Menstrual Disorders

Question 1

Dysmenorrhea

Answer 1

• Definition:
  
  • painful menstruation that affects normal activities
• Types:
  
  • Primary: due to increased prostaglandin (PGF2a) production by endometrium → painful uterine wall contractions; teens/early 20s
  • Secondary: due to pelvis or uterus pathology (i.e. endometriosis, PID, adenomyosis, leiomyomas (fibroids)); common with increased age
• S/sxs:
  
  • recurrent cramping at the midline of the lower abdomen at the onset of menses that gradually diminishes over 12-72 hours (primary) or throughout menses (secondary)
• PE:
  
  • **Usually normal
    
    • Normal pelvic exam, no physical findings that support symptoms → primary dysmenorrhea
  • Asymmetry or irregular uterine enlargement → fibroid (leiomyomas)
  • Tender, asymmetrical enlarged “boggy” uterus → adenomyosis
  • Cervical Motion Tenderness, adnexal pain, inguinal lymphadenopathy, fever, purulent cervical drainage → PID
• Dx:
  
  • Clinical diagnosis
  • Labs/imaging may be needed if pelvic disease is suspected
  • Note: childbearing has no effect on primary or secondary dysmenorrhea
• Tx:
  
  • Supportive: hot compresses
  • Primary: NSAIDs
    
    • -Estrogen-Progestin OCPs
    • -Laparoscopy: if unresponsive to 3 cycles of initial therapy to r/o secondary causes
  • Secondary: tx the underlying condition
    
    • (ex. Combined OCPs for endometriosis)

Question 2

Premenstrual Syndrome

Answer 2

• Definition: cluster of physical, behavioral, and mood changes with cyclical occurrence during the of the luteal phase menstrual cycle
• Epidemiology:
  
  • very common (premenstrual symptoms in 75-85% of women, 5-10% have PMS)
• S/sxs:
  
  • *symptoms occurring 1-2 weeks before menses & relieved with onset of menses
    
    • Physical: abd bloating, fatigue, breast tenderness/swelling, weight gain, headache, changes in bowel habits
    • Emotion: irritability, tension, depression, anxiety, libido changes
    • Behavioral: food cravings, poor concentration, noise sensitivity
• PE:
  
  • have pts record a diary of symptoms for multiple cycles
• Dx:
  
  • subjective Dx
  • PMDD Criteria
• Tx:
  
  • Lifestyle mods: stress reduction & exercise, reduction of caffeine/EtOH/salt
  • PMS: NSAIDs (for dysmenorrhea), OCPs (1st line for some)
  • PMDD: SSRIs (fluoxetine, sertraline, citalopram) are gold standard

Question 3

Premenstrual Dysphoric Dysphoric Disorder Criteria (DSM-V)

Answer 3

• *5 of the following with at least 1 from the first 4

1. Depressed mood or hopelessness
2. anxiety or Tension
3. Lability (strong emotions)
4. Increased or Persistent Anger, irritability of conflicts

• decreased interest, difficulty concentrating, lethargy, change in appetite, hyper/insomnia, overwhelmed

Question 4

Amenorrhea (Primary)

Answer 4

• Definition:
  
  • failure of menarche onset by age 16 (in the presence of secondary sex characteristics) or by age 13yo (in the absence of secondary sex characteristics)
• S/sxs:
  
  • No menstrual bleeding
• PE:
  
  • consider eval by age 15 or no menstruation within 3 years of thelarche (onset of breast development)
• Dx:
  
  • hCG to r/o pregnancy if sexually active
  • FSH, TSH, Prolactin
• Tx:
  
  • tx the underlying problem

Question 5

Amenorrhea (Secondary)

Answer 5

• Definition:
  
  • absence of menses for >3 months in a pt with a previously normal menstruation cycle or for the duration of 3 typical menstrual cycles for the patient with oligomenorrhea
• Etiology:
  
  • Pregnancy = MCC (95%)
  • Hypothalamus dysfx: function (poor nutrition/stress alters feedback to the brain that regulates the menstrual cycle), drug induced, psychogenic (anorexia), head injury
  • Pituitary Dysfnx: prolactinoma or pituitary infarct (Sheehan syndrome)
  • Ovarian Dysfnx: decreased estrogen & increased LH/FSH; PCOS, premature ovarian failure, Turner Syndrome, savage syndrome
  • Outflow tract dysfxn: Asherman’s syndrome (acquisition of scar tissue in uterus that causes blockage often d/t surgery or cancer tx) , imperforate hymen, no uterus/vagina
• S/sxs:
  
  • no menstrual bleeding
  • Female Athlete Triad:
  • -hypothalamic amenorrhea, eating disorder, osteoporosis
  • *Note: you need to be ~115 lbs to maintain cycle
• Dx:
  
  • hCG = 1st test to r/o pregnancy
  • *if hCG negative then order:
    
    • → serum prolactin, FSH, LH, TSH, estrogen
    • → testosterone if evidence of hirsutism or hyperandrogenism

Question 6

Hypothalamic Dysfunction in Amenorrhea (secondary)

Answer 6

• Disruption of GnRH pulsatile release & feedback of sex steroids from ovaries → pituitary not stimulated to secrete FSH/LH
  
  • → absence of normal follicular development (despite some estrogen production)
  • → no ovulation or support of corpus luteum
  • → no stimulation of endometrium
  • → no menstruation
  • **age matters: axis is immature the first decade after menses, mature from 20-40, & declines after 40

Question 7

Abnormal Uterine Bleeding

Answer 7

• Definition:
  
  • unexplained abnormal bleeding in nonpregnant woman in regard to quantity, frequency, or duration. Usually occurs just after menarche or in perimenopausal period
• Etiology:
  
  • Pregnancy
  • Uterine-Structural (PALM): polyp, adenomyosis, leiomyoma, malignancy (any postmenopausal bleed is cancer until proven otherwise)
  • Uterine-nonstructural (COEIN): coagulopathy (von Willebrand), ovulatory dysfunction (PCOS, stress, adrenal hyperplasia, thyroid probs), endometrial, iatrogenic (OCPs, warfarin), not yet known/classified
• S/sxs:
  
  • abnormal bleeding
  • Types:
    
    • Anovulatory = most common: unpredictable bleeding with variable flow/duration d/t chronic estrogen production unopposed by progesterone → endometrium proliferation that eventually outgrows its blood supply & is necrotic
    • Ovulatory: cyclic but heavy/prolonged bleeding d/t uterine structural conditions, normal gonadotropin/sex steroid levels
• PE:
  
  • Skin: hirsutism, acne, striae, acanthosis, nigricans, easy bruising
  • Breast: galactorrhea
  • Thyroid
  • Abdomen: uterine fibroids, enlarged uterus, splenomegaly
  • Pelvic: atrophic changes, cervicitis, cervical carcinoma
• Dx:
  
  • hCG to r/o pregnancy
  • 3 question algorithm?
    
    • Is she pregnant?
    • Is the bleeding from the uterus or elsewhere?
    • If bleeding is from the uterus, is she ovulating or having anovulatory bleeding?
  • CBC: hgb & hct
  • TSH, PAP screen, Prolactin, FSH/LH, STI screen, serum androgens & testosterone: if hirsutism
  • Endometrial biopsy to r/o endometrial biopsy to r/o endometrial carcinoma in all women > 35 yo with obesity, HTN, or DM
  • *if ovulatory: do US to check for polyps or fibroids
• Tx:
  
  • Tx the underlying etiology (i.e. surgery for structural lesions)
  • Progestin based treatment: medroxyprogesterone acetate x 10 days (1st line), OCPs or IUD as alternative
  • Acute heavy menstrual bleeding: high-dose estrogen & progestin therapy OR OCP 3 pills/day x1 week + Tranexamic acid → ongoing therapy with IUD, OCPs, progestins, tranexamic acid, & NSAIDs

Question 8

When to Evaluate for Endometrial Cancer

Answer 8

• Any post-menopausal bleeding
• 45 yo to menopause: any AUB that is frequen, heavy or prolonged
• < 45 yo: any AUB with chronic ovulatory dysfunction, exposure to estrogen unopposed by progesterone, failed medical management bleeding, Lynch or Cowden syndrome
• Premenopausal: with amenorrhea/anovulatory > 6 months

Question 9

Menopause: definition, Premature menopause, S/sxs, PE, & Dx

Answer 9

• Definition:
  
  • cessation of menses for more than 12 consecutive months due to natural loss of ovarian follicular function (follicles become less responsive to FSH & LH) → decreased estrogen & progesterone production
  • Average age: 52 yo
• Premature Menopause (<40yo):
  
  • can occur with medical intervention (chemotherapy, bilateral oophorectomy, radiation, medication, impaired ovarian function); also called induced menopause
• S/sx:
  
  • variable bleeding pattern
  • Vasomotor instability: hot flashes (75%), night sweats
  • vaginal dryness → dyspareunia
  • Sleep disturbance
  • Mood changes: depression, anxiety, moodiness (worse if prior hx)
  • Cognitive concerns: memory concentration (d/t normal aging but also menopause)
• PE:
  
  • dry & thin skin
  • vaginal atrophy
  • decreased breast size
  • decreased bone density → increased risk of osteoporosis
• Dx:
  
  • increased FSH & LH
  • Decreased estrogen
  • **do not need these to confirm dx

Question 10

Tx of Menopause

Answer 10

Hormone Replacement Therapy = “individualized therapy”

• *ideal candidate = recently menopausal (within 10 years), highly symptomatic, no contraindications, age < 60yo
  
  • Hormone replacement therapy: estrogen & progestin (if uterus present), estrogen (if no uterus), or bioidentical hormone therapy
    
    • may increase risk of breast cancer & clots → need to screen for ASCVD: ≥7.5 = contraindication; risk of breast cancer > 5% = also contraindication
  • Hormones not used for disease prevention, just to tx annoying sxs
  • Contraindications:
    
    • high triglycerides
    • undiagnosed vaginal bleeding
    • endometrial cancer
    • hx of breast Ca or estrogen sensitive cancers
    • CVD hx
    • DVT or PE hx
• Other tx options:
  
  • lifestyle: dress in layers, reduce EtOH & caffeine consumption, cool air temp, sip cool drinks, maintain healthy BMI, exercise
  • low dose OCPs
  • Antidepressants: SSRI (Fluoxetine), SNRI (Venlafaxine)
  • Anticonvulsant: gabapentin
  • Neuropathic Pain: Pregabalin
  • Bazedoxifene: selective estrogen receptor modulator
  • Osteoporosis: calcium & vitamin D supplements

Question 11

Postmenopausal Concerns

Answer 11

• Osteoporosis, weight management, cardiovascular disease, sexual function, dermatologic (skin & hair), cancer risks (d/t age)
• **Body adjusts to hormone changes after a couple years (hot flashes resolve after 3-5yrs)

Question 12

Perimenopause

Answer 12

• Definition:
  
  • “menopause transition”. Starts when menstrual cycle length starts to vary by > 7days & lasts up until final menstrual period; usually lasts 3-5 years.
• S/sxs:
  
  • variable bleeding patterns: light & sporadic vs heavier menses
  • *More symptomatic than during menopause
• Dx:
  
  • increased FSH (fluctuates)