Menstrual disorders Flashcards
What is primary amenorrhea?
No menarche by 15y/o w/ signs of puberty
OR
No menarche and no signs of puberty by 13y/o
What is the MC genetic cause of primary amenorrhea?
Turner’s syndrome
What is the 1st and 2nd MC causes of primary amenorrhea?
1- Chromosomal abnormalities causing gonadal dysgenesis (Turners)
2- Hypothalmic hypogonadism
If you have a patient with primary amenorrhea and low body weight what are you thinking is the cause
hypothalmic dysfunction
The following are possible causes of what?
- Chrom abnormalities causing gonadal dysgenesis
- Hypothalmic hypogonadism (functional/hypothalmic amenorrhea, tumors, hyperprolactinemia, hypothyroid)
- Mullerian agenesis
- Transverse vag septum
- Imperforate hymen
- Pituitary dz
- Androgen insensitivity syndrome
Primary amenorrhea
If you have a patient with primary amenorrhea with cyclic pelvic pain and a perirectal mass, what are you thinking is the cause?
imperforate hymen
Primary amenorrhea:
What is functional/hypothalmic amenorrhea associated with?
eating disorders, times of extreme stress, excessive exercise, etc
What 5 labs should be ordered to evaluate for the cause of primary amenorrhea?
- HCG!!!!!
- Serum FSH/LH
- Serum prolactin and TSH
- Serum testosterone
- +/- Karyotype
What does an elevated FSH in a person with primary amenorrhea indicate?
Gonadal dysgenesis
What does an decreased or normal FSH in a person with primary amenorrhea indicate?
Hypogonadotropic hypogonadism
What are the 2 possible causes of a person with primary amenorrhea and normal puberty?
- Outflow tract obstruction
- H-P-O axis dysfunction
What are the 4 possible causes of primary amenorrhea w/ delayed puberty?
- Gonadal dysgenesis
- Mullerian agenesis
- Physiologic delay of puberty
- Genetic abnormality
What is secondary amenorrhea?
No menses x3 mo if previously regular cycles
OR
No menses x6mo if previously irregular cycles
What is the MCC of secondary amenorrhea?
Pregnancy!!
Then PCOS
If you have a patient with secondary amenorrhea and they have a history of uterine surgical procedure or infection, what shoudl you be thinking is the cause?
Asherman’s syndrome
If you have a patient with secondary amenorrhea along with worsening acne, weight gain and hirsutism, what shoudl you be thinking is the cause
PCOS
Hypothyroidism
If you have a patient with secondary amenorrhea along with HA, visual changes and nipple discharge what should you be thinking?
Pituitary disease/tumor
Sheehan Syndrome
If you have a patient with secondary amenorrhea along with h/o weight loss, strenuous exercise or eatind disorder, what should you be thinking?
Hypothalmic dysfunction
What 6 labs could be drawn to evaluate secondary amenorrhea?
1. HCG!!!!!
- TSH
- Prolactin
- FSH/LH
- Total testosterone
- Progestin challenge ( not done often- looking to see if get withdrawal bleed)
What is the Ddx for abnormal uterine bleeding? (PALM COEIN)
Polyp
Adenomyosis
Leiomyoma
Malignancy/hyperplasia
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
What is the MCC of abnormal uterine bleeding?
anovulatory cycle
What is dysfunctional uterine bleeding?
dx of exclusion after identifiable causes of abnormal uterine bleeding are ruled out
What are the 4 treatment options for abnormal uterine bleeding?
- Observation (less significant bleeding)
- Hormonal treatments (COCs)
- Endometrial ablation
- Hysterectomy (extreme cases)
What is dysmenorrhea?
Painful menstruation
What is the pathophys of dysmenorrhea?
The corpus Luteum causes pain by releasing prostaglandins which causes uterine contraction and ischemia
Is primary or secondary dysmenorrhea due to organic pelvic disease?
secondary
Primary is due to an unidentifiable cause
What age group is primary dysmenorrhea MC in? Secondary dysmenorrhea?
Primary: 17-20y/o
Secondary: 30-40y/o
Primary or secondary dysmenorrhea?
- Hours before or just after onset of menstruation
- lasts ~12-72hrs
Primary
What are the 2 main treatment options for primary dysmenorrhea
- 1st line= NSAIDs
- Hormonal contraceptives (COCs, ECOCs, Depo)
How do you treat resistant primary dysmenorrhea?
CCBs
In what 5 instances would you want to follow up or refer a patient with primary dysmenorrhea?
- Pain worsening with ea. menses
- Pain longer than the 1st 2 days of menses
- Meds no longer controlling pain
- Increased heaviness of bleeding
- Pain at times unrelated to menses
Primary or secondary dysmenorrhea?
- Pain NOT limited to menses but may worsen at this time
- a/w other sxs (dyspaurenia, infertility, AUB)
- less related to 1st day of menses
secondary dysmenorrhea
What are the 4 causes of Secondary dysmenorrhea?
- Endometriosis
- PID
- Uterine fibroids
- Ovarian cysts
What are the 3 tx options for secondary dysmenorrhea?
1. COCs (can use for almost all cases)
- If estrogens CI: Progestins or NSAIDs
3 +/- pelvic sx for complicated cases
PMS is correlated with which phase of the menstrual cycle?
luteal phase
What condition a/w luteal phase of menstrual cycle?
- Abd bloating
- fatigue
- breast tenderness
- HAs
- irritability, depressed mood
- etc
PMS
PMDD must have > _____ sxs + at least 1 of what 4 affective disorders?
>5 sxs
+
at least 1 of the following affective disorders: depressed, anxious, mood swings/sensitive, angry/irritable
How many sxs must be present to dx PMS? PMDD?
PMS: 1-4 sxs
PMDD: >5 sxs + at least 1 affective sx
What questionairre helps distinguish PMS from PMDD?
Daily Record of Severity of Problems (DRSP) form
The following are on the Daily Record of Severity of Problems form used to distinguish PMS from PMDD. What type of sxs are these considered and are they more helpful in distinguishing PMS or PMDD?
- Depressed/sad
- Anxious
- Mood swings, sensitive
- Angry/irritable
Affective sxs
PMDD
What is the gold standard for treating PMDD? What is special about how patients can take these?
SSRIs (fluoxetine, sertraline, citalopram, paroxetine, escitalopram)
Can do cyclical tx (start when enter luteal phase)
The following are some sxs of what? (must be present during week prior to menses, resolving witha few days after menses)
- Mood swings
- Anger/irritability
- Depressed
- Anxiety
- Difficulty concentrating
- Changes in appetite (increased)
- Fatigue
- Overwhelmed
- Breast tenderness, bloating, joint/mm aches
- Increased sleep
PMDD
(1 of the first 4 affective sxs MUST be present)
Sxs of PMDD must be present when? When should they resolve
must be present during week prior to menses, resolving within a few days after menses
