menstruation Flashcards
what is the average blood loss is during menstruation?
30mL
what are the 3 sites of hormonal control?
hypothalamus
anterior pituitary
ovary
What happens during the follicular phase?
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
what happens during the ovulation phase?
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
What happens during the ovulation phase
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
what happens during the Luteal phase?
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
What happens during the luteal phase if pregnancy occurs?
corpus luteum persists b/c the embryo produces hCG which is very similar to LH and preserves the corpus luteum
What happens during the luteal phase if pregnancy does not occur
corpus lutem degenerates 4 days before the next menses because of the low levels of FSH/LH
what is the first sign that the woman is not pregnant
menstruation
how long is the menstruation cycle
avg duration is 3-5
1-8 days is normal
what affects menstruation?
thickness of endometrium, medications, underlying disease
what is the proliferative phase
restoration of the endometrium from preceding menstruation
Second phase during the uterine cycle?
lining of the uterus proliferates/grows
Ovarian follicles secrete estradiol (estrogen) as they mature
What effect does estrogen have during the uterine cycle?
initiates the formation of a new layer of endometrium in the uterus
stimulates the cervix to produce fertile cervical mucus
what happens during the secretory phase
preparation of the uterus for implantation of fertilized egg
What is the function of the corpus luteum during the secretory phase?
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
What happens if fertilization does not occur during the secretory phase?
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)
A patient has a cycle of 21days when does she ovulate?
day 7
A patient has a cycle of 36days when does she ovulate?
day 22
regular spontaneous menstruation requires the following?
functional hypothalamic-pituitary-ovarian endocrine axis
competent endometrium
Intact outflow tract from internal to external genitalia (uterus, cervix and vagina)
How does estrogen affect cervical mucus changes?
makes the mucus thinner and more alkaline (promotes transport and survival of sperm )
how does progesterone affect the mucus?
makes the mucus thicker
what effect does estrogen have on the breasts?
causes proliferation of mammary ducts
what effect for progesterone have on the breasts?
causes growth of lobules and alveoli
what is menorrhagia
heavy or prolonged menstrual flow
what is hypomenorrhea
light menstrual flow
what is polymenorrhea?
bleeding at <21 day intervals
what is Oligomenorrhea?
bleeding at > 35 day intervals
what is metrorrhagia
bleeding that occurs at irregular intervals
what is dysmenorrhea
painful menstruation
what is the most common cause of secondary cause of amenorrhea
pregnancy
what are uterine causes for amenorrhea?
pregnancy
asherman’s syndrome
what are cervical causes for amenorrhea?
stenosis/scarring
what are vaginal reasons for amenorrhea?
vaginal agenesis
transverse vaginal septum
Imperforate hymen
what are Ovarian reasons for amenorrhea?
menopause
what is asherman’s syndrome?
uterine scarring
MC occurs after surgery d/t dilation and curettage
what are symptoms of ashermans
spotting
infertility
what is the Tx for ashermans
remove scar tissue
what is the etiology of cervical stenosis?
may be present at birth or develop secondary to cervical Surgery (cone biopsy, loop excision, or cryotherapy, trauma)
what are the Signs of cervical stenosis
amenorrhea, pelvic pain, and endometriosis, infertility
how is the dx of cervical stenosis made?
made clinically inability to pass small cervical dilator
what is the Tx for cervical stenosis?
opening/widening the cervical canal
what is mullerian aplasia?
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
what is the Tx for mullerian aplasia
multidisciplinary approach
what will an imperforate hymen look like in an infant on exam?
infants may present as mucocolpos (accumulation of vaginal secretions behind the hymen and it appears shiny
what does imperforate hymen look like on adolescents?
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
what is the Tx for imperforate hymen?
surgery
How is a transverse vaginal septum present
in incomplete septum asymptomatic but may appear at the beginning sexual intercourse resulting in dyspareunia
how is a transverse vaginal septum dx?
US or MRI
what is the tx for transverse vaginal septum
surgery
What is sheehan’s syndrome?
postpartum amenorrhea resulting from post-partum pituitary necrosis secondary to severe hemorrhage and hypotension
how is sheehan’s syndrome tx
surgical ablation and irradiation
How does thalassemia major cause amenorrhea?
iron deposits in the pituitary resulting in destruction of the cells that produce LH and FSH
how does a prolactinoma present in amenorrhea?
galactorrhea
what is the Tx on prolactinoma
bromocroptine
what meds can cause hyperprolactinemia?
anti-psychotics, anti-depressants, anti-HTN, morphine, H2 antagonists
what cause defects in GnRH transport
trauma, compression, radiation, tumors and infiltrative disorders
Menorrhagia is defined as?
> 80mL per cycle and interferes with
what are some causes of menorrhagia?
Pregnancy IUD Uterine Fibroids Cancer DUB Endometiral hyperplasia hyperthyroidism
How to tx menorrhagia d/t IUD
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
What is the first thing you want to do in the management of menorrhagia?
1st exclude pregnancy moderate hemorrhage Oral contraceptives at 2-4x usual dose Conjugated estrogen 2.5mg q4-6Hrs Methoxyprogesterone acetate
How to manage severe hemorrhage
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
what is the definition of metrorrhagia?
intermenstrual bleeding/spotting
what causes metrorrhagia?
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
what are causes of postcoital bleeding
cervical polyps
cervicitis
cervical cancer
atrophhy on menopausal female d/t low estrogen
what is oligomenorrhea?
> 35 days between menses
what are causes for oligomenorrhea?
pregnancy
hypogonadotropic hypogonadism: stress, weight loss, excessive exercise
anovulation
hypothyroidism
what is polymenorrhea
<21days between menses
causes for polymenorrhea
anovulation incorrect use of OCP pregnancy fibroids polyps
what is hypomenorrhea
unusually light menstrual flow/ spotting
what are causes of hypomenorrhea
cervical stenosis following cervical surgery
OCP’s very normal w/low dose pill and does not indicated an increased risk of pill failure
what is painful menstruation that prevents normal activity and requires medication
dysmenorrhea
what are the 2 types of dysmenorrhea
primary no organic causes
secondary pathologic cause
what is the physiology of dysmenorrhea?
associated with ovulatory cycles, does not occur at menarche but later in adolescence
secondary to abnormal and increased prostaglandins induces abnormal uterine contractions
what are the sings and symptoms of dysmenorrhea primary dz?
starts on the first day of menses or the second day
nausea, vomiting, diarrhea, H/A
what are the signs/symptoms of secondary dz of dysmenorrhea
starts 1-2 weeks before menses, peaks 1-2 days before day 1 and the pain stops on day 1 of menses
what is the Tx of dysmenorrhea?
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
what is dysfunctional uterine bleeding?
bleeding that is not associated with ovulation after all other pathology
DUB makes up what percent of abnormal bleeding?
60%
how will DUB present in adolescents?
first few cycles are frequently anovulatory and therefore are irregular, though heavy bleeding may occur
what type of work up would you want to do for DUB?
physical exam w/ pelvic and rectal exam, pelvic U/S and basic blood work to exclude pregnancy or pathologic cause
what is the Tx for DUB
acute hemorrhage: High dose estrogen IV
Hemodynamically stable: oral estrogen followed by medroxyprogesterone
what is the cause of DUB in post menopausal women?
more likely to secondary to pathologic causes therefore requires further work up
what are possible causes of DUB in postmenopausal women?
exogenous hormone
vaginal atrophy
vulvar lesions
tumors of the reproductive tract
what type of work up should you do for a postmenopausal
Pelvic US to evaluate ovaries
Hysteroscopy
endocervical curettage w/endometrial sampling/biopsy
If dx unknow D&C
what us premenstrual syndrome
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
when is premenstrual dysphoric disorder given?
when PMS symptoms disrupt daily functioning
what percent of women experience some PMS symptoms
75%
when is the highest incidence of PMS in women
late 20’s to early 30’s
rare adolescence
resolves after menopause
what are the symptoms of PMS
HA, breast tenderness, pelvic pain, bloating, tension, irritability, dysphoria, mood, lability, lack of energy, sleep changes, altered ADLs, social w/d, change in appetite
How is the Dx of PMS made
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
what is the Tx of PMS
avoid caffeine, alcohol, tobacco,salt stress reduction, exercise, sports bra calcium carbonate-bloating Vit B6 and Vit E Magnesium NSAID SSRI Anxiolytics
what is Adenomyosis
extension of endometrial glands into uterine musculature
what are the signs and symptoms of adenomyosis?
severe secondary dysmenorrhea and menorrhagia or may be asymptomatic
how is the dx of adenomyosis?
r/o other major causes of pain/bleeding
endometrial bx, D&C or hysteroscopy will rule out ednometrial cancer
what is the Tx for adenomyosis?
D&C
HnRH agonist
hysterectomy
what is endometriosis
condition in which endometrial tissue grows outside the endometrial cavity
found almost exclusively in pre-menopausal women
starts in 20-30s
where is the most common site for endometriosis?
ovary
where are other common sites of implantation for endometriosis?
fallopian tubes Uterine cul de sac uterosacral ligaments uterus colon lung brain scar tissue
what are complications of endometriosis/
adhesions infertility chronic pain endometriomas obstruction and impairment of vital organs catamenial pneumothoraces caramenial seizures
what are the positive risk factors for endometriosis?
Fm Hx Early menarche long duration of menstrual flow heavy bleeding during menses shorter cycles
what are negative risk factors for endometriosis
regular exercise
higher parity
longer duration of lactation
what were the signs/symptoms of endometriosis
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
what will the physical exam look like for Endometriosis?
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
how is endometriosis diagnosed?
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
how is endometriosis treated
based on severity of symptoms, location and severity of dz
medical
surgical
what is the medical tx for endometriosis?
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
what is the surgical tx for endometriosis
used in severe dz
consevative to preserve fertility
attempt to destroy endometriotic tissue
laparotomy
what is the definitive tx for endometriosis
TAH
