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menstruation Flashcards

1
Q

what is the average blood loss is during menstruation?

A

30mL

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2
Q

what are the 3 sites of hormonal control?

A

hypothalamus
anterior pituitary
ovary

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3
Q

What happens during the follicular phase?

A

variable in length from cycle to cycle
ovarian follicles mature w/in the ovary and get ready an egg
follicles secrete estradiol as they mature
overlaps w/ uterine proliferative phase
Rise in FSH during the first few days of the cycle results in stimulation of ovarian follicles
Only one dominant follicle will grow to maturity

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4
Q

what happens during the ovulation phase?

A

mature egg is released from the follicle
estradiol stimulates a large amount LH (LH surge) which starts around day 12
Release of LH matures the egg and weakens the wall of the follicle to rupture and release its secondary oocyte
Follicle that ruptures fills with blood and there may be some bleeding into the abdominal cavity which can cause peritoneal irritation and lower abdominal pain called Mittelschmerz

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5
Q

What happens during the ovulation phase

A

if both ovaries release an egg and both eggs are fertilized-fraternal twins
which of the 2 ovaries ovulates every month occurs at random
after the egg is released-fallopian tube. After 1 day, if the egg is not fertilized it will disintegrate/dissolve in the fallopian tube
If fertilized by sperm w/in the fallopian tube, the embryo will take 3 days to implant into the endometrium

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6
Q

what happens during the Luteal phase?

A

consistent in length from cycle to cycle
FSH and LH cause the remaining parts of the follicle that released the egg to transform into the corpus luteum (requires FSH/LH to maintain itself)
the corpus luteum secretes progesterone which induces the production of estrogen
progesterone and estrogen suppresses FSH/LH
Over time the corpus luteum atrophies if it is not fertilized which results in decreased progesterone production which triggers menstruation

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7
Q

What happens during the luteal phase if pregnancy occurs?

A

corpus luteum persists b/c the embryo produces hCG which is very similar to LH and preserves the corpus luteum

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8
Q

What happens during the luteal phase if pregnancy does not occur

A

corpus lutem degenerates 4 days before the next menses because of the low levels of FSH/LH

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9
Q

what is the first sign that the woman is not pregnant

A

menstruation

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10
Q

how long is the menstruation cycle

A

avg duration is 3-5

1-8 days is normal

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11
Q

what affects menstruation?

A

thickness of endometrium, medications, underlying disease

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12
Q

what is the proliferative phase

A

restoration of the endometrium from preceding menstruation

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13
Q

Second phase during the uterine cycle?

A

lining of the uterus proliferates/grows

Ovarian follicles secrete estradiol (estrogen) as they mature

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14
Q

What effect does estrogen have during the uterine cycle?

A

initiates the formation of a new layer of endometrium in the uterus
stimulates the cervix to produce fertile cervical mucus

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15
Q

what happens during the secretory phase

A

preparation of the uterus for implantation of fertilized egg

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16
Q

What is the function of the corpus luteum during the secretory phase?

A

produces progesteron (pro gestation) which helps increase blood flow to the uterus and increase uterine secretions. It also reduces the contractility of the smooth muscle in the uterus and raises the woman’s basal body temperature

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17
Q

What happens if fertilization does not occur during the secretory phase?

A

the corpus luteum regresses (decreased progesterone and estrogen which supports the endometrium) so endometrium cannot maintain itself resulting in vascular spasms-endometrial ischemia-menstruation
(length of phase is constant 14days)

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18
Q

A patient has a cycle of 21days when does she ovulate?

A

day 7

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19
Q

A patient has a cycle of 36days when does she ovulate?

A

day 22

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20
Q

regular spontaneous menstruation requires the following?

A

functional hypothalamic-pituitary-ovarian endocrine axis
competent endometrium
Intact outflow tract from internal to external genitalia (uterus, cervix and vagina)

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21
Q

How does estrogen affect cervical mucus changes?

A

makes the mucus thinner and more alkaline (promotes transport and survival of sperm )

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22
Q

how does progesterone affect the mucus?

A

makes the mucus thicker

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23
Q

what effect does estrogen have on the breasts?

A

causes proliferation of mammary ducts

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24
Q

what effect for progesterone have on the breasts?

A

causes growth of lobules and alveoli

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25
Q

what is menorrhagia

A

heavy or prolonged menstrual flow

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26
Q

what is hypomenorrhea

A

light menstrual flow

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27
Q

what is polymenorrhea?

A

bleeding at <21 day intervals

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28
Q

what is Oligomenorrhea?

A

bleeding at > 35 day intervals

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29
Q

what is metrorrhagia

A

bleeding that occurs at irregular intervals

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30
Q

what is dysmenorrhea

A

painful menstruation

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31
Q

what is the most common cause of secondary cause of amenorrhea

A

pregnancy

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32
Q

what are uterine causes for amenorrhea?

A

pregnancy

asherman’s syndrome

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33
Q

what are cervical causes for amenorrhea?

A

stenosis/scarring

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34
Q

what are vaginal reasons for amenorrhea?

A

vaginal agenesis
transverse vaginal septum
Imperforate hymen

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35
Q

what are Ovarian reasons for amenorrhea?

A

menopause

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36
Q

what is asherman’s syndrome?

A

uterine scarring

MC occurs after surgery d/t dilation and curettage

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37
Q

what are symptoms of ashermans

A

spotting

infertility

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38
Q

what is the Tx for ashermans

A

remove scar tissue

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39
Q

what is the etiology of cervical stenosis?

A

may be present at birth or develop secondary to cervical Surgery (cone biopsy, loop excision, or cryotherapy, trauma)

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40
Q

what are the Signs of cervical stenosis

A

amenorrhea, pelvic pain, and endometriosis, infertility

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41
Q

how is the dx of cervical stenosis made?

A

made clinically inability to pass small cervical dilator

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42
Q

what is the Tx for cervical stenosis?

A

opening/widening the cervical canal

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43
Q

what is mullerian aplasia?

A

congenital absence of the uterus and upper 2/3rds of the vagina.
may have normal external genitalia or reveal only a small dimple at the vaginal introitus
46,XX karyotype

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44
Q

what is the Tx for mullerian aplasia

A

multidisciplinary approach

45
Q

what will an imperforate hymen look like in an infant on exam?

A

infants may present as mucocolpos (accumulation of vaginal secretions behind the hymen and it appears shiny

46
Q

what does imperforate hymen look like on adolescents?

A

presents as primary ammenorrhea and cyclic pelvic pain, difficulty w/ defication or urination secondary to mass effect.
Inspection will reveal a purplish-red hymen membrane

47
Q

what is the Tx for imperforate hymen?

A

surgery

48
Q

How is a transverse vaginal septum present

A

in incomplete septum asymptomatic but may appear at the beginning sexual intercourse resulting in dyspareunia

49
Q

how is a transverse vaginal septum dx?

A

US or MRI

50
Q

what is the tx for transverse vaginal septum

A

surgery

51
Q

What is sheehan’s syndrome?

A

postpartum amenorrhea resulting from post-partum pituitary necrosis secondary to severe hemorrhage and hypotension

52
Q

how is sheehan’s syndrome tx

A

surgical ablation and irradiation

53
Q

How does thalassemia major cause amenorrhea?

A

iron deposits in the pituitary resulting in destruction of the cells that produce LH and FSH

54
Q

how does a prolactinoma present in amenorrhea?

A

galactorrhea

55
Q

what is the Tx on prolactinoma

A

bromocroptine

56
Q

what meds can cause hyperprolactinemia?

A

anti-psychotics, anti-depressants, anti-HTN, morphine, H2 antagonists

57
Q

what cause defects in GnRH transport

A

trauma, compression, radiation, tumors and infiltrative disorders

58
Q

Menorrhagia is defined as?

A

> 80mL per cycle and interferes with

59
Q

what are some causes of menorrhagia?

A 
Pregnancy
IUD
Uterine Fibroids
Cancer
DUB
Endometiral hyperplasia
hyperthyroidism
60
Q

How to tx menorrhagia d/t IUD

A

remove the IUD
also remember the presence of an IUD does not mean that other pathology is not present need to rule out pregnancy, hyperplasia and cancer

61
Q

What is the first thing you want to do in the management of menorrhagia?

A 
1st exclude pregnancy
moderate hemorrhage 
Oral contraceptives at 2-4x usual dose
Conjugated estrogen 2.5mg q4-6Hrs
Methoxyprogesterone acetate
62
Q

How to manage severe hemorrhage

A

D&C
Emergency Hysterectomy
In malignancy radiation to control bleeding
Endometrial ablation- cauterizing the endometrium
results in amenorrhea or reduces menses need to ensure no further children are desired

63
Q

what is the definition of metrorrhagia?

A

intermenstrual bleeding/spotting

64
Q

what causes metrorrhagia?

A

midcycle or ovulatory
endometrial polyps which would be found on bx or w/hysteroscopy
OCP
Endometritis-occurs after pregnancy or w/use of IUD
Cancer-dx w/ pap smear

65
Q

what are causes of postcoital bleeding

A

cervical polyps
cervicitis
cervical cancer
atrophhy on menopausal female d/t low estrogen

66
Q

what is oligomenorrhea?

A

> 35 days between menses

67
Q

what are causes for oligomenorrhea?

A

pregnancy
hypogonadotropic hypogonadism: stress, weight loss, excessive exercise
anovulation
hypothyroidism

68
Q

what is polymenorrhea

A

<21days between menses

69
Q

causes for polymenorrhea

A 
anovulation
incorrect use of OCP
pregnancy
fibroids
polyps
70
Q

what is hypomenorrhea

A

unusually light menstrual flow/ spotting

71
Q

what are causes of hypomenorrhea

A

cervical stenosis following cervical surgery

OCP’s very normal w/low dose pill and does not indicated an increased risk of pill failure

72
Q

what is painful menstruation that prevents normal activity and requires medication

A

dysmenorrhea

73
Q

what are the 2 types of dysmenorrhea

A

primary no organic causes

secondary pathologic cause

74
Q

what is the physiology of dysmenorrhea?

A

associated with ovulatory cycles, does not occur at menarche but later in adolescence
secondary to abnormal and increased prostaglandins induces abnormal uterine contractions

75
Q

what are the sings and symptoms of dysmenorrhea primary dz?

A

starts on the first day of menses or the second day

nausea, vomiting, diarrhea, H/A

76
Q

what are the signs/symptoms of secondary dz of dysmenorrhea

A

starts 1-2 weeks before menses, peaks 1-2 days before day 1 and the pain stops on day 1 of menses

77
Q

what is the Tx of dysmenorrhea?

A

NSAIDs or acetaminophen
-best if taken at earliest onset of symptoms and even starting 1-2 days
Heating pad in addition to NSAID/Tylenol can give added benefit
Codeine or a stronger analgesic may be required in severe pain
OCP’s lowest dosage however pills w/ increased estrogen can prevent pain

78
Q

what is dysfunctional uterine bleeding?

A

bleeding that is not associated with ovulation after all other pathology

79
Q

DUB makes up what percent of abnormal bleeding?

A

60%

80
Q

how will DUB present in adolescents?

A

first few cycles are frequently anovulatory and therefore are irregular, though heavy bleeding may occur

81
Q

what type of work up would you want to do for DUB?

A

physical exam w/ pelvic and rectal exam, pelvic U/S and basic blood work to exclude pregnancy or pathologic cause

82
Q

what is the Tx for DUB

A

acute hemorrhage: High dose estrogen IV

Hemodynamically stable: oral estrogen followed by medroxyprogesterone

83
Q

what is the cause of DUB in post menopausal women?

A

more likely to secondary to pathologic causes therefore requires further work up

84
Q

what are possible causes of DUB in postmenopausal women?

A

exogenous hormone
vaginal atrophy
vulvar lesions
tumors of the reproductive tract

85
Q

what type of work up should you do for a postmenopausal

A

Pelvic US to evaluate ovaries
Hysteroscopy
endocervical curettage w/endometrial sampling/biopsy
If dx unknow D&C

86
Q

what us premenstrual syndrome

A

cyclic occurrence of symptoms that are sufficient severity to interfere w/some aspects of life and that appear w/ consistent and predictable relationship to the menses

87
Q

when is premenstrual dysphoric disorder given?

A

when PMS symptoms disrupt daily functioning

88
Q

what percent of women experience some PMS symptoms

A

75%

89
Q

when is the highest incidence of PMS in women

A

late 20’s to early 30’s
rare adolescence
resolves after menopause

90
Q

what are the symptoms of PMS

A

HA, breast tenderness, pelvic pain, bloating, tension, irritability, dysphoria, mood, lability, lack of energy, sleep changes, altered ADLs, social w/d, change in appetite

91
Q

How is the Dx of PMS made

A

1 somatic and 1 affective sx
occurring during the 5 days before menses in each of the 3 prior menstrual cycles
relieved w/in 4 days of the onset of menses w/o recurrence until at least cycle day 13

92
Q

what is the Tx of PMS

A 
avoid caffeine, alcohol, tobacco,salt
stress reduction, exercise, sports bra
calcium carbonate-bloating
Vit B6 and Vit E
Magnesium
NSAID
SSRI
Anxiolytics
93
Q

what is Adenomyosis

A

extension of endometrial glands into uterine musculature

94
Q

what are the signs and symptoms of adenomyosis?

A

severe secondary dysmenorrhea and menorrhagia or may be asymptomatic

95
Q

how is the dx of adenomyosis?

A

r/o other major causes of pain/bleeding

endometrial bx, D&C or hysteroscopy will rule out ednometrial cancer

96
Q

what is the Tx for adenomyosis?

A

D&C
HnRH agonist
hysterectomy

97
Q

what is endometriosis

A

condition in which endometrial tissue grows outside the endometrial cavity
found almost exclusively in pre-menopausal women
starts in 20-30s

98
Q

where is the most common site for endometriosis?

A

ovary

99
Q

where are other common sites of implantation for endometriosis?

A 
fallopian tubes
Uterine cul de sac 
uterosacral ligaments
uterus
colon
lung
brain
scar tissue
100
Q

what are complications of endometriosis/

A 
adhesions
infertility
chronic pain
endometriomas
obstruction and impairment of vital organs
catamenial pneumothoraces
caramenial seizures
101
Q

what are the positive risk factors for endometriosis?

A 
Fm Hx
Early menarche
long duration of menstrual flow
heavy bleeding during menses
shorter cycles
102
Q

what are negative risk factors for endometriosis

A

regular exercise
higher parity
longer duration of lactation

103
Q

what were the signs/symptoms of endometriosis

A

the extent of the dz does not correlate with the severity of the symptoms
maybe completely asymptomatic
secondary dysnmenorrhea
infertility
chronic pelvic pain
bloody stools, hematuria, pain w defecation or urination

104
Q

what will the physical exam look like for Endometriosis?

A

may have no evidence on PE
tender nodules in the posterior vaginal fornix
pain upon uterine motion
uterus may be fixed and retroverted d/t adhesions
tender adnexal mass
implants in healed wounds

105
Q

how is endometriosis diagnosed?

A

direct visualization of lesions/implants is required
-lapraoscopy
diagnostic imaging studies do not help in the diagnosis w/ the exception of ruling out other disorders

106
Q

how is endometriosis treated

A

based on severity of symptoms, location and severity of dz
medical
surgical

107
Q

what is the medical tx for endometriosis?

A 
1st line
NSAIDs
hormonal tx (goal is to interrupt the cycles of stimulation and bleeding of endometrial tissue)
(OCP's
progestins)
2nd line:
high dose progestin (medroxyprogesterone acetate)-induces pseudomenopause 
GnRH agonists
108
Q

what is the surgical tx for endometriosis

A

used in severe dz
consevative to preserve fertility
attempt to destroy endometriotic tissue
laparotomy

109
Q

what is the definitive tx for endometriosis

A

TAH

womens health (6 decks)

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