Menstruation

Question 1

Definition of primary amenorrhea

Answer 1

• absence of spontaneous menstruation by 16yo WITH secondary sex characteristics or 14yo WITHOUT secondary sex characteristics
• 4 main categories based on karyotype
  
  • Turner syndrome (Gonadal agenesis) - 45 XO
  • Hypothalamic-pituitary insufficiency - 46 XX
  • Androgen insensitivity - 46 XY
  • Imperforate hymen - 46 XX

Question 2

Definition of secondary amenorrhea

Answer 2

• woman who has previously menstruated
• absence of menses for 3 months if previous cycles nl
• absence of menses for 6 months if previous cycles irreg
• Cause
  
  • THE MCC 2ary amenorrhea = PREGNANCY
  • Drug use, stress, significant weight change, or excessive exercise
  • PCOS, CNS tumor, hyperPRL, Sheehan syndrome (causes postpartum hypopit - pituitary gland is damaged, caused by excess blood loss (hemorrhage) or extremely low blood pressure during or after labor)
  • previously normal menstrual cycles and normal E, think stress or outflow obstruction (Asherman syndrome - scar tissue forms in the uterus, rare but can be a complication of multiple D&Cs)
  • If galactorrhea present, prolactinemia is MCC

Question 3

Amenorrhea

Answer 3

• Primary or secondary
• women with no menstruation in presence of E stimulation of endometrium have increased risk of endometrial cancer

Question 4

Turner Syndrome: karyotype, PE, Labs, management

Answer 4

• Karyotype: 45 XO
• PE: short webbed neck, no breast development
• Labs: High FSH
• Management: cyclic estrogen and progestins

Question 5

Hypothalamic-pituitary insufficiency: karyotype, PE, Labs, management

Answer 5

• Karyotype: 46 XX
• PE: no breast development
• Labs: Low FSH, Low LH
• Managment: Cyclic estrogen and progestins

Question 6

Androgen insensitivity: karyotype, PE, Labs, management

Answer 6

• karyotype: 46XY
• PE: Normal breast development
• Labs: High testosterone
• Management: Remove testes; start estrogen

Question 7

Diagnostic studies for amenorrhea

Answer 7

• First line: B-hCG, TSH, PRL
• Second line: FSH, E, LH, T
• If bleeding occurs after progesterone challenge, anovulatory cycles are the cause

Question 8

Characteristics of dysfuncitonal uterine bleeding (DUB or AUB)

Answer 8

• Presents as abnormal bleeding with a generally unremarkable PE
• Abnormal uterine bleeding in non-pregnant women
  
  • different from normal cycle in terms of regularity, flow, duration, and volume
• normally occurs right after menarche or during perimenopause
• Causes = PALM-COIEN (polyp, adenomyosis, leiomyoma, malignancy - coag, ovulatory dysFN, endometrial, iatrogenic, not otherwise classified)
• Menorrhagia = heavy or prolonged bleeding
• Metrorrhagia = irregular bleeding between menses
• PE includes speculum, evaluate for bleeding from other sources

Question 9

Diagnostic studies for DUB

Answer 9

• B-hCG, CBC, iron, PT, PTT, documentation of ovulation, thyroid, serum P, LFTs, PRL, serum FSH
• Pap, US, hysterosalpingography, hysteroscopy, and/or D&C
• endometrial bx should be done on all women over 35yo w/ obesity, HTN, or DM and on all postmenopausal pts

Question 10

management of DUB (AUB)

Answer 10

• depends on severity of bleeding - may include observation, iron therapy, and volume replacement
• progestin trial - if bleeding stops, anovulatory cylces are confirmed
• OCPs:
  
  • older women w/o risk factors
  • OCPs should NOT be used in women over 35 who smoke, have HTN, DM, or hx of vascular dz, breast CA, liver dz, or focal HA
• D&C can be dx and curative
• refractory cases may require endometrial ablation or vaginal hysterectomy

Question 11

Dysmenorrhea general characteristics

Answer 11

• PRIMARY: painful menstruation caused by increased prostaglandin and leukotriene levels - painful uterine cramping, N/V/D
  
  • Onset: usually w/in 2yrs menarche, peak incidence = late teens/early 20s
  • THERE IS NO PATHOLOGIC ABNORMALITY
• SECONDARY: painful menstruation caused by identifiable condition (usually uterus or pelvis - endometriosis, adenomyosis, fibroids, PID, IUD)
  
  • usually affects older women (>25yo)

Question 12

clinical features of dysmenorrhea

Answer 12

• Primary: sxs are central lower abdomen or pelvis radiating to back or thighs, beginning before or at onset of menses, lasting 1-3 days
  
  • PE, labs, radiologic tests = nl
• Secondary: similar sxs as above but may also include bloating, heavy menstrual bleeding, and dyspareunia
  
  • less related to first day of flow

Question 13

diagnostic studies for dysmenorrhea

Answer 13

• dx of primary dysmenorrhea based on hx, use of menstrual diary, PE
• specific tests for secondary dysmenorrhea - hysteroscopy, D&C, laparoscopy
  
  • all allow both dx and tx

Question 14

management of dysmenorrhea

Answer 14

• Primary:
  
  • start NSAIDs right before expected menses, continue 2-3 days
  • OCPs, vit B (B1, thiamine; B6, pyridoxine), magnesium, acupuncture, heat, regular exercise
• Secondary:
  
  • underlying conditions should be treated
  • sx treatment may be sufficient

Question 15

general characteristics of menopause

Answer 15

• definition: menopause is the last menses, and perimenopause (usually lasting 3-5 yrs) is the time surrounding menopause.
• Dx made: 1 yr of no periods after age 40 with no pathologic cause
  
  • FSH elevated (21-100), estradiol low (<20)
  • progesterone levels nl
• mean age = 51.5 yrs
• smoking is associated with early menopause
• premautre menopause (spontanous premature ovarian failure) is cessation of menses before age 40 years
• ovaries continue to produce testosterone and androstenedione; estrone is the predominant postmenopausal circulating estrogen

Question 16

clinical features of menopause

Answer 16

• vasomotor sxs (hot flashes) vary in intensity - usually resolve in 2-3 yrs (3-6 wks with E tx)
• urogenital atrophy can cause poor vaginal lubrication, dyspareunia, dysuria, urge incontinence, pelvic relaxation, atrophic cystitis, easy bleeding
• accelerated bone loss may cause osteoporosis
• E related cardiovascular protection declines
• changes in sleep cycle
• skin thins, becomes less elastic, facial hair increases, hair loss increases and nails become brittle
• confusion, memory loss, lethargy, depression, loss of sex interest

Question 17

diagnostic studies for menopause

Answer 17

• FSH of greater than 30 is diagnostic of menopause

Question 18

management of menopause

Answer 18

• treated on the basis of individual risk factors and sxs
• lifestyle modifications may help sxs, reg exercise can decrease menopausal sxs
• women with INTACT uterus should NOT use E alone (increased risk of endometrial CA)
• combined hormone replacement tx indicated for short-term tx of hot flashes
  
  • can increase risk of CV dz, breast CA, and cognitive changes
• contraindications to hormone tx include undiagnosed vaginal bleeding, acute vascular thrombosis, liver dz, hx of endometrial or breast CA
• Ca and vit D supplementation, bisphosphonates, SERMs, calcitonin all used for osteoporosis
• topical E can improve urogenital sxs
• SSRI and SNRIs (caution with use with tamoxifen)
• soy, black cohosh, and ginseng may also help alleviate sxs

Question 19

the menstrual cycle

Answer 19

• typical cycle defined as 28 +/- 7 days
• flow lasts 4 +/- 2 days
• first day of bleeding = day 1 of menstrual cycle
• luteal phase is stable, lasting 13-14 days
  
  • variation in cycle length generally a result of variations in the duration of the follicular phase

Question 20

ovarian function and cycle

Answer 20

• no new ova formed after birth
• ova undergo first meiotic division and arrest in prophase until adulthood
• just before ovulation, first meiotic division is complete
• secondary oocyte: begins second meiotic division and stops at metaphase - completed only when sperm penetrates
• Mittelshmerz: ovulation pain

Question 21

premenstrual dysphoric disorder

Answer 21

• severe PMS with functional impairment
• PMS and PMDD are highly associated with unipolar depressive disorder and anxiety disorders, such as obsessive-compulsive disorder, panic disorder, and generalized anxiety disorder
• type of depression that occurs during the luteal phase of the menstrual cycle
• Criteria: 5+ sxs were present most of the cycle and during the last week of luteal phase
• Treatment:
  
  • 1st line = SSRI
  • 2nd line - OCP, xanax, GnRH agonists

Question 22

PMS risk factors

Answer 22

• FHx of PMS, vitamin B6, calcium, or magnesium deficiency

Question 23

clinical sxs of PMS

Answer 23

• HA
• Breast tenderness
• Pelvic pain
• bloating
• premenstrual tension
• more severe: irritability, dysphoria, mood lability
• Abdominal discomfort, clumsiness, lack of energy, sleep changes, mood swings
• Behavioral: social withdrawal, altered daily activities, marked change in appetite, increased crying, changes in sexual desire

Question 24

treatment of PMS

Answer 24

• Step 1 (mild sxs): limit caffeine, alcohol, tobacco, chocolate
  
  • eat small frequent meals high in complex carbs
  • decrease sodium intake
  • supplements (calcium, magnesium, etc.)
  • NSAIDs
  • Bromocriptine for mastalgia
  • spironolactone for cyclic edema
  • stress management: CBT, aerobic exercise
• Step 2 (moderate sxs): SSRIs (14d prior to the onset of menstruation and continue through the end of cycle)
  
  • anxiolytics: alprazolam, buspirone
• Step 3 (severe sxs): hormonal ovulation suppression
  
  • OCPs
  • GnRH agonist: lupron
  • Danazol for mastalgia
  • definitive surgical tx: bilateral oophorectomy