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Foundations III-Women's Health > menstrual disorders > Flashcards

menstrual disorders Flashcards

1
Q

what is primary amenorrhea

A

Absence of menarche (first menses) by age 15 despite normal growth and secondary sexual development

Absence of menarche by age 13 in absence of normal growth or secondary sexual development

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2
Q

what is secondary amenorrhea

A

Absence of menses for more than 3 months (previously regular cycles), or 6 months (previously irregular cycles) in women who were previously menstruating

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3
Q

primary amenorrhea etiology

A

MC = Chromosomal abnormality causing gonadal dysgenesis

Hypothalamic hypogonadism

Absence of the uterus, cervix and/or vagina, mullerian agenesis

Transverse vaginal septum or imperforate hymen

Pituitary disease

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4
Q

Turner’s syndrome (45, XO) and gonadal dysgenesis

A

Results in premature depletion of oocytes and follicles

assoc. w/short stature, widely spaced nipples, webbed neck, and sexual infantilism

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5
Q

hypothalamic and pituitary causes primary amenorrhea

A

Hypogonadotropic hypogonadism

fx or hypothalamic amenorrhea, congenital GnRH deficiency (Kallmann syndrome), infiltrative dz/tumors, hyperprolactinemia, hypothyroidism

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6
Q

uterine and vaginal causes of primary amenorrhea

A

Vaginal agenesis (Mullerian agenesis)

Imperforate hymen

transverse vaginal septum

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7
Q

receptor abnormalities and enzyme deficiency causes for Primary amenorrhea?

A

Androgen Insensitivity Syndrome

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8
Q

how do you dx androgen insensitivity syndrome

A

Dx: absent upper vagina, uterus and fallopian tubes on physical exam and pelvic ultrasound; high serum testosterone concentrations; and male (46,XY) karyotype

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9
Q

when to initiate clinical eval for primary amennorrhea?

A

Age 15 if no uterine bleeding has occurred

Age 13 if no evidence of breast development
(Breast development = thelarche)

Age 13 if patient has failed to menstruate within 2 years of thelarche

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10
Q

hx q’s for primary amenorrhea?

A

Timeline of other stages of puberty

Time of menarche in pt’s mother and sisters

Symptoms of virilization

Stress, change in weight, diet, exercise habits, or illness

Galactorrhea

Headaches, visual field defects, fatigue, polyuria, polydipsia

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11
Q

Lab studies for primary amenorrhea

A

Urine or Serum HCG
Serum FSH/LH:
- High FSH suggests gonadal dysgensis
-Low or normal FSH suggests hypogonadotropic hypogonadism

karyotype
serum prolactin and TSH
serum testosterone

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12
Q

imaging for primary amenorrhea

A

Based on H&P findings

Pelvic sonogram: if suspected pelvic anomalies

CT or MRI: If suspected pituitary pathology

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13
Q

Tx for primary amenorrhea

A

Goals: est. firm dx
Restore ovulatory cycles and achieve fertility (if desired)
Prevent complications of disease process

counseling
referral to endocrine/gyn
surgical referral if necessary

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14
Q

secondary amenorrhea causes

A

PREGNANCY!!!!!

Ovarian dysfunction

Hypothalamic dysfunction

Pituitary dysfunction

Uterine dysfunction

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15
Q

hypothalamic/pituitary causes for secondary amenorrhea

A

Functional or hypothalamic amenorrhea: wt. loss, stress, celiac dz

Pituitary disease: high prolactin, Sheehan’s syndrome

Hypothyroidism

Head Trauma

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16
Q

Ovarian dysfx reasons for secondary amenorrhea

A

Polycystic Ovary syndrome

Primary Ovarian Insufficiency (premature ovarian failure)

Autonomous hyperandrogenism

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17
Q

uterine reasons for secondary amenorrhea

A

Asherman’s syndrome- acquired scarring of the endometrial lining

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18
Q

secondary amenorrhea hx q’s

A 
Previous menstrual hx
Previous pregnancies
Meds
Weight loss or gain
Galactorrhea
Symptoms of estrogen deficiency
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19
Q

PE secondary amenorrhea

A

vitals, skin, HEENT (parotid gland swelling, dental enamel erosion for balemia), cardiac, pulm, breast (axillary hair, galactorrhea, pelvic exam (estrogen deficiency, clitorimegaly)

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20
Q

Lab studies for secondary ameorrhea

A 
Urine or serum HCG
TSH
Prolactin
FSH and LH
Total testosterone
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21
Q

what is the progestin challenge test

A

for secondary amenorrhea

Performed to assess estrogen status when initial lab studies are WNL

Medroxyprogestone

If pt has adequate levels of estrogen, should experience withdrawal bleeding within 2 weeks

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22
Q

imaging for secondary amenorrhea

A

Pelvic sonogram

CT of adrenal glands
If significant virilization and elevated testosterone

CT or MRI
If suspected pituitary pathology

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23
Q

Tx for secondary amenorrhea

A

Based on underlying etiology

Goals: Establish firm dx, restore ovulatory cycles and treat infertility, tx hypoestrogenemia and hyperandrogenism

Counseling:
If hypothalamic failure due to anorexia, excessive exercise, abuse, stress

Possible referral to Endocrinology and/or GYN

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24
Q

etiology of abnormal uterine bleeding?

A

anovulation

25
Q

what is Polymenorrhea

A

Abnormally frequent menses at intervals <24 days

26
Q

what is Menorrhagia (Hypermenorrhea)

A

Excessive and/or prolonged menses (>80mL and/or >7 days) occurring at normal intervals

27
Q

what is Menometrorrhagia

A

Heavy & irregular uterine bleed

28
Q

what is Metrorrhagia

A

Irregular episodes of uterine bleeding

29
Q

what are some causes for AUB? PALM - COIEN stand for?

A 
Polyp
Adenomyosis
Leiomyoma
Malignancy and Hyperplasia
-					Coagulopathy					Ovulatory dysfunction						Endometrial						Iatrogenic						Not yet classified
30
Q

what is included on Ddx for AUB?

A 
systemic disorders (hepatic dz, renal dz, thyroid dz)
trauma
pregnancy, endometritis, cervicitis
31
Q

what is dysfunctional uterine bleeding?

A

When all identifiable causes for abnormal uterine bleeding are ruled out

dx of exclusion

32
Q

initial eval for AUB

A

Confirm the uterus is the source of bleeding

Determine if the patient is premenarchal or postmenopausal

Exclude pregnancy

33
Q

further eval for AUB

A

Determine the bleeding pattern, if endometrial sampling is needed, if a coagulation evaluation is needed, if the bleeding is related to a contraceptive method, consider concurrent factors

34
Q

hx questions to ask for AUB

A
  • Age of menarche and menstrual hx
  • Detailed description of menstrual bleeding/Bleeding pattern
  • Normal cyclic ovulatory symptoms
  • Current birth control method(s) (CBM)
  • Meds
  • Personal and family history of bleeding disorders
    Weight changes
  • Sxs of anemia
35
Q

PE for AUB

A

exclude all causes

check for pallor, tachycardia, hypotension, excessive bruising

Pelvic exam: verify source of bleeding is uterine, check for IUD strings, uterine size

36
Q

Lab/diagnostic studies for AUB

A

labs based on H&P: HCG, CBC, Iron studies +/- coag, bleeding time, TSH, LFTs, FSH

Pap smear and vaginal/cervical cultures

Pelvic sonogram

Endometrial biopsy (In-office sampling vs. D&C)

37
Q

management of AUB

A

Obs: for less significant bleeding

Hormonal tx’s

Endometrial ablation: Amenorrhea rate of ~50% and relief of excessive bleeding in most of the remaining 50%

Hysterectomy (extreme cases)

38
Q

what is dysmenorrhea? what is primary and secondary?

A

painful menstruation

Primary: no readily identifiable cause exists

Secondary: due to organic pelvic disease

39
Q

what age range is typical for dysmenorrhea?

A

17-22yo typical age for primary dysmenorrhea

secondary MC as woman ages

40
Q

what % of women are affected by dysmenorrhea?

A

50% of menstruating women

10% have sxs needing time off from school/work

41
Q

primary dysmenorrhea?

A

Regression of corpus luteum

Prostaglandins released from endometrium at time of menstruation as a result of cell lysis

Occurs during ovulatory cycles

Uterine contractions with ischemia

42
Q

clinical presentation for primary dysmenorrhea?

A

Begins few hours before or just after onset of menstruation and lasts ~12-72 hours

Pain typically = cramp-like, intermittent

most intense in lower abd. and may radiate to lower back, upper thighs

assoc. sxs = N/V/D, HA, LBP, fatigue

pelvic exam normal

43
Q

lab/diagnostic studies for primary dysmenorrhea?

A

HCG

Possible pap smear and vaginal cultures

If H&P consistent, other lab studies or imaging not typically indicated

44
Q

conservative Tx for primary dysmenorrhea

A 
Decrease caffeine intake
Apply heat
Gently massage lower abd
Adequate sleep
Exercise
Yoga, acupuncture
Nutritional supplements: Calcium, Mg, B-complex
Smoking cessation
45
Q

Pharm Tx for primary dysmenorrhea

A

NSAIDS 1st line therapy (Ibuprofen 400mg, 1 po q6hrs x 3-4 days)

If not desiring pregnancy, hormonal contraceptives reduce menstrual flow and inhibit ovulation
(COCs, ECOCs, Depo-Provera)

Resistant cases: CCB’s (nifedipine)

46
Q

management and referral for primary dysmenorrhea?

A

required if:
Pain worsening with each menses
Pain lasts longer than first 2 days of menses
Meds patient has used in the past is no longer controlling the pain
Menstrual bleeding has become increasingly heavy
Pain is accompanied by fever
There is abnormal dc or bleeding
The pain occurs at times unrelated to menses

47
Q

secondary dysmenorrhea clinical presentation

A

Pain depends on an underlying cause

Pain not limited to menses, but may worsen at this time

Usu. assoc. w/ other sxs: dyspareunia, infertility, abnl uterine bleeding

Less related to first day of menses

Usually develops in women aged 30-40yo

48
Q

potential underlying causes for secondary dysmenorrhea?

A 
Pelvic inflammatory disease
Uterine fibroids
Ovarian cysts
Pelvic congestion
Endometriosis
49
Q

Tx for secondary dysmenorrhea?

A

Can use COCs for almost all cases – if they can’t take estrogen, try progestins or NSAIDs

Complicated cases may require pelvic surgery: Diagnostic laparoscopy
Hysterectomy
Oophorectomy
Myomectomy

50
Q

what is PMS

A

A group of physical, mood-related, & behavioral changes that occur in a regular, cyclic relationship to the luteal phase that interfere with some aspect of the patient’s life

occur in most cycles, resolves with onset of menses

51
Q

what is PMDD

A

PMS with more severe emotional symptoms

52
Q

incidence for menstrual cycle assoc. disorders

A

Premenstrual sxs occur in ~75%

Premenstrual syndrome causing significant disruption in daily life occurs in ~3-8%

PMDD affects ~2%

both can present at menarche or later in life

53
Q

physical manifestations of menstrual cycle assoc. disorders

A

Abdominal bloating
Fatigue
Breast tenderness
Headaches

54
Q

behavior sxs for menstrual cycle assoc. disorders

A 
Labile mood, irritability
Depressed mood
Increased appetite
Forgetfulness
Difficulty concentrating
55
Q

what is the DRSP?

A

Self rating questionnaire which helps distinguish PMS from PMDD

depressed, sad, hopeless?
anxious or tense?
mood swings, sensitive?
angry or irritable?

56
Q

PMS dx criteria?

A

1-4 symptoms physical, behavioral or affective/psychological in nature

≥ 5 symptoms physical or behavioral
– If ≥ 5 symptoms and one is an affective symptom then think PMDD

57
Q

PMDD DSM-5 dx criteria

A

Documentation of sxs for most of preceding year

≥ 5 symptoms present during week prior to menses, resolving with a few days after menses

one or more sxs: mood swings, anger, hopelessness, anxiety

one or more for total of 5:
difficulty concentrating, diminished interest, change in appetite, feeling overwhelmed, etc.

58
Q

Management of menstrual cycle assoc. disorders

A

based on sxs

Nonpharm tx’s:
Aerobic exercise & Stress reduction techniques

Pharm tx:
SSRI’s –> fluoxetine, sertraline, citalopram, paroxetine, escitalopram
+/- ovulation suppression (ECOCs, GnRH agonists)

Foundations III-Women's Health (13 decks)

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