Menstrual D/O Flashcards
___ is the absence of menarche by 15 y/o
Primary amenorrhea
____ is the absence of menses for 6+ months in a woman previously menstruating
Secondary amenorrhea
What are some causes of primary amenhorrhea?
Chromosomal abnormalities
Structural abnormalities
Hypothalamic/pituitary/ovarian causes
____ is the most common cause of primary amenorrhea and is characterized by a woman only having 1 chromosome
Turner syndrome
____% of 45, XO (turner syndrome) conceptions are lost prior to birth, usually in the first or second trimester
99%
What are common S/s of a pt w/ turner syndrome?
Short stature
Infertility
Primary gonadal failure
Osteoporosis
What is meant by “streak gonads”?
Description given to ovaries of a pt w/ turner syndrome
*little to no estrogen is produced
T/F Pregnancy is possible in a pt w/ turner syndrome w/ a donated egg or IVF
T
**pts w/ turner syndrome have a normal uterus and vagina
~ ___% of girls w/ turner sydnrome are missing the X chromosome in SOME of their cells, which is then called _______
30%
turner mosaic syndrome
People with mosaic 45,XO syndrome are at risk for ____ and have (MORE/LESS) sx?
premature menopause
LESS
How do you manage a pt w/ turner syndrome?
Hormone replacement starting in their teens
What are structural causes of primary amenorrhea?
Absence of the uterus, cervix, or vagina
Transverse vaginal septum
Imperforate hymen
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
WTF do you think Mayer-Rokitansky-Kuster-Hauser syndrome means?
“Old school” name for the family of Mullerian agenesis conditions, LOL
___ is the result of abnormal apoptosis of the vaginal plate and can obstruct the outflow of blood causing amenhorrhea
Transverse Vaginal Septum
_____ 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
____ is the collection of blood due to outlet obstruction that can cause pain
Hematocolpos
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
____ 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)
How do you tx functional hypothalamic amenorrhea?
Address behavioral issues/stressors –> Weight gain if indicated
Hormone supplementation
Consider combined OCs for osteoporosis prevention
____ is a congenital GnRH deficiency classically associated w/ anosmia, that also causes primary amenorrhea
Kallmann Syndrome
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
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
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
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
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?
- 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
