Menstrual D/O Flashcards by Lauren Lover

___ is the absence of menarche by 15 y/o

Primary amenorrhea

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____ is the absence of menses for 6+ months in a woman previously menstruating

Secondary amenorrhea

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What are some causes of primary amenhorrhea?

Chromosomal abnormalities

Structural abnormalities

Hypothalamic/pituitary/ovarian causes

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____ is the most common cause of primary amenorrhea and is characterized by a woman only having 1 chromosome

Turner syndrome

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____% of 45, XO (turner syndrome) conceptions are lost prior to birth, usually in the first or second trimester

99%

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What are common S/s of a pt w/ turner syndrome?

Short stature
Infertility
Primary gonadal failure
Osteoporosis

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What is meant by “streak gonads”?

Description given to ovaries of a pt w/ turner syndrome

*little to no estrogen is produced

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T/F Pregnancy is possible in a pt w/ turner syndrome w/ a donated egg or IVF

**pts w/ turner syndrome have a normal uterus and vagina

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~ ___% of girls w/ turner sydnrome are missing the X chromosome in SOME of their cells, which is then called _______

30%

turner mosaic syndrome

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People with mosaic 45,XO syndrome are at risk for ____ and have (MORE/LESS) sx?

premature menopause

LESS

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How do you manage a pt w/ turner syndrome?

Hormone replacement starting in their teens

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What are structural causes of primary amenorrhea?

Absence of the uterus, cervix, or vagina

Transverse vaginal septum

Imperforate hymen

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Mullerian abnormalities are caused by the failure of the ______ to fuse

What are possible consequences of this failure?

Paramesonephric ducts

Absence of the uterus, cervix, and upper 1/3 of vagina

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WTF do you think Mayer-Rokitansky-Kuster-Hauser syndrome means?

“Old school” name for the family of Mullerian agenesis conditions, LOL

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___ is the result of abnormal apoptosis of the vaginal plate and can obstruct the outflow of blood causing amenhorrhea

Transverse Vaginal Septum

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_____ is the absence of appropriate apoptosis of the cells of the hymenal membrane, which originates from cells of the urogenital sinus (external tissue)

Imperforate hymen

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____ is the collection of blood due to outlet obstruction that can cause pain

Hematocolpos

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What is the management for primary amenorrhea?

Resection if it is an imperforate hymen, vaginal septum

Hysterectomy for absent cervix

Creation of neovagina if necessary

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____ is a hypothalamic malfunction due to significant physical or psychological stressors such as:

Eating d/o (anorexia nervosa)
Vigorous exercise
Very low body fat
High emotional or physical stress

Functional hypothalamic amenorrhea
**can cause secondary amenorrhea too!

**affects 4-8% of the population at some point (usually presents as secondary amenorrhea)

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How do you tx functional hypothalamic amenorrhea?

Address behavioral issues/stressors –> Weight gain if indicated

Hormone supplementation

Consider combined OCs for osteoporosis prevention

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____ is a congenital GnRH deficiency classically associated w/ anosmia, that also causes primary amenorrhea

Kallmann Syndrome

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GnRH neurons are born from stem cells in the ____

What is the most common cause of Kallmann Syndrome?

Nasal placode

Migration failure is the most common cause–> GnRH neurons that fail to migrate properly are nonfunctional

People born w/ olfactory tract dysgenesis are at very high risk for Kallman Syndrome

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What sx may a pt w/ Kallman Syndrome have besides anosmia?

How can they be managed?

Delayed tanner staging

Manage w/ estrogen/progestin therapy

GnRH can be used to induce ovulation

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Infiltrative dz and tumors of the hypothalamus can cause primary amenhorrhea (can also cause secondary amenorrhea!)

What are some examples of these? (just FYI)

Tumors –> 90% prolactinomas

Craniopharyngioma
Germinoma
Lymphoma
Sarcoidosis

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What are pituitary causes of priamry or secondary amenorrhea? Ovarian causes of primary or secondary amenorrhea?

Pituitary adenoma PCOS: cause of 20% secondary amenorrhea Premature ovarian failure: depletion of functional oocytes <40 y/o) ** CA tx, genes, autoimmune things cause this

___ is characterized by 46 XY karyotype w/ nonfunctional androgen receptors

Androgen insensitivity syndrome (“testicular feminization”)

A pt w/ Androgen insensitivity syndrome (“testicular feminization”) have a ___ phenotype but ___ may be absent, and __ may be present in the labia

female (XX phenotype) female organs testes (XY genotype )

What labs should you order for a pt w/ primary amenorrhea if a uterus/vagina are present?

B-HCG FSH Karyotype if FSH elevated Prolactin

What labs should you order for a pt w/ primary amenhorrhea if a uterus/vagina are absent?

Karyotype | Serum testosterone

What is the most common cause of secondary amenorrhea?

Pregnancy *Must get a b-hCG every time!

Other than pregnancy, what are the other causes of secondary amenorrhea?

Hypothalamic – 35% Ovarian – 40% Pituitary – 19 % Uterus – 5%

What medical interventions can cause secondary amenorrhea? (x4)

Hormonal contraceptives Progestin IUD Metoclopramide (Reglan) (Causes hyperprolactinemia) Antipsychotic drugs (Thorazine, Haldol, Risperdal) (Cause hyperprolactinemia)

___ is a nutritional deficiency that can impact hypothalamic function and cause secondary amenorrhea

Celiac dz

Is Athletic Amenorrhea a real thing?

Yep. Yupp. Yeppers.

T/F Elevated prolactin levels can cause amenorrhea

T/F TSH will not impact the menstrual cycle

F, it will!

____ is acquired scarring of the endometrial lining, due to prior surgery or intrauterine infection and can cause (secondary/primary) amenorrhea

Asherman’s syndrome Secondary

If a pt has a BMI >30 and is experiencing amenorrhea, what underlying condition should you suspect?

PCOS

If a pt has a BMI <18.5 and is experiencing amenorrhea, what underlying condition should you suspect?

Functional hypothalamic amenorrhea

What labs should be ordered to work-up secondary amenorrhea?

``` B-hCG Prolactin FSH TSH Serum testosterone (if signs of androgen excess) ```

Describe the Progestin w/drawal test What does w/drawl bleeding indicate?

1. Provera 10 mg/d x 10 d, then stop. If they have w/drawal bleeding, they are not making progesterone, and may not be ovulating

If no menses occurs after preforming the Progestin w/drawal test what should be done next? What would a lack of bleeding indicate? What would bleeding at this point indicate?

Supplement w/ estrogen, then repeat progestin w/drawal No bleeding= Asherman’s syndrome Bleeding = intact uterus/endometrium that is not receiving estrogen/progesterone– POF, hypothalamic amenorrhea

What other tests may you order to work up secondary amenorrhea?

US for endometrial thickness pituitary MRI Karyotype if FSH elevated (r/o partial chromosome deletion) Evaluate for ovarian or adrenal tumor if high androgen levels

How is hyperprolactinemia tx'd?

Rx: Dopamine agonist (cabergoline, bromocriptine) Surgery for selected macroadenomas (large, poor response to medication)

What is the tx for premature ovarian failure?

Estrogen/progestin therapy to prevent bone loss, manage menopausal sxs

What is the recommended tx for Asherman's syndrome?

Hysteroscopic lysis of adhesions | Long-term estrogen supplementation for endometrial growth

___ is pelvic pain that occurs during menstruation in the absence of pelvic pathology Cramps may be accompanied by what other sx?

Primary dysmenorrhea N/V/D, back pain, HA, dizziness

___ is pain w/ menses that results from pathologic changes in the pelvic viscera

Secondary dysmenorrhea

Primary dysmenorrhea begins w/ the onset of what? Sx start (before/after) flow onset and may last several days

regular ovulatory cycles before

Primary dysmenorrhea occurs in ___% of teens --> only ___% will seek attention

60% | 15%

What causes primary dysmenorrhea?

Excess production of endometrial prostaglandins

What are the effects of excess production of endometrial prostaglandins?

Increased uterine contractions Dysrhythmic or tetanic uterine contractions Increased uterine muscle tone GI tract stimulation

When working up primary dysmenorrhea, when is a pelvic exam indicated?

Sxs are severe | Pt is sexually active

When should labs be ordered for primary dysmenorrhea?

Only if the pt is sexually active Screen for chlamydia, gonorrhea *Do a hCG test no matter who it is!

What is the primary management for primary dysmenorrhea?

NSAIDS! | Ibuprofen, naproxen, mefenamic acid

After initiating NSAIDs, what is the next step in managing a pt w/ primary dysmenorrhea?

Combined OCPs **use if pt is sexually active, NSAIDs tx failed, or not tolerated

If NSAIDs and OCP fail, what do you need to do next for tx of primary dysmenorrhea?

May need to perform a laparoscopy to r/o endometriosis or ovarian pathology Other indications for laparoscopy * * Pelvic pain outside of menses * * Hx of STI * * Onset of sx w/ menarche

What are some causes of secondary dysmenorrhea? (there are a lot just be able to recognize)

``` Endometriosis Adenomyosis Uterine leiomyomata Ovarian cysts Pelvic adhesions Chronic PID Obstructive uterovaginal anomalies Cervical stenosis Copper IUD IBS Inflammatory bowel disease Interstitial cystitis ```

The prevalence of secondary dysmenorrhea (increases/decrease) with age The prevalence of primary dysmenorrhea (increase/decreases) with age, and may remit after a term pregnancy

increase decrease

what are hx facts that may be suggestive of dysmenorrhea?

``` onset after 25 y.o. abnormal uterine bleeding pain is non-mid-line absence of other menstrual sxs dysparunia, dyschezia progressive sxs ```

How can you tx secondary dysmenorrhea?

``` NSAIDs OCPs tx underlying d/o (below is fyi) - abx for pelvic infxn - Cautery of endometrial implants - Hormonal tx for endometriosis - Resection of symptomatic fibroids - Ovarian cystectomy - Hysterectomy - Drug tx for inflammatory bowel disease - Drug tx for interstitial cystitis ```

___ is menstrual blood loss >80 ml (avg. = 35-40 ml)

Menorrhagia

___ is duration of menses greater than 7 days

Prolonged menses

___ is irregular bleeding, especially between menses

Metrorrhagia

___ is excessive and irregular uterine bleeding

Menometrorrhagia

___ is abnormal bleeding not from anatomic abnormality, generally anovulatory bleeding.

Dysfunctional uterine bleeding (DUB)

___ is a cycle length less than 24 days

Polymenorrhea

What are causes of menorrhagia?

Anovulation/DUB Anatomic abnormalities Coagulopathy

___ is common in adolescence, perimenopause, PCOS, thyroid d/o

Anovulation/DUB

What is a key thing you should try to determine on the PE of Menorrhagia?

where is the bleeding site

What should be included in the work-up for Menorrhagia?

``` B-hCG CBC Cervical ctyology endometrial biopsy STI screen TSH Coagulation studies pelvic US Hysterscopy ```

how can you treat menorrhagia If it’s due to anovulation?

Cycling with combined OCs Scheduled progestin withdrawal bleeds Medicated IUD (Mirena)

how can you treat menorrhagia If it’s caused by an anatomic abnormality?

Hysteroscopic resection of endometrial polyps, submucous myomas OCs and medicated IUD may have some efficacy at controlling heavy bleeding from myomas and adenomyosis Endometrial ablation Myomectomy Hysterectomy