menstrual disorders Flashcards
What is primary amenhorrhea
absence of menarche by age 15 despite normal puberty
absence of menarche by age 13 without normal puberty
What is secondary amenorrhea
absence of menses for >3 months (if previously regular) or >6 months (if previously irregular) in women who were previously menstruating
First test you do for amenorrhea
PREGNANCY
If a woman comes in with complaints of no period for 3 months, what should you do
get a pregnancy test
A 24 year old woman presents to the ED with complaints of difficulty sleeping. She slips in that she hasn’t had period in 2 months, but she is not sexually active. What is your work up
PREGNANCY TEST! do not trust her, she is a fugly slut.
What are the possible causes of primary amenorrhea
chromosome abn causing gonadal dysgenesis
hypothalamic hypogonadism
No uterus, cervix, vagina, or mullerian agenesis
transverse vaginal septum, imperforate hymen
pituitary disease
What is mullerian agenesis
lacking the upper 1/3 of the vagina/uterus
What is Turner’s syndrome
45 XO genetic d/o causing gonadal dysgenesis
Causes premie depletion of oocytes and follicles (oavrian regression)
associated with short stature, widely spaced nipples, webbed neck, sexual infantilism
What lab abnormality will you see with Turner syndrome
high FSH and LH, because the ovaries cant respond to those hormones, so the pituitary tries to overstimulate and compensate
PCOS usually causes
Secondary amenorrhea
Hypothalamic and pituitary disorders are due to
GnRH transport dysfunction (tumors)
GnRH pulse discharge
Congenital absence of GnRH
What is Functional/Hypothalamic amenorrhea due to
Abnormal secretion of GnRH
MC 2/2 eating disorders, physical/psych stress, weight loss, excessive exercise
What are types of congenital GnRH deficiency (causing primary amenorrhea)
Idiopathic hypogonadotropic hypogonadism Kallman Syndrome (w/ anosmia)
Other types of hypothalamic disorders causing primary amenorrhea include
Hyperprolactinemia
Hypothyroidism
Infiltrative disease
What are signs of an imperforate hymen
Cyclic pelvic pain perirectal mass (blood sequestered in vagina)
What is androgen insensitivity syndrome
Testosterone is in the body, but receptors don’t respond to it;
Inside they are male (karyotype), but externally they are female (phenotype)
How do you diagnose androgen insensitivity syndrome
Absent upper vagina, uterus, and fallopian tubes
High serum testosterone
male 46 XY karyotype
Briefly describe the primary amenorrhea algorithm
Prior menstrual period? no
Recent sexual intercourse? (yes= bHCG) (no= delayed puberty, normal puberty, malnourished/low weight?)
Low weight= hypothalamic dysfunction
Normal puberty= outflow obstruction, HPO dysfxn
Delayed puberty= gonad dysgenesis, genetic
When do you initiate primary amenorrhea clinical evaluation
13 if no evidence of breast development
13 if patient has not menstruated w/in 2 years of thelarche
15 in no uterine bleeding (but with breast development)
Sexual activity questions important for primary amenorrhea evaluation
timeline of other stages of puberty
When mom and sisters had menarche
Patient’s height relative to other family
Symptoms of virilization (hirsutism, deep voice)
stress, weight change, diet, exercise, illness
Galactorrhea
Anosmia (kallman’s syndrome)
HA, visual field defects
Hx of head trauma
Sexual activity
PE for primary amenorrhea should include
vitals
skin
GEneral (female body shape, signs of abuse)
Cardiac (everyone)
Pulmonary (everyone)
Breast exam (development, axillary hair growth)
Pelvic (ext genitalia, pubic hair growth, presence of uterus)
Labs for primary amenorrhea should include
beta HCG FSH (if high= gonadal dysgenesis) (low-norm= hypogonadotropic hypogonadism) Karyotype Prolactin, TSH Testosterone
Imaging for primary amenorrhea include
base these on H&P findings!
Pelvic sonogram if you suspect pelvic anomalies
CT/MRI if you suspect pituitary pathology
What are goals in primary amenorrhea treatment
Establish a firm diagnosis (and treat it)
Restore ovulatory cycles and achieve fertility if desired
Prevent complications (hypoestrogenism, hyperandrogenism)
Increasing estrogen in primary amenorrhea may induce
thelarche!
Refer primary amenorrhea patient to
counseling
endocrine or Gyno
surgery if necessary
What are the possible causes of secondary amenorrhea
PREGNANCY!!!!!!!! Ovarian dysfunction Hypothalamic dysfunction pituitary dysfunction uterine dysfunction
Functional or hypothalamic disorders causing secondary amenorrhea include
weight loss exercise nutrition deficiency stress celiac disease
Pituitary diseases causing secondary amenorrhea include
prolactin secreting tumor hyperprolactinemia Sheehan syndrome hypothyroidism head trauma
What is Sheehan syndrome
post-partum amenorrhea 2/2 pituitary necrosis from severe hemorrhage and hypotension after giving birth
What are ovarian causes of secondary amenorrhea
PCOS Primary ovarian insufficiency (premie ovarian failure, no oocytes before 40) Autonomous hyperandrogenism (androgen secreting tumors)
What are causes of primary ovarian insufficiencu
turner syndrome
fragile x permutation
AI ovarian destruction
chemo/radiation
What is Asherman’s syndrome
Scarring of the endometrial lining 2/2 postpartum hemorrhage or endometrial infection w/ D&C
PE that should be performed in secondary amenorrhea include
vitalls
general
skil (oily? acne? hirsutism?)
HEENT (parotid swelling, dental erosion= bulemia)
Carciac, pulm (everyone)
Breast
Pelvic (clitorimegaly, estrogen deficiency)
Lab studies you should get for secondary amenorrhea include
PREGNANCY!!! HCG (urine or serum) TSH Prolactin FSH/LH total testosterone
What si the progestin challenge test
Administer 10mg Medroxyprogesterone for 10 days to assess ESTROGEN status
If patient has enough estrogen, they should have a withdrawal bleed w/in 2 weeks
If no withdrawal bleed, patient may be pregnant, severe hypoestrogenism, or uterine defect
Imaging for secondary amenorrhea should include
Pelvic sonogram
CT adrenals (virilization, elevated testosterone)
CT/MRI (suspect pit problem)
Goals of secondary amenorrhea treatment include
establish firm Dx (and Tx it)
restore ovulatory cycles and treat infertility
Tx hypoestrogen and hyperandrogen
What is the MCC of abnormal uterine bleeding
anovulatory cycles
What is polymenorrhea
abnormally frequently menses at intervals <24 days
What is menorrhagis
Excess/prolonged menses (>80ml or >7 days) at normal intervals
What is metorrhagia
Irregular episodes of uterine bleeding
FIGO says these acronyms are causes of abnormal uterine bleeding
PALM-COEIN Polyp Adenomyosis Leiomyoma Malignancy/hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
Other DDx for abnormal uterine bleeding are
systemic disorders (hepatic dz, renal dz, thyroid dz) Trauma (lac, abrasion, FB) Organic conditions (pregnancy, endometriotis, cervicitis)
What is dysfunctional uterine bleeding
when all identifiable causes of AUB are ruled out!
DUB is a Dx of EXCLUSION
Initial eval for abnormal uterine bleeding should include
confirm that the uterus is actually the source of bleeding
setermine if pt is pre menarchal or postmenopausal
Exclude PREGNANCY
On further evaluation of abnormal uterine bleeding, determine
bleeding pattern If endometrial sampling is needed (if post-menopausal or obese) Coag evaluation If it started 2/2 contraceptiove method consider concurrent factors
If a woman comes in with AUB, PE should include
check for pallor, tachycardia, hypotension, and excessive bruising
Pelvic (verify uterine source, check for IUD strings, uterine size)
Labs for AUB should include
HCG, CBC, iron
+/- coags, bleeding time, TSH, LFT, FSH
Diagnostics for AUB should include
pelvic sonogram
Pap and cervical cultures
endometrial biopsy
How can you manage AUB
If less significant, obs
hormonal treatments
endometrial ablation
hysterectomy (extreme cases)
What are the types of dysmenorrhea
Primary: no readily identifiable cause (MC in 17-22)
Secondary: 2/2 organic pelvic dz (MC as women age)
Why does dysmenorrhea occur
Corpus luteum regresses
PGE2 and PGF2 are released from the endometrium 2/2 cell lysis during menstruation
Uterus contracts, causing ischemia
Primary dysmenorrhea may present like this
Few hours before, or just after onset of menstruation; lasts 12-72 hours
Cramp like, intermittent
Most intense in lower abdomen, radiates to low back and upper thighs
Associated n/v/d, HA, LBP, fatigue
Pelvic is normal
Lab tests for primary dysmenorrhea should include
HCG
+/- PAP with cultures
But, if H&P is consistent with other lab studies then no other labs or imaging is necessary
Conservative treatment for primary dysmenorrhea includes
Decrease caffeine intake apply heat gently massage lower abdomen get sleep! exercise yoga, acupuncture Calcium, Mg, B-complex Stop smoking
Pharm Tx for primary dysmenorrhea is
1 line: NSAIDS! (Ibu 300mg q6hr x 3-4 d)
If not desiring pregnancy, OCP to reduce menstrual flow and inhibit ovulation
If resistant: CCB (nifedipine) for vasodilation
When is follow up or referral required for primary dysmenorrhea
Pain worsens with each menses Pain lasts > first 2 days Meds pt used to take no longer work Menstrual bleeding increasingly heavy Pain accompanied by fever Abnormal discharge Pain occurs unrelated to menses
How does secondary dysmenorrhea usually present
depends on underlying cause; not limited to menses but can worsen w/ menstruation
Associated with dyspareunia, infertility, and AUB
Develops in 30-40 y/o
NOT as related to first day of menses
Potential causes of secondary dysmenorrhea include
PID Uterine fibroids Ovarian cysts pelvic congestion endometriosis
How do you treat secondary dysmenorrhea
COC work great! can try POP or NSAIDS if can’t take estrogen
Complicated cases +/- surgery (laparoscopy for Dx, hysterectomy, oopherectomy, myomectomy)
What is PMS
physical, mood related and behavioral changes tat occur in a regular, cyclic relationship to LUTEAL phase
usually RESOLVE with onset of menses
What is PMDD
premenstrual dysphoric disorder; basically PMS with more severe emotional symptoms
Etiology of PMS is
unclear; may be genetic, or 2/2 abnormal SEROTONIN response to hormone fluctuations
Physical manifestations of PMS include
Bloating
Fatigue
Breast tenderness
Headaches
Behavioral manifestations of PMS include
Labile mood, irritability
Increased appetite
Forgetfulness
Difficulty concentrating
What are PMDD self rating questions that help distinguish from PMS (Affective Sx)
Depressed, sad, down, or feeling hopeless? feel worthless or guilty?
Anxious, keyed up, or on edge?
Mood swings, sensitive to rejection or feelings easily hurt?
Angry or irritable?
What is PMS diagnostic criteria
1-4 Sx of physical, behavioral, or affective
What are PMDD diagnostic criteria
5+ symptoms of physical, behavioral, or affective
DSM 5 criteria for PMDD is
5+ Sx present the week prior to menses and resolves a few days after menses:
Need 1+: mood swings, sudden sadness, sensitive to rejection, anger, irritable, feel hopeless, depressed, tense, anxious, feel on edge
Need 1+: Hard to concentrate, appetite change, diminished interest in usual activities, fatigue, feel overwhelmed, breast tenderness, bloating, weight gain, joint aches, sleep too much or not enough
In order to diagnose PMS or PMDD, you must R/O
Underlying psych d/o
menopausal transition
thyroid disorder
mood disorder
How do you manage PMS/PMDD
Non-pharm: aerobic exercise, stress reduction technique
Pharm: SSRI (fluoxetine, sertraline, citalopram, paroxetine, escitalopram) during luteal phase only
+/- ovulation suppression (GnRH agonist, ECOC)
