menstrual disorders (15%) Flashcards
normal menstrual cycle
24-38 days w menstruation x4-8 days
phases of menstrual cycle
follicular/proliferative (0-14)
luteal (14-28)
what occurs in the follicular phase
endometrium thickens under influence of ESTROGEN. dominant follicle in ovaries matures
what occurs during days 1-12 of cycle
pulsatile GnRH from hypothalamus releasing more FSH + LH –>
FSH causes follicle + egg maturation in ovary + LH causes follicle to produce estrogen –>
estrogen builds up endometrium + causes NEGATIVE FEEDBACK in HPO –>
inhibits hypothalamic GnRH release to inhibitt LH + FSH release so no more follicles grow at this time.
what occurs during days 12-14 of cycle
inc estrogen from follicle switches from negative to POSITIVE FEEDBACK on GnRH –>
inc estrogen, FSH + LH –>
LH surge causes OVULATION.
what occurs during the luteal phase
ruptured follicle becomes corpus luteum which secretes progesterone + some estrogen but PROGESTERONE PREDOMINATES) –>
Progesterone maintains endometrium to prep for implantation
what happens if pregnancy occurs
blastocyst keeps C.L functional –>
secretes progesterone + estrogen to keep endometrium from sloughing
what happens if pregnancy does not occur
C.L degenerates which decreases progesterone + estrogen –>
sloughing of endometrium (menstruation) + negative feedback on GnRH subsides –>
inc pulsatile GnRH –> starts cycle again
what are the 2 etiology types of DUB
chronic anovulation (90%)- in teenagers or perimenopausal, unopposed estrogen (PCOS) –> inc endometrial overgrowth –> irregular, unpredictable shedding
ovulatory (10%)- regular cyclical shedding + ovulation w prolonged progesterone secretion –> inc blood loss from endometrial vessel dilation + PGs –> menorrhagia
what is cryptomenorrhea
light flow/spotting
what is menorrhagia
normal intervals but heavy/prolonged bleeding
what is metrorrhagia
irreg bleeding
what is menometrorrhagia
irregular, heavy/long bleeding
what is oligomenorrhea
infreq periods (cycle length >35 days, <6mo)
what is polymenorrhea
freq periods (cycle <21 days)
tx of acute severe bleeding
high-dose IV estrogen or high-dose OCPs
D+C if failed
tx of DUB
1st OCPs (Combo)- progesterone if estrogen CI leuprolide (GnRH analog)
what is dysmenorrhea
painful menstruation
what is primary vs secondary dysmenorrhea
primary- no pelvic pathology but increased PGs –> painful uterine muscle wall activity (usu 1-2yrs after menarche in teenagers)
secondary- pelvic patho, MC >25yo (endometriosis, adenomyosis, leiomyomas, adhesions, PID)
tx of dysmenorrhea
nsaids- start before sx + give for 2-3 days
hormonal birth control
laparoscopy if meds fail to R/O 2ry causes (endometriosis if younger, adenomyosis if older)
definition of menopause
> 1yr w/o menses d/t loss of ovarian function
average age of menopause
50-52yo
premature menopause
<40yo
usu DMs, smokers, vegetarians, malnourished
complications of menopause
inc CV events
HLD
osteoporosis
dx of menopause
FSH assay most sensitive (inc FSH >30)
inc LH
dec estrogen
tx of hot flashes in menopause
estrogen, progesterone, clonidine, SSRIs, gabapentin
tx of vaginal atrophy in menopause
estrogen
tx of osteoporosis in menopause
Ca + Vit D wt bearing exercise bisphosphonates SERM (RAL, TAM) calcitonin estrogen
estrogen-only HRT pros + cons
pros- most effective sx tx, transdermal or vaginal > PO, no inc breast CA
cons- inc endo CA, VTE
estrogen-progesterone HRT pros + cons
pros- sx relief, dec heart + stroke risk, dec osteoporosis, protects against endo CA
cons- VTE, inc breat CA
what differentiates PMS from PMDD
PMDD = anger + irritability + functional impairment
when does PMS/PMDD occur
during luteal phase (1-2wks before menses)
relieved w.i 2-3 days of menses onset
7+ sx-free days during follicular phase
what medication is approved for PMDD
drospirinone
what is primary vs secondary amenorrhea
primary- no period by age 15yo (if 2ndary sex characteristics), 13yo (if none)
secondary- no period for >3mo in pt w previously normal menses or >6mo in pt w previous oligomenorrhea
etiologies of primary amenorrhea if uterus + breasts present
outflow obstruction (transverse vaginal septum, imporforate hymen)
etiologies of primary amenorrhea if uterus present+ breasts absent
elevated FSH/LH = ovarian causes - premature ovarian failure (46, XX), gonadal dysgenesis (45, XO)
normal/low FSH/LH = hypothalamus-pituitary failure or puberty play (athlete, illness, anorexia)
etiologies of primary amenorrhea if uterus absent + breasts present
mullerian agenesis (46, XX) androgen insensitivity (46, XY)
etiologies of primary amenorrhea if uterus + breasts absent
rare- usu defect in testosterone synthesis
will often have intraabdominal testes
MC etiology of secondary amenorrhea
pregnancy
other etiologies of secondary amenorrhea
hypothalamus dysfunction pituitary dysfunction (pituitary adenoma) ovarian disorders uterine disorders (ashermans)
how does hypothalamus dysfunction cause amenorrhea
disruption of normal pulsatile GnRH secretion –> dec FSH +/or LH
causes of hypothalamus dysfunction –> amenorrhea
hypothalamic disorder, anorexia, exercise, stress nutritional deficiency, systemic dz (celiac)
diagnosis of hypothalamus dysfunction –> amenorrhea
normal/dec FSH/LH, low estradiol, normal PRL
tx of hypothalamus dysfunction –> amenorrhea
clomiphene, menotropin (stimulate GnRH secretion)
how does pituitary adenoma cause amenorrhea
prolactin-secreting pituitary adenoma –> suppresses GnRH –> dec FSH/LH
dx of pituitary adenoma –> amenorrhea
low FSH/LH
inc PRL
MRI of pituitary sella
tx of pituitary adenoma –> amenorrhea
transsphenoidal surgery
what ovarian disorders can cause amenorrhea
PCOS, premature ovarian failure, follicular failure/resistance to LH/FSH, turners syndrome
clinical presentation/dx of ovarian disorders –> amenorrhea
sx of estrogen deficiency (hot flashes, sleep + mood disturbances, dyspareunia, dry/thin skin, vaginal atrophy)
INC FSH/LH
progesterone challenge test- 10mg medroxyprogesterone x10 days –> withdrawal bleeding indicates ovarian issue, no withdrawal bleeding indicates HPO or uterine issue
what uterine disorder causes amenorrhea
asherman’s syndrome (Scarring of uterine cavity 2ry to PP hemorrhage, s/p D+C or endometritis)
how do you dx asherman’s syndrome
pelvic US = absence of uterine stripe
hysteroscopy
tx of ashram’s syndrome
estrogen to stimulate endometrial regeneration
