
Breast pain that occurs in the cyclical occurrence in the luteal phase of menstrual cycle
Is directly correlated with degree of ductal dilation as well
- *is repeated to high gonadotropin levels**
- estrogen = stimulates ductal dilation
- progesterone = stimulates the breast stroma
Is believed that prolactin has also been suggested as a contributor
- *always rule out neoplasms, fibrocystic change **
- get FNA and ultrasound or mammograms to help monitor/rule out other causes
Treatments for PMS
1) lifestyle
- Limit caffeine, alcohol, tobacco, chocolate
- Decrease sodium intake as well as eat small, frequent meals
- Stress management and CBT
- Aerobic exercise
Supplements
- calcium carbonate = bloating and cravings
- magnesium = water retention
- vitamin B6
- vitamin E
- NSAIDs
- spironolactone = cyclic edema
- bromocriptine = mastalgia
Medications
- fluoxetine and sertraline (SSRIs) = start 14 days prior to onset of menstration and continue to the end of the cycle as needed
- Drospirenone, and estradiol patch (OCP)
- **GnRH agonists can help but there is increased risk for osteoporosis
- danazol = mastalgia only
Surgery
- bilateral oophorectomy with estrogen replacement = definitive but invasive
Dysmenorrhea
Painful menstruation that prevents normal activity
- occurs usually layer in adolescence (not menarche)
- pain ALWAYS occurs at first day of menses
3 types:
1) primary = no organic cause
2) secondary = pathological cause
3) membranous = cast of endometrial cavity is the cause
Pathogenesis
- occurs with ovulation cycles and is likely attributed to PGE and leukotriene activity
- ** there is some evidence showing psychological factors are genetic
Clincial findings:
- N/V, diarrhea and headaches are common
- **the PE shows no significant pelvic disease
- there generalized pelvic tenderness though
Diagnosis
- get US/ laparoscopy to rule out pelvic abnormalities (PID, ovarian cyst, endometriosis, etc)
- ** the most common misdiagnosis = secondary dysmenorrhea due to endometriosis (the difference is endometriosis shows pain 1-2 weeks BEFORE menses and is relieved the first day of menses)
- also endometriosis = severe pain during sex and adnexal tenderness
Treatment for dysmenorrhea
NSAIDs (celeoxikib) and acetaminophen = 1st line
- can give OCPs at lowest dose estrogen to help relieve pain also
For severe debilitating pain = codeine
Adjuvant treatments
- continuous heat to abdomen when pain is present
- exercise
- transcutaneous electrical nerve stimulation (TENS)
- DONT use herbal or dietary therapies (no evidence)
What must be ruled out for any diagnosis of abnormal uterine bleeding?
Pregnancy
Systemic diseases
Cancers
Hypomenorrhea
Unusually Light menstrual flow
- usually caused by obstruction (hymenal or cervical stenosis)
- can be caused by uterine synechiae (Asherman’s syndrome)
- can be caused by OCPs as well
Uterine synechiae (Asherman syndrome)
Intrauterine adhesions that result secondary to trauma to the basal layer of the endometrium with subsequent scarring
- commonly = previous pregnancy, dilation, surgery or infections (especially TB)
Often associated with infertility
Metrorrhagia
Bleeding that occurs at any time between menstrual periods
- is called “spotting”
Endometrial polyps and carcinomas are pathological causes
Exogenous estrogen administration = common cause of this type of bleeding
Polymenorrhea
Periods occur more often then once every 21 days
- is almost always anovulation as the cause
Menometrorrhagia
Sudden onset of irregular bleeding episodes at irregular intervals
- can be any condition, but have to rule out malignant tumors and pregnancy (normal in pregnancy)
Oligomenorrhea
Is a cycle length >35 days or <10 menses per year
must differ from amenorrhea which is if no menstrual period occurs for > 6 months
- *highly associated with polycystic ovarian syndrome (PCOS)**
- its usually this unless you can rule it out
Contact bleeding (postcoital bledding)
Bleeding that occurs after sex
- *is always a sign of cervical cancer until proven otherwise (must work this up immediately)**
- remember a negative cytology smear doesn’t rule out invasive cervical cancer
Other causes
- cervical eversion
- cervical polyps
- cervical/vaginal infections (trichomoniasis)
- atrophic vaginitis
The 9 basic categories to describe bleeding abnormalities
“PALM_COEIN”
- Polyp
- adenomyosis
- Leiomyomas
- Malignancy and hyperplasia
- Coagulopathy
- Ovulatory disorders
- Endometrium
- Iatrogenic
- Not yet classified
What needs to be included in abnormal uterine bleeding
CBC
HCG assay
TSH levels
Exclude systemic diseases that clinical symptoms may suggest (varies on what tests)
Cytologic examination
Gestational Trophoblastic disease (GTD)
Is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception
- **a tumor will grow after conception in the uterus with the fetus (“molar pregnancy”)
What history should always be included in abnormal uterine bleeding?
Amount of menstrual flow
Length of the menstrual cycle and periods
The length and amount of intermenstral bleeding per episode
Any contact bleeding?
