Menstrual Disorders Flashcards
avg age of menarche…
12-13 yo
average menstrual cycle length (1st day of bleeding through next cycle of bleeding)
24-38 days
normal menstrual bleeding should be how long…
8 or fewer days
amount of blood loss in menstrual bleed?
5-80mL
The normal menstrual cycle depends on normal function of what three factors?
Hypothalamic-pituitary-ovarian axis
endometrial hormone response
intact outflow tract
Failure to reach menarche by age 15 with normal secondary sex characteristics
OR
by 13 without secondary sex development
primary amennorhea
absence of menses for more than 3 cycles or 6 consecutive months
secondary amenorrhea (cessation)
2 most common etiologies of primary amenorrhea…
gonadal dysgenesis and PCOS
ovarian dysfunction
what results in high FSH hypergonadotropic hypogonadism?
gonadal dysgenesis
what type of gonadal dysgenesis?
ovaries unable to respond to gonadotropins
MC cause of premature ovarian insufficiency
turner syndrome (45 XO)
What type of gonadal dysgenesis?
vanishing testes:
streak gonads don’t secrete AMH or T
46 XY
A patient presents with:
-premature depletion of oocytes and follicles
- shield chest
- webbed neck
- side spaced nipples
- streaked ovaries
Turner syndrome (45 XO)
A patient presents with:
indifferent gonads
female internal and external genetalia
no secondary male characteristics
rare d/o
46 XY, sawyer syndrome
46 XY is caused by…
SRY gene mutation
Patient presents with:
ovulatory dysfunction
hyperandrogenism
PCOS
If sxs of hypogonadotropic hypogonadism presents with anosmia, what should you suspect?
Kallman syndrome: congenital GnRH deficiency
Primary amenorrhea can be caused by hypothalamic disrutions. What is the female athlete triad?
insufficient calorie intake
amenorrhea
low bone density
2 pituitary causes of primary amennorhea
adenoma
hyperprolactinemia
This is an outflow tract d/o that is a common cause of primary amennorhea:
blind end vagina
cyclic pelvic pain and mass
normal gonadal function
breast development
mullerian agenesis
this is a congenital absence of oviducts, uterus and upper vagina with 46 XX genotype
mullerian agenesis
46 XY
female phenotype
high serum T
androgen insensitivity syndrome
testes make T and AMH but not responsive to T or DHT due to complete or partial androgen receptor insensitivity
androgen insensitivity syndrome
on US you notice absent upper vagina, uterus and fallopian tubes.
Physical exam reveals intra-abd or partially distended testes
androgen insensitivity syndrome
46 XY
can’t convert T to DHT
ambiguous genitalia at birth
5 alpha reductase deficiency
Phenotypic female with HTN and lack of pubertal development
decreased cortisol and sex steroids
17 alpha hydroxylase deficiency
which gene mutation causes 17 alpha hydroxylase deficiency?
CYP17
MC cause of secondary amennorhea…
pregnancy
initial workup of primary amenorrhea…
HCG FSH TSH Prolactin Pelvic US
If primary amenorrhea and absent uterus, what two tests should be ordered?
karyotype
total T
3 tx goals of primary amenorrhea…
underlying cause
fertility
complication mgmt (osteoporosis)
Negative pregnancy test
history of wt. loss, strenuous exercise, eating d/o
hypothalamic dysfunction (anorexia, bulimia, exercise, stress)
negative pregnancy test
hx of uterine surgery or infx
scarred endometiral lining
asherman syndrome
Negative pregnancy test
HA
Visual Changes
galactorrhea
(2)
sheehan syndrome
infiltrating pituitary dz/tumor
negative pregnancy test
worsening acne hirsutism wt. gain insulin resistance abnormal ovaries on US androgen excess
PCOS
negative pregnancy test
recent or recurrent meds (OCPs, danezol, andipsychotics)
post pill amenorrhea
DA/gonadotropin/releasing hormone antagonists
negative pregnancy test
hx of: renal failure, CA, infx, RA
amenorrhea due to systemic illness
negative pregnancy test
worsening acne
hirsutism
wt. gain
hypothyroidism
Evaluate for cause of primary amenorrhea when? (3)
no uterine bleeding by 15
no menses/thelarche by 13
no menarche w/in 3 years of thelarche
what DDx for primary amenorrhea?
Low/normal FSH, (+) breast development and uterus present
PCOS/thyroid
What tests should be ordered for primary amenorrhea for the below results and why?
L ow/normal FSH, (+) breast development and absent uterus:
DDx: mulerian agenesis
order karyotype, T r/o AIS
What course of action?
L ow/normal FSH, ( (–) breast development
pituitary MRI
if pituitary MRI is negative and normal prolactin… what two tests should be ordered?
transferrin saturation (hemochromotosis)
Progesterone challenge
If low FSH/no estrogen or no withdrawal bleed on progesterone challenge, what type of amenorrhea should be considered?
functional hypothalamic
If unopposed estrogen/high LH to FSH ratio and withdrawal bleed on estrogen challenge, what type of amenorrhea should be considered?
PCOS
Initial workup for secondary amenorrhea
HCG FSH TSH prolactin T
the below are most common causes of..
anovulation
structural pathology
bleeding disorder
uterine neoplasia
abnormal uterine bleeding
The PALM-COEIN Classification seeks to differentiate what?
structural/nonstructural cause of AUB
The below are ____ causes of AUB
polyp
adenomyosis
leiomyoma (fibroid)
malignancy
structural
The below are ____ causes of AUB
coagulopathy ovulatary dysfunction endometrial iatrogenic not classified
nonstructural
MC cause of AUB for 13-18 yo
anovulatory bleeding via immature HPO axis
common cause of AUB for 19-39
structural leisions
common cause of AUB for 40 to menopause
anovulatory bleeding, carcinoma, hyperplasia
unpredictable bleeding is suggestive of what type of AUB?
anovulatory
regular cycle length and associated with sxs of ovulation is what type of AUB?
ovulatory
heavy AUB is usually what cause?
uterine (fibroid, adenomyosis, coagulopathy)
the below often cause what type of AUB?
polyp
contraception
PID
cervical d/o
intermenstrual
post-coital bleed should be sugestive of _____ pathology
cervical
irregular/anovulatory bleed is likely due to (3)
PCOS
thyroid
hyperprolactinemia
T/F: any post-menopausal bleed is abnormal
tru
if a patient with AUB is hemodynamically unstable, what is tx?
admit for IV estrogen
the below is a cause of:
PGs released from endometrium
cause uterine contractions/ischemia
primary dysmenorrhea
Patient presents w.
normal pelvic exam
cramp like, intermittent pain
onset hours before or just after onset of menstruation
primary dysmenorrhea
how is primary dysmenorrhea diagnosed?
clinical (if h & p consistent)
Tx for primary dysmenorrhea…
ibuprofen 400mg q 4-6 hours x 3-4 days
hormonal contraceptives
The below complications are indications for…
Pain worsening with each menses Pain lasts longer than first 2 days of menses Medication is no longer controlling the pain Menstrual bleeding becomes increasingly heavy Pain accompanied by fever Abnormal discharge or bleeding occur Pain occurs at times unrelated to menses
referral
resistant primary dysmenorrhea can be treated with…
laproscopy
GnRH analogue
30-40 yo pt presents with:
pain not limited to menses
dyspareunia
infertility
AUB
secondary dysmenorrhea
the below are common causes of…
Endometriosis (presence of endometrial tissue outside the uterus) Adenomyosis (endometrium grows into the wall of the Adhesions Pelvic inflammatory disease (PID) Leiomyomas (uterine fibroid
secondary dysmenorrhea
tx for secondary dysmenorrhea…
underlying cause +/- hormone therapy
PMS is related to the _____ phase
luteal phase
what Nt is decreased in the luteal phase that may be responsible for PMS/PMDD due to progesterone’s increase of MAO
serotonin
A patient presents with:
irritability, depression, anxiety, sensitivity
increased appetite
bloating
fatigue
breast tenderness
HA
PMS
PMS can be diagnosed if what two factors…
1+ sx occurs during luteal phase
sxs remit at menses
PMDD requires ____/11 sxs present during____
5 during most menstrual cycles
the below are sxs of ____
mood swings
hopelessness
anger
anxiety
AND
sxs of depression (DIGFAST)
PMDD
PMS, PMDD, or MDD?
+/- predominant mood sxs
+ physical sxs
- social impairment
monthly cycle
PMS
PMS, PMDD, or MDD?
+ predominant mood sxs
+ physical sxs
+ social impairment
+ monthly cycle
PMDD
1st line therapy for PMDD
SSRIs
