Menstrual disorders Flashcards
PMDD differs from PMS how
PMDD more severe and usually mood sxs
how to treat PMS
pain mngmt OCP diet- low Na low Caffeine, exercise NSAIDS, SSRI for mood sxs
ddx for PMS
hypothyroidism
depression
PMDD
anemia
labs for momma with PMS depression sxs
UPT CBC TSH CHEM7 HROMONES SX chart
tx options for depression exacerbated by menses
SSRI
continuous therapy
counseling
behavioral, exercise, rest
tests for irregular menses in 15 yo
CBC- factor V PTT von willibrands testosterone (PCOS)
irregular menses 15 yo ddx
anovulatory cycles PCOS thyroid pregnancy thyroid disorder bleeding disorder pituitary or adrenal disorder
labs for irregular menses
CBC
TSH, PROLACTIN, DHEA-S, INSULIN
CHEM 7
PT/PTT, additional coag tests if indicated
tx for anovulatory cycle
can do really low dose bc pill if don’t need contraception
what tests would you run for a pt with migraines associated with recent BC
cbc
tsh
chem7
need to check BP (if increasing and hx of CVD not a good idea to be taking estrogen)
what causes migraines associated with hormones
withdrawl of estrogen
Fatigue and HA assoc with menses ddx
hypothyroid
anemia
neuro
UPREG
32 yo c/o PMS
fatigue
sad lonely irritable
Rule out thyroid disorders, anemia, blood sugar, etc.
Rule out thyroid disorders, anemia, blood sugar, etc.
the best screening test if you suspect premature ovarian failure
. Serum FSH
when would you not check hormone levels in a pt complaining of PMS
Do not check hormone levels if pt on OCP/HRT.
if having sxs all month long
dx is mild depression with exacerbation during menses
tx options
SSRI
therapy
bx therapy exercise rest
when do you follow up with SSRI
f/u in 4 weeks
if suspect perimenopausal want to get these tests
May do FSH, LH, estradiol if suspect perimenopausal
15 yo w/ irregular menses 3-4x normal cycles and now heavy bleeding or spotting
need to know how heavy is heavy bleeding
is she sexually active
Anovulatory cycles PCOS Pregnancy Thyroid disorder Bleeding disorder Pituitary or adrenal disorder
screening for bleeding disorders
PT & PTT as screening for bleeding disorders
. Often bleeding disorders in females present
. Often bleeding disorders in females present
LABS with irregular 15yo
CBC TSH prolactin DHEA-S, insulin (if indicated) Chem 7 panel (fasting) PT / PTT, additional coag tests if indicated UPT GC/Chlamydia? Other sti testing
pill warning sign
ACHES
abdominal -blood clot, vomiting, cramping, weakness
chest pain-blood clot in lung or heart
hear attack
HA-stoke
eye problems-stoke
leg pain -inflammartion
Tx for 16 yo that can be on bc
Can out on birth control to normalize cycle
21 yo
Returns for refill and states she has been getting more migraines than before starting the pill. H/o migraines, but they seem to be worse recently.
Menstrual migraines Tension ha Depression/anxiety Anemia Cerebrovascular complication of OCP
DX testing
Diary of migraines Consider labs if indicated by h&p Cbc Tsh Chem 7 (fasting)
TX for menstrual migraines
Discontinue or change OCP Consider alternative birth control method NSAID Triptan-day before off week Supportive therapy
menstrual migraines is the result of
Estrogen withraw
37 yo with amenorrhea x2mos w/ 8 mos of irregularity
ddx
pregnancy
Anovulatory cycles
Premature ovarian failure /
perimenopause
Hypothyroidism
Prolactinoma
Pcos
endometriosis
dx tests
upt
Tsh, prl, fsh, testosterone/dhea-s (if indicated)
Chem 7 (fasting)
Cbc
DUB is a dx of exclusion, can be caused by
fibroids, polyps, hormone imbalance, uterine cancer, etc
49 yo woman with hx of breast cancer and hot flashes
was her breast cancer estrogen receptive?
what are non hormonal therapy for menopausal sxs
Ssri/snri
Clonidine
Pregabalin
Cbt, hypnosis
______ cells of corpus luteum begin producing progesterone
Granulosa cells –> progesterone
oligomenorrhea
- Irregular cycles lasting longer than 34 days
polymenorrhea
<25 days
when should you measure serum progesterone
Measurement of the serum progesterone concentration in the mid-luteal phase,
18-24 days after menses or 7 days before next menses is expected
when should you measure FSH
Measurement of an early follicular phase serum FSH level on Day 3 of the menstrual cycle is used as a marker for ovarian reserve in older or infertile women
highest probability of conception is with
Highest probability of conception is with intercourse 1-2 days prior to ovulation
when does a rise LH occur
Rise in LH occurs about 36 hours prior to ovulation
most common etiology of primary amenorrhea
Chromosomal abnormalities causing gonadal dysgenesis (50%)
other causes of primary amenorrhea
Hypothalamic hypogonadism including functional hypothalamic amenorrhea (20%)
Absence of the uterus, cervix and/or vagina, müllerian agenesis (15%)
Transverse vaginal septum / imperforate hymen (5%)
Pituitary disease (5%)
evaluation of primary menorrhea dx tests
a. Presence or absence of breast development (Tanner staging)
b. Presence or absence of the vagina, uterus, cervix, and ovaries
c. FSH serum level
MCC if
pregnancy #1
Ovarian disease (40%) Hypothalamic dysfunction (35%)
. Pituitary disease (19%)
. Uterine disease (5%)
High FSH, LH: Dx = Ovarian Failure
i. ≥40 yrs: Menopause
ii. <40 yrs: Premature menopause
1. Karyotype if <30 yrs
if you have a low FSH and LH
Normal/Low FSH, LH: Dx = Central Failure
Evaluate pituitary: MRI brain
Rx estrogen replacement
If pregnancy desired, induce ovulation
elevated DHEAS
adrenal tumor
PCOS
Elevated testosterone
PCOS
ovarian tumor
progesterone challenge in a patient with amenorrhea
Withdrawal bleed: anovulation
No withdrawal bleed: check FSH, LH
when do menstrual migraines occur
2 days prior to 3 days after onset of menses
prometherin
progesterone
premarin
estrogen
theory behind menstraul migraines
: estrogen stimulates nitric oxide release which affects the vasculature leading to migraine
Progesterone concentration has no significant effect
NSAID recommendation for menstrual migraines
- Taken 5-7 days prior to onset of menses, continue until 1-2 days after onset
triptan recommendation for menstrual migraines
- Taken 2-3 days prior to anticipated onset of migraine
Mastodynia occurs when, relieved with what
Occurs in luteal phase; relieved with menses
Most often assoc with fibrocystic changes of breast.
mastodonia is the result of….
what is the Tx 1st and 2nd line
Due to high gonadotropin levels
there fore is relieved with danazol
androgen inhibitor of GnRH
OCP MOST useful and commonly
Tamoxifen, bromocriptine may be used off-label and with caution
PMS sxs must occur during this phase of the menstrual cycle
Symptoms must occur in the luteal phase
May be related to decreased levels of prostaglandins
menstrual migraine tx
1 - using monophasic pills (or monophasic ethinyl estradiol doses)
only one inactive pill week a few times a year, rather than monthly (ie. “Seasonale”)
main problem is breakthrough bleeding
2 - using OCP for BCM uses approx 20 mcg of EE in OCP day 1-21, then day 22-28 use 0.9 mg conjugated estrogens (Premarin)
3 - using low dose estrogen during the time when HA would normally occur
also GnRH agonists - but not FDA approved and high cost and side effects
OTC FOR MILD PMS
Mild diurectic
Analgesics
Prostaglandin inhibitors
Antihistamines
The only diuretic that has been shown in studies to alleviate fluid retention and breast tenderness associated with PMS
spironolactone
RX for pMS SSRI
Sarafem (fluoxetine) 20mg po qd
Zoloft 25-50mg po qd
Celexa 20mg po qd
when would you administer SSRI for PMS
Tx during last 2 weeks of cycle or given few days before anticipated start of symptoms. Efficacy for intermittent tx similar to continuous tx
conditions that may worsen with the menstrual cycle
Migraine Depression Seizures Irritable Bowel Syndrome Asthma Chronic Fatigue Syndrome Allergies
