Menstruation Flashcards
premenstrual syndrome and premenstrual dysphoric disorder are marked by BOTH physical and behavioral symptoms that occur when?
Second half (luteal phase) of menstrual cycle
when are sx of premenstrual syndrome and premenstrual dysphoric disorder alleviated
onset of menses
Do mild sx count as premenstrual syndrome or premenstrual dysphoric disorder?
NO
dx premenstrual syndrome
at least one symptom associated with economic or social dysfunction during at least part of the 5 days before the onset of menses and recurring in at least three consecutive cycles
sx for premenstrual dysphoric disorder
at least one of the following symptoms: mood swings, sudden sadness, increased sensitivity, anger, irritability, depressed mood, anxiety, and tension. In addition, one or more of the following symptoms must be present: difficulty concentrating, change in appetite, diminished interest in usual activities, decreased energy, feeling overwhelmed, breast tenderness, bloating, weight gain, muscle aches, and sleep changes.
must be associated with significant distress or interference with usual activities, such as work, school, or social life
There must be at least five of the above symptoms in total
tx premenstrual disorder
selective serotonin reuptake inhibitors, such as sertraline or fluoxetine (first line)
COCs
Gonadotropin-releasing hormone agonists (leuprolide and nafarelin)
Bilateral oophorectomy
what tx for premenstrual disorder is a good option for people desiring contraception
COCs
what tx for premenstrual disorder is used in severe cases
Gonadotropin-releasing hormone agonists (leuprolide and nafarelin)
last resort tx for premenstrual disorders
bilateral oophorectomy
dosing for SSRIs in tx of premenstrual disorders
dosed continuously or only during the luteal phase
labs for natural menopause
decreased estrogen
elevated FSH
(more specifically estradiol level < 20 pg/mL and a follicle-stimulating hormone level of 21–100 mU/mL)
due to depletion of ovarian follicles
definition of menopause
12 consecutive months of amenorrhea without any other alternate causes
premature ovarian failure
Women who experience menopause before 40 years of age
perimenopausal period begins an average of how many years before final menstrual period
4 years
when should you do further workup for someone with irregular cycles
If a woman is < 45 years old, if she is > 45 years old reporting irregular cycles but no other symptoms of menopause
labs if you have to do workup for menopause sx
serum hCG to determine whether she is pregnant, serum prolactin to evaluate for hyperprolactinemia, and serum thyroid-stimulating hormone to screen for hyperthyroidism
is measurement of FSH needed to dx menopause
no
when might measurement of FSH be useful
for women who have undergone a hysterectomy or endometrial ablation and cannot manifest changes to menstrual bleeding
when is measurement of FSH unreliable
in women who are taking estrogen-progestin contraceptives
due to exposure of excess exogenous estrogen
would have to measure FSH 2-4 weeks after D/C BC
Secondary amenorrhea
cessation of menses for 3 consecutive months (in women who have had previously regular menses) or 6 months (in women who have had previously irregular menses) in women who have passed menarche
MC cause of secondary amenorrhea
pregnancy
testing for secondary amenorrhea
human chorionic gonadotropin hormone
follicle-stimulating hormone luteinizing hormone
prolactin
thyroid-stimulating hormone
what is warranted in someone with hyperprolactinemia or hypopituitarism
brain MRI
tx for secondary amenorrhea w no abnormal lab values
10 day course of progestin
Endometriosis
growth of endometrial glands and stroma outside of the uterus, particularly in the pelvis and ovaries
in what ages is endometriosis MC
women with a mean age of 25 to 35 years
sx endometriosis
triad of dysmenorrhea, dyspareunia, and dyschezia
cyclical pelvic pain and urinary symptoms such as dysuria, hematuria, urgency, or frequency
PE for endometriosis
tenderness on vaginal exam, nodules in the posterior fornix, adnexal masses, and immobility or lateral displacement of the cervix or uterus
PE may also be normal!!
when is imaging for endometriosis useful
only useful if a pelvic or adnexal mass is present
TVUS endometriosis
hypoechoic, vascular, or solid mass
definitive dx endometriosis
exploratory laparoscopy and biopsy
tx mild to moderate endometriosis
nonsteroidal anti-inflammatory drugs and oral contraceptives
tx severe endometriosis
Leuprolide with oral contraceptives, laparoscopy, and hysterectomy with bilateral salpingo-oophorectomy (definitive treatment) are reserved for severe endometriosis
PALM-COEIN
polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified
MC cause of abnormal uterine bleeding in adolescent women, especially within the first 1–2 years of menarche
immature hypothalamic-pituitary axis
what should be performed in all women w abnormal uterine bleeding
complete blood count to rule out anemia and a urine hCG to rule out pregnancy
Patients with abnormal uterine bleeding and aged ≥ 45 years warrant consideration for
endometrial biopsy to rule out endometrial malignancy
tx for pts with acute heavy menstrual bleeding with stable vital signs
short course of estrogen or progestin can abort the bleeding episode
tx for patients with severe uterine bleeding and who are hemodynamically unstable
uterine tamponade, intravenous estrogen, and surgical intervention (uterine artery embolization, dilation and curettage, or hysterectomy) may be indicated
at what age can women be clinically diagnosed with menopause
≥ 45 years of age
tx for sx associated w menopause in ppl who do have a uterus
combined hormone therapy with estrogen and progesterone
The progesterone helps prevent endometrial hyperplasia and endometrial cancer.
tx for sx associated w menopause in ppl who DO NOT have a uterus
estrogen alone
tx for vaginal atrophy only and no other bothersome sx of menopause
topical estrogen
overview of Premenstrual dysphoric disorder (PMDD)
severe form of premenstrual syndrome
sx may become more severe over time
daily functioning at work, school, typical activities, and relationships with others during the luteal phase must be affected for most cycles in the past 12 months
lab testing for PMDD
thyroid-stimulating hormone test, human chorionic gonadotropin, complete blood count, and follicle-stimulating hormone level should be ordered
nonpharm tx PMDD
acupuncture, relaxation techniques, light therapy, and cognitive behavior therapy. Aerobic exercise can also be helpful, especially in patients who have depression or bloating as predominant symptoms
pharm tx PMDD
hormones (e.g., combined oral contraceptives), diuretics (e.g., spironolactone), nonsteroidal anti-inflammatory drugs (e.g., naproxen), and antidepressants (e.g., selective serotonin reuptake inhibitors).
what is curative for PMDD
Hysterectomy plus bilateral oophorectomy
Is premenstrual syndrome in the DSM-5
no
is PMDD in DSM-5
yes
when does menarche usually occur
age 11–15 years
primary amenorrhea
Failure of the menses to appear by age 15 with normal growth and secondary sex characteristics or by age 13 in the absence of secondary sex characteristics, such as breast developmentd
does primary amenorrhea prompt further evaluation
yes
MC cause primary amenorrhea
gonadal dysgenesis
evaluation for primary amenorrhea
A pelvic exam should be performed to assess for hymen patency and the presence of a uterus. Initial laboratory evaluation should consist of FSH, LH, prolactin and testosterone levels, TSH, free T4, and a pregnancy test. Pelvic ultrasound is also recommended. MRI of the hypothalamus should be performed when patients have a low or normal FSH and LH, especially if they have high prolactin levels. Patients with a normal uterus, high FSH, and without the features of Turner syndrome should have a karyotype to evaluate for X chromosome mosaicism
Postmenopausal bleeding
vaginal bleeding that occurs 6 months or more after the cessation of menstruation and should always be evaluated
MC causes postmenopausal bleeding
endometrial atrophy, proliferation, or hyperplasia; endometrial or cervical cancer; and resulting from exogenous estrogens with or without added progestin
Endometrial thickness in postmenopausal women
endometrial thickness < 4 mm indicates a low probability of hyperplasia or cancer, but thickness > 4 mm should be evaluated with endometrial biopsy
Simple endometrial hyperplasia can be treated with
cyclic or continuous progestin therapy (medroxyprogesterone acetate or norethindrone acetate) for 21 or 30 days of every month for 3 months
Endometrial biopsy should be repeated every 3 to 6 months
Alternatively, a levonorgestrel intrauterine system may be used
persistent hyperplasia with atypia, endometrial carcinoma, or who do not tolerate medical treatment should undergo
total hysterectomy
fibroids and classification
benign tumors arising from the smooth muscle cells of the myometrium. Fibroids are extremely common and are often classified as submucosal, subserosal, or intramural, according to their anatomic location within the uterus
RF fibroids
genetics
early menarche
sx fibroids
abnormal uterine bleeding, pelvic pain or pressure, reproductive dysfunction, and enlarged uterus
MC = heavy or prolonged menses
commonly asx
classic pelvic exam for fibroids
enlarged, mobile uterus with irregular contour
how do fibroids appear on US
hypoechoic, round, well-circumscribed masses
definitive tx fibroids
hysterectomy
least invasive tx fibroids
levonorgestrel-releasing intrauterine device
when do fibroids tend to get smaller and resolve
postmenopause
Turner syndrome
(45,XO) is the most common type of gonadal dysgenesis
commonly presents as short stature, low-set ears, low hairline, high arched palate, webbed neck, and widely spaced nipples
Risks of estrogen replacement therapy
increased risk of endometrial cancer, thromboembolic disease, stroke, gallbladder disease, increased lipids, and ovarian cancer
when is hormone replacement therapy contraindicated
patients with undiagnosed uterine bleeding, a history of breast cancer, estrogen-dependent neoplasia, a history of a deep vein thrombosis (DVT) or PE (pulmonary embolism), new-onset DVT or PE, myocardial infarction, stroke, or liver disease or dysfunction
Adenomyosis
endometrial glands and stroma are present within the myometrium
sx adenomyosis
heavy menstrual bleeding and dysmenorrhea
pelvic exam adenomyosis
mobile, globular, boggy uterus
A fixed uterus should increase suspicion for endometriosis, which can occur with adenomyosis
first line for eval of adenomyosis
TVUS
when is MRI indicated when you think someone has adenomyosis
if there is a need to differentiate between adenomyosis and leiomyomas for treatment purposes
definitive dx adenomyosis
histologic evaluation after hysterectomy
definitive tx adenomyosis
hysterectomy
other tx options for adenomyosis (if don’t want hysterectomy)
levonorgestrel-releasing intrauterine device is the recommended pharmacologic treatment
depot gonadotropin-releasing hormone analogs or aromatase inhibitors may also be used
how long should patients with suspicion for premenstrual syndrome should record their symptoms
for 2 months in relation to menstrual cycle
further evaluation for persistent thick and irregular endometrium visualized on TVUS
tissue biopsy
what next If bleeding persists or tissue from an endometrial biopsy is inadequate
hysteroscopy with dilation and curettage should be performed
If tissue biopsy shows hyperplasia of the endometrium, it is further classified as
simple or complex with or without atypia
Hyperplasia without atypia
a benign condition characterized by the crowding of glands in the stroma without atypia
The characteristic appearance of hyperplasia with atypia
endometrial glands lined with enlarged cells and increased nuclear activity
Hyperplasia with atypia is considered
premalignant
Conditions with chronically high estrogen levels
nulliparity, late menopause, obesity, early menarche, polycystic ovarian syndrome, metabolic syndrome, chronic anovulation, estrogen producing tumors, and unopposed estrogen replacement therapy. Patients with Lynch syndrome are also at an increased risk for both endometrial and colon cancers
Patients with complex hyperplasia with or without atypia should undergo
dilation and curettage for thorough endometrial sampling as it is necessary to rule out coexisting carcinoma
tx for Complex hyperplasia without atypia and hyperplasia with atypia that occurs in patients who wish to preserve fertility
progestin therapy - Megestrol acetate and depot medroxyprogesterone acetate are approved treatments
when is vaginal or abdominal hysterectomy recommended for complex hyperplasia without atypia and hyperplasia with atypia
patients who relapse after progestin therapy
those who cannot tolerate the side effects
those with pathology suggesting coexisting endometrial carcinoma
those who do not desire to preserve fertility
What condition is FDA approved for treatment with anastrozole?
breast CA
Müllerian agenesis, also known as
vaginal agenesis or Mayer-Rokitansky-Küster-Hauser syndrome
may result in primary amenorrhea
Müllerian agenesis results in
congenital absence of the vagina with variable uterine development. Most patients with müllerian agenesis will have cervical and uterine agenesis in addition to vaginal agenesis
what Urologic anatomical abnormalities may be seen in Müllerian agenesis
unilateral agenesis, horseshoe kidney, or collection system irregularities
do pts with Müllerian agenesis have a normal female karyotype
yes
what is not affected in müllerian agenesis
ovaries
pts will have normal secondary sexual characteristics (e.g., breast development, axillary hair, pubic hair)
physical exam müllerian agenesis
normal external genitalia. While the hymenal tissue is typically normal, examination of the vagina will reveal a dimple or a small vaginal pouch.
tx müllerian agenesis
nonsurgical vaginal self-dilation
Elective surgery is an option if self-dilation fails
are pts w müllerian agenesis able to have normal intercourse after tx
yes
can ppl w müllerian agenesis carry a pregnancy
no
family planning options for Müllerian agenesis
harvesting the eggs for a gestational surrogate or uterine transplantation
Sheehan syndrome
rare complication of postpartum hemorrhage that is also referred to as postpartum hypopituitarism. The pituitary gland is enlarged during pregnancy, which makes it particularly prone to infarction from hypovolemia
ischemia of pituitary gland –> decreased release of pituitary hormones
classic presentation of Sheehan syndrome
failure to lactate after delivery and amenorrhea or oligomenorrhea.
Other possible manifestations due to hypopituitarism include hypotension, hyponatremia, and hypothyroidism
Which hormones are produced by the anterior pituitary gland?
Follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin, adrenocorticotropic hormone, and growth hormone
Which of the following cancers would this patient be at significant increased risk of if she is treated with combined menopausal hormone therapy?
breast
which of the following cancers would this patient be at significant increased risk of it she is treated with unopposed estrogen if she still has a uterus
endometrial
what hormones does hypothalamus secrete in relation to menstrual cycle
gonadotropin-releasing hormone
what hormones does anterior pituitary secrete in relation to menstrual cycle
LH and FSH
what hormones do ovaries produce in relation to menstrual cycle
progesterone and estrogen
follicular phase
follicle-stimulating hormone causes multiple follicles to be developed, with one ultimately becoming the dominant follicle. As these follicles develop, estrogen levels rise, which produces a spike in luteinizing hormone that triggers ovulation. The rising estrogen levels also cause the cervical mucus to become thin, giving sperm the best chance for fertilization.
The cervical mucus at this stage in the cycle is sometimes described as similar in consistency to a raw egg white. Estrogen levels are high and progesterone levels are low when the cervical mucus is thin
Following ovulation, the remainder of the dominant follicle is called the
corpus luteum
The corpus luteum produces
more progesterone than estrogen, and thus progesterone is more prevalent than estrogen during the luteal phase and helps to thicken the endometrial lining. However, the corpus luteum eventually degenerates until it becomes the corpus albicans, which does not produce hormones. Therefore, estrogen and progesterone levels decrease, which leads to shedding of the endometrial lining. This manifests as the vaginal bleeding that represents the start of a new menstrual cycle
what is the only diuretic shown to improve symptoms such as bloating, fluid retention, and breast tenderness
spironolactone
first-line imaging of choice for diagnosing and further evaluating the etiology of abnormal uterine bleeding
pelvic US (best is transvaginal)
classic pain associated with primary dysmenorrhea
crampy, intermittently intense, and located midline in the lower abdomen
Indications for a transvaginal ultrasound for primary dysmenorrhea
failure to improve after 3 months of nonsteroidal anti-inflammatory drugs, such as ibuprofen, or hormonal contraception (COCs or POPs are equally effective)
How long after menarche do ovulatory cycles typically start?
2-5 years
United States Preventive Services Task Force (USPSTF) screening for osteoporosis
all women ≥ 65 years of age and postmenopausal women < 65 years of age at increased risk for osteoporosis (e.g., recurrent fractures, fractures from minimal trauma, history of rheumatoid arthritis)
there is no recommendation for screening in men
DEXA T score for osteoporosis
≤ −2.5
DEXA T score for osteopenia
between −1.0 and −2.5
postmenopausal women recs for vitamin D and calcium
supplemental calcium to attain a goal of 1,200 mg/day
The recommended amount of daily vitamin D is 800 IU
Which sign associated with hypocalcemia is characterized by carpal spasm due to ulnar nerve ischemia when a blood pressure cuff is inflated over the upper arm?
Trousseau sign.
Menometrorrhagia
abnormal uterine bleeding that is heavy or prolonged and occurs at irregular intervals
first line for Menometrorrhagia
NSAIDs
Menorrhagia
abnormally prolonged (> 7 days per cycle) or heavy (> 80 mL of blood) uterine bleeding that maintains a normal menstrual cycle
Metrorrhagia
abnormal uterine bleeding in between normal cycles that recur at irregular intervals
Polymenorrhea
regular menstrual cycles that occur at shortened intervals (< 21 days)
dysmenorrhea is due to
excess prostaglandin production
Which hormone dominates the luteal phase of the menstrual cycle?
progesterone
Theca cells are stimulated by
LH to produce progesterone and androstenedione
granulosa cells are stimulated by
FSH to convert androstenedione to 17-beta-estradiol
