Menstruation Flashcards
Gonadotropin-Releasing Hormone (GnRH)
Stimulates release of FSH and LH initiating puberty and sustaining menstrual cycle
Secreted by hypothalamus
Follicle-stimulating hormone (FSH)
Secreted by anterior pituitary gland during 1st half of menstrual cycle
Stimulates growth and maturation of Graafian follicle before ovulation
Thins the endometrium
Luteinizing Hormone (LH)
Secreted by the anterior pituitary gland
Stimulates final maturation of Graafian follicle
Surge of LH about 14 days before next menstrual period causes ovulation
Stimulates transformation of Graafian follicle into corpus luteum
Thickens the endometrium
Estrogen
Secreted primarily by the ovaries, corpus luteum, adrenal cortex, and placenta in pregnancy
Stimulates thickening of the endometrium; causes suppression of FSH secretion
Responsible for the development of secondary sex characteristics
Stimulates uterine contractions
High estrogen concentration inhibits secretion of FSH and prolactin but stimulates secretion of LH
Low estrogen concentration after pregnancy stimulates secretion of prolactin
Progesterone
Secreted by the ovary, corpus luteum and placenta during pregnancy Inhibits secretion of LH Has thermogenic effect Relaxes smooth muscles thereby decreases contractions of uterus Causes cervical secretion of thick mucus Maintain thickness of endometrium Allows pregnancy to be maintained Prepares breasts for lactation
Prolactin
Secreted by anterior pituitary gland
Stimulates secretion of milk
Oxytocin
Secreted by posterior pituitary gland
Stimulates uterine contractions during birth and compress uterine blood vessels and control bleeding
Stimulates let-down or milk-ejection reflex during breastfeeding
Prostaglandins
Fatty acids categorized as hormones
Produced by many organs of the body, including endometrium
Affects menstrual cycle
Influences the onset and maintenance of labor
Follicular phase of menstruation
Varies in length more than other phases
In the first half, the primary event is growth of recruited follicles
Levels of estrogen, progesterone, FSH, and LH in first half of follicular phase
Estrogen and progesterone production is low. As a result, overall FSH increases slightly
Circulating LH levels increase slowly
What happens with estradiol with recruited ovarian follicles?
It increases
What occurs during the second half of the follicular phase?
The follicle selected for ovulation matures
FSH levels decrease; LH levels are affected less
Levels of estrogen increase exponentially
Ovulatory phase- estradiol and progesterone
Ovulation occurs. Estradiol levels usually peak as the phase begins
Progesterone levels also begin to increase
LH levels during ovulatory phase
Stored LH is released in massive amounts, usually over 36-48 hrs
How are estradiol and progesterone levels affected during the LH surge in the ovulatory phase?
Estradiol levels decrease, but progesterone levels continue to increase
How LH works during the ovulatory phase
Surge stimulates enzymes that initiate breakdown of the follicle wall and release of the now mature ovum within about 16-32 hrs. It also triggers completion of the first meiotic division of the oocyte within about 36 hrs
What occurs during the luteal phase?
The follicle is transformed into a corpus luteum
The corpus luteum secretes primarily progesterone in increasing quantities, peaking 6-8 days after ovulation, which stimulates development of the secretory endometrium
What occurs with LH and FSH during the luteal phase?
Estradiol and progesterone?
LH and FSH levels decrease
Estradiol and progesterone levels decrease late in this phase
What happens if implantation occurs?
The corpus luteum does not degenerate but remains, supported by hCG that is produced by the developing embryo
Amenorrhea
Absence of menses
Dysmenorrhea
Painful menstruation
Oligomenorrhea
Scanty menstruation
Polymenorrhea
Too frequent menstruation
Menorrhagia
Excessive menstrual bleeding
Metorrhagia
Bleeding between periods of less than 2 wks (can be spotting or heavy)
Hypomenorrhea
Abnormally short menses
Hypermenorrhea
Abnormally long menses
What ties all the s/sx of PMS together?
They affect your pt only in the 14 days just before her monthly period
During luteal phase
Emotional and behavioral sx of PMS
Tension or anxiety Depressed mood Crying spells Mood swings and irritability or anger Appetite changes and food cravings Trouble falling asleep Social withdrawal Poor concentration
Physical signs and sx of PMS
Joint or muscle pain HA Fatigue Wt gain from fluid retention Abdominal bloating Breast tenderness Acne flare-ups Constipation or diarrhea
Tx options for PMS
Antidepressants NSAIDs Diuretics Oral contraceptives Depo Provera
Alternative med ideas for PMS
Calcium Magnesium Vitamin B6 Vitamin E Herbal remedies Natural progesterone creams
What is the difference between PMS and PMDD?
Sx of PMDD are similar to those of PMS, but they are generally more severe and debilitating
Timeline of PMDD
Sx occur during the 7-10 days just before menstrual bleeding and usually improve within a few days after the period starts
Diagnostic criteria for PMDD
Five or more of the following sx must be present:
- Disinterest in daily activities and relationships
- Fatigue or low energy
- Feeling of sadness or hopelessness, possible suicidal thoughts
- Feelings of tension or anxiety
- Feeling out of control
- Food cravings or binge eating
- Mood swings marked by periods of teariness
- Panic attack
- Persistent irritability or anger that affects other ppl
- Trouble concentrating
- Physical sx, such as bloating, breast tenderness, HAs, and joint or muscle pain
- Sleep disturbances
Tx for PMDD
Balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol and caffeine)
Adequate rest
Regular exercise 3-5 times per week
Diary or calendar to record the type, severity, and duration of sx
SSRIs, nutritional supplements, and OTC meds for symptomatic relief
Primary amenorrhea
The absence of menstrual bleeding and secondary sexual characteristics in a girl by age 14 yrs
OR
The absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 yrs
Secondary amenorrhea
The absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for 6 or more mos
Reasons for amenorrhea
An abnormality in the hypothalamic-pituitary-ovarian axis
Anatomical abnormalities of the genital tract
Functional causes
Hypothalamic causes of amenorrhea
Craniopharyngioma Teratoma Sarcoidosis Kallman syndrome Nutritional deficiency/eating disorders Low body weight Constitutional delay
Pituitary causes of amenorrhea
Prolactinemia Other pituitary tumors Postpartum pituitary necrosis Autoimmune hypophysitis Pituitary radiation Sarcoidosis
Ovarian causes of amenorrhea
Anovulation Hyperandrogenemia PCOS Premature ovarian failure Turner syndrome-primary Pure gonadal dysgenesis Autoimmune oophoritis Fragile X premutation Radiation or chemo
Other causes of amenorrhea
Galactosemia
Anatomical abnormalities of the genital tract
-Intrauterine adhesions
-Mullerian defects
–Imperforate hymen
–Transverse vaginal septum
–Aplasia of the vagina, the cervix, or the uterus
Functional causes of amenorrhea
Anorexia/bulemia Chronic diseases Excessive wt gain or wt loss Malnutrition Depression or other psychiatric disorders and/or their therapeutic tx Recreational drug abuse Excessive stress or excessive exercise Cycle suppression with systemic birth control methods
Work up secondary amenorrhea
If 3 consecutive menses have been missed, work up is indicated
Pregnancy test
Hormone levels (FSH, LH, estradiol, free and total testosterone, androstenedione), thyroid funciton, serium prolactin
CT or MRI of head
Pelvic exam to r/o physical cause
U/s or other evaluation of the uterus
Tx is dependent on cause
Causes of oligomenorrhea
Prolactinomas Systemic contraceptives PCOS Thyrotoxicosis Hormonal changes in perimenopause Graves disease
Workup for oligomenorrhea
PCOS labs Thyroid panel FSH LH Estradiol levels
Reasons for abnormal uterine bleeding
Polyps Adenomyosis Leiomyomata Malignancy or hyperplasia Coagulopathy Ovarian dysfunction Endometrial Iatrogenic Not yet classified
When are irregular menses common in premenopausal pts?
For up to 2 yrs after menarche
What is the most likely dx of AUB in premenopausal women with nl findings on PE?
AUB secondary to anovulation
Check for PCOS or thyroid dz
Other differentials of AUB in premenopausal women
Pregnancy
Infection
Coagulopathy
DDx of perimenopausal AUB
Fibroids Polyps Anovulatory bleed d/t declining ovarian function Adenomyosis Endometrial hyperplasia or neoplasm
What must be considered early in the investigation of AUB in perimenopausal women?
Endometrial bx and other methods of detecting endometrial hyperplasia or carcinoma
What is commonly seen with AUB in postmenopausal women?
Uterine pathology, particularly endometrial carcinoma
What is included in the intial investigation of AUB in postmenopausal women?
Endometrial bx and/or transvaginal u/s
What is considered CA until it is ruled out?
Postmenopausal bleeding
Tx of premenopausal AUB
May respond to oral contraceptives, cyclic medroxyprogesterone therapy or cyclic clomiphene
Tx of perimenopausal AUB
Low-dose oral contraceptives if they don’t smoke or medroxyprogesterone or a progesterone IUD
Primary dysmenorrhea
Dysmenorrhea that has no cause
Tx of primary dysmenorrhea
Primary cause is believed to be related to prostaglandin secretion Based on symptomatic relief: -NSAIDs at a therpeutic dose (ALWAYS first line) -OCPs -Progestin only pills -Progesterone IUDs -Heating pads/hot showers -Exercise
When does primary dysmenorrhea start?
Once ovulatory cycles begin
Causes of secondary dysmenorrhea
Endometriosis PID Myomata Uterine adenomyosis Endometrial polyps Ovarian cysts Retroverted uterus Cervical stenosis Pelvic adhesions Congenital uterine anomalies IUD
Hx questions to ask in regards to secondary dysmenorrhea
How painful? What changed? Is it getting worse? What other sx are you having? Any FHx? What meds (including BC) are you on? STD exposure
Tx of secondary dysmenorrhea
Based upon cause
Any existing pathology must be addressed
Pain control
Cycle control if indicated
