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Summer FDTN Exam 3 > menstrual disorders > Flashcards

menstrual disorders Flashcards

1
Q

What is primary amenhorrhea

A

absence of menarche by age 15 despite normal puberty

absence of menarche by age 13 without normal puberty

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2
Q

What is secondary amenorrhea

A

absence of menses for >3 months (if previously regular) or >6 months (if previously irregular) in women who were previously menstruating

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3
Q

First test you do for amenorrhea

A

PREGNANCY

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4
Q

If a woman comes in with complaints of no period for 3 months, what should you do

A

get a pregnancy test

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5
Q

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

A

PREGNANCY TEST! do not trust her, she is a fugly slut.

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6
Q

What are the possible causes of primary amenorrhea

A

chromosome abn causing gonadal dysgenesis
hypothalamic hypogonadism
No uterus, cervix, vagina, or mullerian agenesis
transverse vaginal septum, imperforate hymen
pituitary disease

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7
Q

What is mullerian agenesis

A

lacking the upper 1/3 of the vagina/uterus

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8
Q

What is Turner’s syndrome

A

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

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9
Q

What lab abnormality will you see with Turner syndrome

A

high FSH and LH, because the ovaries cant respond to those hormones, so the pituitary tries to overstimulate and compensate

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10
Q

PCOS usually causes

A

Secondary amenorrhea

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11
Q

Hypothalamic and pituitary disorders are due to

A

GnRH transport dysfunction (tumors)
GnRH pulse discharge
Congenital absence of GnRH

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12
Q

What is Functional/Hypothalamic amenorrhea due to

A

Abnormal secretion of GnRH

MC 2/2 eating disorders, physical/psych stress, weight loss, excessive exercise

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13
Q

What are types of congenital GnRH deficiency (causing primary amenorrhea)

A 
Idiopathic hypogonadotropic hypogonadism 
Kallman Syndrome (w/ anosmia)
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14
Q

Other types of hypothalamic disorders causing primary amenorrhea include

A

Hyperprolactinemia
Hypothyroidism
Infiltrative disease

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15
Q

What are signs of an imperforate hymen

A 
Cyclic pelvic pain 
perirectal mass (blood sequestered in vagina)
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16
Q

What is androgen insensitivity syndrome

A

Testosterone is in the body, but receptors don’t respond to it;
Inside they are male (karyotype), but externally they are female (phenotype)

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17
Q

How do you diagnose androgen insensitivity syndrome

A

Absent upper vagina, uterus, and fallopian tubes
High serum testosterone
male 46 XY karyotype

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18
Q

Briefly describe the primary amenorrhea algorithm

A

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

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19
Q

When do you initiate primary amenorrhea clinical evaluation

A

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)

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20
Q

Sexual activity questions important for primary amenorrhea evaluation

A

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

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21
Q

PE for primary amenorrhea should include

A

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)

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22
Q

Labs for primary amenorrhea should include

A 
beta HCG 
FSH (if high= gonadal dysgenesis) (low-norm= hypogonadotropic hypogonadism) 
Karyotype 
Prolactin, TSH 
Testosterone
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23
Q

Imaging for primary amenorrhea include

A

base these on H&P findings!
Pelvic sonogram if you suspect pelvic anomalies
CT/MRI if you suspect pituitary pathology

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24
Q

What are goals in primary amenorrhea treatment

A

Establish a firm diagnosis (and treat it)
Restore ovulatory cycles and achieve fertility if desired
Prevent complications (hypoestrogenism, hyperandrogenism)

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25
Q

Increasing estrogen in primary amenorrhea may induce

A

thelarche!

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26
Q

Refer primary amenorrhea patient to

A

counseling
endocrine or Gyno
surgery if necessary

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27
Q

What are the possible causes of secondary amenorrhea

A 
PREGNANCY!!!!!!!!
Ovarian dysfunction 
Hypothalamic dysfunction 
pituitary dysfunction 
uterine dysfunction
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28
Q

Functional or hypothalamic disorders causing secondary amenorrhea include

A 
weight loss 
exercise 
nutrition deficiency 
stress 
celiac disease
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29
Q

Pituitary diseases causing secondary amenorrhea include

A 
prolactin secreting tumor 
hyperprolactinemia 
Sheehan syndrome 
hypothyroidism 
head trauma
30
Q

What is Sheehan syndrome

A

post-partum amenorrhea 2/2 pituitary necrosis from severe hemorrhage and hypotension after giving birth

31
Q

What are ovarian causes of secondary amenorrhea

A 
PCOS 
Primary ovarian insufficiency (premie ovarian failure, no oocytes before 40) 
Autonomous hyperandrogenism (androgen secreting tumors)
32
Q

What are causes of primary ovarian insufficiencu

A

turner syndrome
fragile x permutation
AI ovarian destruction
chemo/radiation

33
Q

What is Asherman’s syndrome

A

Scarring of the endometrial lining 2/2 postpartum hemorrhage or endometrial infection w/ D&C

34
Q

PE that should be performed in secondary amenorrhea include

A

vitalls
general
skil (oily? acne? hirsutism?)
HEENT (parotid swelling, dental erosion= bulemia)
Carciac, pulm (everyone)
Breast
Pelvic (clitorimegaly, estrogen deficiency)

35
Q

Lab studies you should get for secondary amenorrhea include

A 
PREGNANCY!!! HCG (urine or serum) 
TSH 
Prolactin 
FSH/LH 
total testosterone
36
Q

What si the progestin challenge test

A

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

37
Q

Imaging for secondary amenorrhea should include

A

Pelvic sonogram
CT adrenals (virilization, elevated testosterone)
CT/MRI (suspect pit problem)

38
Q

Goals of secondary amenorrhea treatment include

A

establish firm Dx (and Tx it)
restore ovulatory cycles and treat infertility
Tx hypoestrogen and hyperandrogen

39
Q

What is the MCC of abnormal uterine bleeding

A

anovulatory cycles

40
Q

What is polymenorrhea

A

abnormally frequently menses at intervals <24 days

41
Q

What is menorrhagis

A

Excess/prolonged menses (>80ml or >7 days) at normal intervals

42
Q

What is metorrhagia

A

Irregular episodes of uterine bleeding

43
Q

FIGO says these acronyms are causes of abnormal uterine bleeding

A 
PALM-COEIN 
Polyp 
Adenomyosis
Leiomyoma 
Malignancy/hyperplasia 
Coagulopathy 
Ovulatory dysfunction 
Endometrial 
Iatrogenic 
Not yet classified
44
Q

Other DDx for abnormal uterine bleeding are

A 
systemic disorders (hepatic dz, renal dz, thyroid dz) 
Trauma (lac, abrasion, FB) 
Organic conditions (pregnancy, endometriotis, cervicitis)
45
Q

What is dysfunctional uterine bleeding

A

when all identifiable causes of AUB are ruled out!

DUB is a Dx of EXCLUSION

46
Q

Initial eval for abnormal uterine bleeding should include

A

confirm that the uterus is actually the source of bleeding
setermine if pt is pre menarchal or postmenopausal
Exclude PREGNANCY

47
Q

On further evaluation of abnormal uterine bleeding, determine

A 
bleeding pattern 
If endometrial sampling is needed (if post-menopausal or obese) 
Coag evaluation 
If it started 2/2 contraceptiove method 
consider concurrent factors
48
Q

If a woman comes in with AUB, PE should include

A

check for pallor, tachycardia, hypotension, and excessive bruising
Pelvic (verify uterine source, check for IUD strings, uterine size)

49
Q

Labs for AUB should include

A

HCG, CBC, iron

+/- coags, bleeding time, TSH, LFT, FSH

50
Q

Diagnostics for AUB should include

A

pelvic sonogram
Pap and cervical cultures
endometrial biopsy

51
Q

How can you manage AUB

A

If less significant, obs
hormonal treatments
endometrial ablation
hysterectomy (extreme cases)

52
Q

What are the types of dysmenorrhea

A

Primary: no readily identifiable cause (MC in 17-22)
Secondary: 2/2 organic pelvic dz (MC as women age)

53
Q

Why does dysmenorrhea occur

A

Corpus luteum regresses
PGE2 and PGF2 are released from the endometrium 2/2 cell lysis during menstruation
Uterus contracts, causing ischemia

54
Q

Primary dysmenorrhea may present like this

A

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

55
Q

Lab tests for primary dysmenorrhea should include

A

HCG
+/- PAP with cultures
But, if H&P is consistent with other lab studies then no other labs or imaging is necessary

56
Q

Conservative treatment for primary dysmenorrhea includes

A 
Decrease caffeine intake 
apply heat 
gently massage lower abdomen 
get sleep! 
exercise 
yoga, acupuncture 
Calcium, Mg, B-complex
Stop smoking
57
Q

Pharm Tx for primary dysmenorrhea is

A

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

58
Q

When is follow up or referral required for primary dysmenorrhea

A 
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
59
Q

How does secondary dysmenorrhea usually present

A

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

60
Q

Potential causes of secondary dysmenorrhea include

A 
PID 
Uterine fibroids 
Ovarian cysts 
pelvic congestion 
endometriosis
61
Q

How do you treat secondary dysmenorrhea

A

COC work great! can try POP or NSAIDS if can’t take estrogen
Complicated cases +/- surgery (laparoscopy for Dx, hysterectomy, oopherectomy, myomectomy)

62
Q

What is PMS

A

physical, mood related and behavioral changes tat occur in a regular, cyclic relationship to LUTEAL phase
usually RESOLVE with onset of menses

63
Q

What is PMDD

A

premenstrual dysphoric disorder; basically PMS with more severe emotional symptoms

64
Q

Etiology of PMS is

A

unclear; may be genetic, or 2/2 abnormal SEROTONIN response to hormone fluctuations

65
Q

Physical manifestations of PMS include

A

Bloating
Fatigue
Breast tenderness
Headaches

66
Q

Behavioral manifestations of PMS include

A

Labile mood, irritability
Increased appetite
Forgetfulness
Difficulty concentrating

67
Q

What are PMDD self rating questions that help distinguish from PMS (Affective Sx)

A

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?

68
Q

What is PMS diagnostic criteria

A

1-4 Sx of physical, behavioral, or affective

69
Q

What are PMDD diagnostic criteria

A

5+ symptoms of physical, behavioral, or affective

70
Q

DSM 5 criteria for PMDD is

A

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

71
Q

In order to diagnose PMS or PMDD, you must R/O

A

Underlying psych d/o
menopausal transition
thyroid disorder
mood disorder

72
Q

How do you manage PMS/PMDD

A

Non-pharm: aerobic exercise, stress reduction technique
Pharm: SSRI (fluoxetine, sertraline, citalopram, paroxetine, escitalopram) during luteal phase only
+/- ovulation suppression (GnRH agonist, ECOC)

Summer FDTN Exam 3 (25 decks)

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