menstrual disorders Flashcards
what is primary amenorrhea
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
what is secondary amenorrhea
Absence of menses for more than 3 months (previously regular cycles), or 6 months (previously irregular cycles) in women who were previously menstruating
primary amenorrhea etiology
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
Turner’s syndrome (45, XO) and gonadal dysgenesis
Results in premature depletion of oocytes and follicles
assoc. w/short stature, widely spaced nipples, webbed neck, and sexual infantilism
hypothalamic and pituitary causes primary amenorrhea
Hypogonadotropic hypogonadism
fx or hypothalamic amenorrhea, congenital GnRH deficiency (Kallmann syndrome), infiltrative dz/tumors, hyperprolactinemia, hypothyroidism
uterine and vaginal causes of primary amenorrhea
Vaginal agenesis (Mullerian agenesis)
Imperforate hymen
transverse vaginal septum
receptor abnormalities and enzyme deficiency causes for Primary amenorrhea?
Androgen Insensitivity Syndrome
how do you dx androgen insensitivity syndrome
Dx: absent upper vagina, uterus and fallopian tubes on physical exam and pelvic ultrasound; high serum testosterone concentrations; and male (46,XY) karyotype
when to initiate clinical eval for primary amennorrhea?
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
hx q’s for primary amenorrhea?
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
Lab studies for primary amenorrhea
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
imaging for primary amenorrhea
Based on H&P findings
Pelvic sonogram: if suspected pelvic anomalies
CT or MRI: If suspected pituitary pathology
Tx for primary amenorrhea
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
secondary amenorrhea causes
PREGNANCY!!!!!
Ovarian dysfunction
Hypothalamic dysfunction
Pituitary dysfunction
Uterine dysfunction
hypothalamic/pituitary causes for secondary amenorrhea
Functional or hypothalamic amenorrhea: wt. loss, stress, celiac dz
Pituitary disease: high prolactin, Sheehan’s syndrome
Hypothyroidism
Head Trauma
Ovarian dysfx reasons for secondary amenorrhea
Polycystic Ovary syndrome
Primary Ovarian Insufficiency (premature ovarian failure)
Autonomous hyperandrogenism
uterine reasons for secondary amenorrhea
Asherman’s syndrome- acquired scarring of the endometrial lining
secondary amenorrhea hx q’s
Previous menstrual hx Previous pregnancies Meds Weight loss or gain Galactorrhea Symptoms of estrogen deficiency
PE secondary amenorrhea
vitals, skin, HEENT (parotid gland swelling, dental enamel erosion for balemia), cardiac, pulm, breast (axillary hair, galactorrhea, pelvic exam (estrogen deficiency, clitorimegaly)
Lab studies for secondary ameorrhea
Urine or serum HCG TSH Prolactin FSH and LH Total testosterone
what is the progestin challenge test
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
imaging for secondary amenorrhea
Pelvic sonogram
CT of adrenal glands
If significant virilization and elevated testosterone
CT or MRI
If suspected pituitary pathology
Tx for secondary amenorrhea
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
etiology of abnormal uterine bleeding?
anovulation
what is Polymenorrhea
Abnormally frequent menses at intervals <24 days
what is Menorrhagia (Hypermenorrhea)
Excessive and/or prolonged menses (>80mL and/or >7 days) occurring at normal intervals
what is Menometrorrhagia
Heavy & irregular uterine bleed
what is Metrorrhagia
Irregular episodes of uterine bleeding
what are some causes for AUB? PALM - COIEN stand for?
Polyp Adenomyosis Leiomyoma Malignancy and Hyperplasia - Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
what is included on Ddx for AUB?
systemic disorders (hepatic dz, renal dz, thyroid dz) trauma pregnancy, endometritis, cervicitis
what is dysfunctional uterine bleeding?
When all identifiable causes for abnormal uterine bleeding are ruled out
dx of exclusion
initial eval for AUB
Confirm the uterus is the source of bleeding
Determine if the patient is premenarchal or postmenopausal
Exclude pregnancy
further eval for AUB
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
hx questions to ask for AUB
- 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
PE for AUB
exclude all causes
check for pallor, tachycardia, hypotension, excessive bruising
Pelvic exam: verify source of bleeding is uterine, check for IUD strings, uterine size
Lab/diagnostic studies for AUB
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)
management of AUB
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)
what is dysmenorrhea? what is primary and secondary?
painful menstruation
Primary: no readily identifiable cause exists
Secondary: due to organic pelvic disease
what age range is typical for dysmenorrhea?
17-22yo typical age for primary dysmenorrhea
secondary MC as woman ages
what % of women are affected by dysmenorrhea?
50% of menstruating women
10% have sxs needing time off from school/work
primary dysmenorrhea?
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
clinical presentation for primary dysmenorrhea?
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
lab/diagnostic studies for primary dysmenorrhea?
HCG
Possible pap smear and vaginal cultures
If H&P consistent, other lab studies or imaging not typically indicated
conservative Tx for primary dysmenorrhea
Decrease caffeine intake Apply heat Gently massage lower abd Adequate sleep Exercise Yoga, acupuncture Nutritional supplements: Calcium, Mg, B-complex Smoking cessation
Pharm Tx for primary dysmenorrhea
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)
management and referral for primary dysmenorrhea?
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
secondary dysmenorrhea clinical presentation
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
potential underlying causes for secondary dysmenorrhea?
Pelvic inflammatory disease Uterine fibroids Ovarian cysts Pelvic congestion Endometriosis
Tx for secondary dysmenorrhea?
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
what is PMS
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
what is PMDD
PMS with more severe emotional symptoms
incidence for menstrual cycle assoc. disorders
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
physical manifestations of menstrual cycle assoc. disorders
Abdominal bloating
Fatigue
Breast tenderness
Headaches
behavior sxs for menstrual cycle assoc. disorders
Labile mood, irritability Depressed mood Increased appetite Forgetfulness Difficulty concentrating
what is the DRSP?
Self rating questionnaire which helps distinguish PMS from PMDD
depressed, sad, hopeless?
anxious or tense?
mood swings, sensitive?
angry or irritable?
PMS dx criteria?
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
PMDD DSM-5 dx criteria
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.
Management of menstrual cycle assoc. disorders
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)
