menstrual disorders and issues Flashcards
What is the definition of primary amenorrhea?
absence of menses with normal secondary sexual characteristics by a 16 year old or absence of both menses and secondary sexual characteristics by a 13 year old
What is the definition of secondary amenorrhea?
absence of menses for 6 months in a woman it a prior history of menstruation
What are the general categories of disease that can lead to primary amenorrhea?
-pituitary or hypothalamic disease, anatomic anomalies (absent uterus, vaginal septa), chromosomal anomalies with gonadal dysgenesis or androgen insensitivity syndrome
What are the general categories of disease that can lead to secondary amenorrhea?
- pregnancy
- menopause/premature ovarian failure
- hypothalamic or pituitary disease (which can include tumors)
- anorexia/malnutrition
- thyroid disease
- uterine anomalies (Asherman’s syndrome)
- PCOS
What is a general testing algorithm for primary amenorrhea?
- pregnancy test
- assess for secondary sexual characteristcs
- If yes, perform exam, ultrasound, and chromosomal analysis
- If no, test FSH and LH
–If high, suspect ovarian issue (gonadal agenesis, dysgenesis, or ovarian failure)
–If low, suspect prolactinoma or HPA dysfunction
—->test prolactin. If prolactin is normal, think about GnRH deficiency or HPA dysfunction
see pg 246
What is the approach to secondary amenorrhea?
- pregnancy test
- thyroid test
- If thyroid normal, check prolactin
- If polactin normal, perform a progesterine challenge…. more, but that is a good start (see pg 246).
- If progestin challenge normal, do an estroen-progesterone challenge
- Check FSH/LH
What diagnoses are likely if pt has negative preg test, normal TSH/T3/T4, and bleeds with a progestin challenge test?
Progestin test: observe pt for bleeding after 5 day administration of progesterone. If bleeding, woman did have uterine lining built up. Suggests PCOS, adrenal tumor, Cushing syndrome, anorexia/malnutrition, or HPA dysfunction. distinguish based on signs of virulization
How does the estrogen/progesterone test help in determining a cause of secondary amenorrhea?
- Consider for patients who have no bleeding with progestin challenge test (ie didn’t build up uterine lining)
- Give estrogen progesterone and then observe for bleeding
- If still no bleeding, you have a uterus problem (Asherman’s syndrome likely)
- If bleeding, consider ovarian failure (high FSH/LH) or HPA dysfunction (low FSH/LH)
What are treatment options for HPA axis dysfunction?
GnRH or gonadotropin replacement
What is the treatment for Asherman’s syndrome?
lysis of adhesions and estrogen administration should be considered
What is the differential for dysmenorrhea? Initial testing?
PID, endometriosis, fibroids, ovarian cysts, adenomyosis; useful to do pregnancy test, blood and vaginal cultures; consider ultrasound
What are some historical features that suggest primary vs. secondary dysmenorrhea?
primary dysmenorrhea usually begins at the beginning of menstruation; secondary dysmenorrhea often begins midcycle before the onset of menstruation and worsens until the period is done
What are key historical features of endometriosis?
dysmenorrhea, dyspareunia, painful bowel movements, pelvic pain, possible infertility, possible palpable adhesions
What are treatment recommendations for endometriosis?
- record a journal of sx
- try OCPs, progestins, danazol (but lots of side effects), or GnRH agonists
- May need laparoscopic ablation
What are considered abnormal menses?
cycle 35 day intervals; lasting >7 days, blood loss >80 mL
