Menstrual Disorders Flashcards
Primary amenorrhea
- no menarche (first menses) by age 15 despite normal growth and secondary sexual characteristics
- no menarche by age 13 + not growing normally or hasn’t developed secondary sex characteristics
Secondary amenorrhea
- No menses for 3 months (previously regular cycles)
- No menses for 6 months (previously irregular cycles)
Primary amenorrhea: ovarian disorders
Gonadal dysgenesis (ex. Turner’s 45, XO)
- short stature
- webbed neck
- widely spaced nipples
Primary amenorrhea: Hypothalamic/pituitary disorders
- Hypothalamic (abnormal GnRH secretion)
- Congenital GnRH deficiency (ex. Kallmann syndrome with anosmia)
- Hyperprolactinemia
- Hypothyroidism
- Tumor
Primary amenorrhea: uterus absent
- Mullerian agenesis (46- XX) (vaginal agenesis)
2. Androgen Insensitivity Syndrome (46 XY) - male but testosterone isn’t having its intended effect
What is the first thing to screen with lack of menses?
PREGNANCY TEST
What should be measured if the patient is not having periods and has not developed 2ndry sex characteristics?
LH and FSH
If low–> hypo-gonatotropic hypogonadism (hypothalamus or pituitary failure)
If high–> check karyotype
In primary amenorrhea, when do you start clinical evaluation?
At age 15 if no menarche
At age 13 if no breasts (thelarche)
At age 13 if no menstration within 2 years of thelarche
Primary amenorrhea: labs
-urine or serum beta hCG
-Serum FSH/LH
(if high FSH suggests gonadal dysgenesis- Turners)
(if low FSH suggests hypothal/pituitary failure)
Reasons for functional amenorrhea
- weight loss, exercise
- nutritional deficiencies
- stress
- celiac disease
Name 2 pituitary diseases that could cause secondary amenorrhea
- Prolactin secretin tumor
2. Sheehan’s syndrome (post-partum)
Secondary amenorrhea: ovarian causes
- Polycystic ovary syndrome (too much androgens)
- hirsutism
- acne - Primary ovarian insufficiency (poop out too soon. Ex. Turner syndrome, or radiation or chemo)
Secondary amenorrhea: uterine disorders
Asherman’s syndrome - acquired scarring of the endometrial lining usually from postpartum hemorrhage, surgical proceedure or infection
Progestin challenge test (secondary amenorrhea)
- helps assess estrogen status
- Give medroxyprogestone for 10 days
- If adequate estrogen levels, should have withdrawal bleeding within 2 weeks
- If no bleed –>pregnant, uterine defect
What proportion of outpatient GYN visits are due to abnormal uterine bleeding?
1/3
What is the most common reason for abnormal uterine bleeding?
anovulation
Menorrhagia
excessive or prolonged menses occurring at normal intervals
What is the diagnosis of exclusion for abnormal uterine bleeding if all other causes have been ruled out?
dysfunctional uterine bleeding (DUB)
For a patient having uterine bleeding, what labs should be ordered?
- hCG*
- CBC*
- Iron studies
For a patient with uterine bleeding, what is the best imaging modality?
Pelvic Ultrasound
Mild uterine bleeding: tx
observation, consider oral contraceptives
Severe uterine bleeding: tx
ablation
Extreme uterine bleeding: tx
hysterectomy
Primary dysmenorrhea
painful menstruation with no readily identifiable cause
-Young patients (17-22yrs)
Secondary dysmenorrhea
painful menstruation due to organic pelvic disease
-more common with age
Primary dysmenorrhea: clinical presentation
- cramp-like intermittent pain
- normal pelvic exam
- begins just before or just after onset of menstruation
For a patient with primary dysmenorrhea, what lab test is the most important to order?
beta-hCG
Primary dysmenorrhea: conservative treatment approach
- drink less caffiene
- get enough sleep
- exercise
- yoga, acupuncture
- calcium, magnesium, B-complex
- stop smoking
Primary dysmenorrhea: Pharmacologic therapy
NSAIDs**
or
oral contraception, Depo-Provera
or
CCBs
Secondary Dysmenorrhea: key points
- women 30-40yrs
- Pain not limited to start of menses
Secondary dysmenorrhea: treatment
oral contraception
Distinguish PMS from PMDD
- both occur during the luteal phase
- occur in most cycles
- resolve with onset of menses
***PMDD has more severe emotional symptoms (affective/psychological)
How do you assess for menstrual cycle associated disorders?
Daily Record of Severity of Problems (DRSP) form
-self rating questionnaire which helps distinguish PMS and PMDD
Premenstrual dysphoric disorder (PMDD): Tx
Pharmacologic: SSRIs (ex. fluoextine, sertraline, citalopram, paroxetine, escitalopram)
