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Women's Health Exam 1 > Menstruation > Flashcards

Menstruation Flashcards

1
Q

Average menarche age

A

12-13 YO

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2
Q

Average age of menopause

A

51

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3
Q

normal cycle

A

24-38 days
<8 dyas long
5-80 mL blood (30 mL = average)

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4
Q

Primary amenorrhea is considered

A

absence of menstruation by 15 YO w/ secondary characteristics
OR
absence by age 13 w/o secondary characteristics

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5
Q

secondary amenorrhea is considered

A

no period for 3 cycles
OR
6 consecutive months in women who were previously menstruating

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6
Q

Causes of primary amenorrhea

A

gonadal dysgenesis/ POI (most common)
Hypothalamic or pituitary
Outflow tract disorders
receptor abnormality or enzyme deficiency

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7
Q

Dysgensis results in

A

hypergonadotropic hypogonadism

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8
Q

Turner syndrome

A

45 XO
ovaries don’t respond to gonadtropins (one of most common causes of premature ovarian failure)

Results in premature depletion of oocytes and follicles

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9
Q

Presentation of turners

A

short, webbed neck, wide nippl

“streak ovaries” and sexual infantilism

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10
Q

Swyer syndrome

A

46, XY
Mutation in SRY gene - gonads fail to differentiate into testes; lack of AMH, T, and DHT = female external & internal genitalia

NO SECONDARY SEX CHARACTERISTICS (in contrast to AIS)

male appears like female

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11
Q

POI

A

46, XX w/ menopause before age 40

usually presents as secondary amenorrhea but can present as primary

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12
Q

Causes of POI

A

chemo
radiation
FX (FMR1 gene mutation)
autoimmune oophoritis

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13
Q

PCOS

A

rarely causes primary amenorrhea
ovulatory dysfunciton
hyperandrogenism w/ amenorrhea in absence of other causes

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14
Q

Hypogonadotropic hypogonadism

A

low FSH due to:

  • abnormal hypothalamic GnRH secretion (leaing to decreased gonadotropin pulse d/c)
  • congenital absence of GnRH
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15
Q

Hypothalamic amenorrhea

A

abnormal GnRH secretion in absence of patho process; decreased FSH/LH pulsations, low or normal FSH & LH, absent LH surge (absent follicular development & ovulation; low estradiol secretion)

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16
Q

Causes of hypothalamic amenorrhea

A

stressors (eating disorders, physical or psychological stress, weight loss, excessive exercise – female athletes triad)

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17
Q

Kallmann’s syndrome

A

idiopathic hypogonadotropic hypogonadism (congenital GnRH deficiency) + anosmia

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18
Q

Pituitary causes of primary amenorrhea

A
  • micro/macroadenomas (cushings, prolactinomas, thyrotropinomas)
  • Isolated hyperprolactinemia (mainly secondary amennorhea): causes galactorrhea, hypothyroidism & some meds increase prolactin levels
  • infiltrative disease/cranial tumors that cause pituitary stalk compression (sarcoid, hemochromatosis)
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19
Q

Outflow tract disorders

A

Uterine- Mullerian Agenesis (vaginal agenesis)

Vagina- Imperforate hymen & transferse vaginal septum

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20
Q

Mullerian agenesis

A

46, XX w/ congenital absence of oviducts, uterus and upper vagina (normal gonad function: estrogen - breasts)

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21
Q

Imperforate hymen & transferse vaginal septum presentation

A

cyclic pelvic pain & perirectal mass from sequestration of blood in vagina

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22
Q

Androgen insensitivity syndrome (receptor/enzyme abnormality)

A

46, XY w/ female phenotype
Abnormality of androgen receptor (complete or partial)
- testes make T and AMH but body is not responsive
- high T concentrations!!!

Have breast development, absence of acne, & voice changes at puberty & absent axillary/pubic hair

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23
Q

Dx for AIS

A

Pelvic US- absent upper vagina, uterus & fallopian tube; tests remain in intra-abdominal or partially descended (mistaken for hernia)

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24
Q

Tx for AIS

A

remove testes (risk of testicular CA)

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25
Q

5-alpha reductase deficiency

A

46, XY
can’t convert T to DHT (no differentiation of male genitaliea)
AMBIGUOUS GENITALIA @ BIRTH
Undergo virilization @ puberty but no enlargement of external genitalia or prostate

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26
Q

Ambiguous genitalis

A

5-alpha reductase deficiency

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27
Q

17-alpha hydroxylase deficiency

A

46, XX or XY

lack enzyme to produe cortisol or sex steroids; overproduction of mineralcorticoids (high ACTH)

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28
Q

Presentation of 17-alpha deficiency

A

female w/ HTN and lack of pubertal development
OR
46, XY w/ incompletely developed external genitalia

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29
Q

HTN

A

17-alpha hydroxylase deficiency

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30
Q

When to initiate eval for amenorrhea

A

15 w/ no bleeding
13 w/ no menses or thelarche
No menarche w/i 3 years of thelarch

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31
Q

Order of sexual development

A

thelarche > pubarche > growth spurt > menarche

“boobs, pubes, grow, flow”

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32
Q

Anosmia

A

Kallman Syndrome

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33
Q

Virilization/hirsutism

A

PCOS

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34
Q

Labs for primary amenorrhea

A 
Urine/serum HCG
serum FSH
prolactin
TSH
Pelvic u/s (uterus?)

no uterus: karyotype & total T (mullerian agenesis (XX) or AIS (XY))

elevated FSH: Karyoptype (XO = turner, XY = swyer)

FSH low/normal:
+ breast: outflow tract or endocrine (PCOS, hyperprolactinemia, thyroid disease)
- breast: recheck FSH, LH, consider pituitary MRI (congenital GnRH deficiency or constitutional delay of puberty)

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35
Q

Tx for primary amenorrhea

A

based on underlying etiology
Goals:
- treat cause
- restore ovulatory cycle/preserve fetility
- prevent complications (hypoestrognemia - osteoporosis)
Psych counseling
Refer to endocrinologist/gyne
Surgical referral for outlet obstruction or gonadectomy

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36
Q

Causes of secondary amenorrhea

A

PREGNANCY

Ovarian dysfunction
Hypothalamic dysfunction
Pituitary dysfunction
Uterine dysfunction

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37
Q

PCOS

A

2/3 to diagnose:

  • androgen excess (acne, hirsutisim, elevated T)
  • ovulatory dysfunction (amenorrhea or oligomenorrhea
  • polycystic ovaries
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38
Q

Causes of ovarian dysfunction

A

PCOS
POI
Hyperandrogenism (tumors secreting androgens- lead to pronounced virilization)

39
Q

Etiologies of POI

A

turner
FX
autoimmune ovarian destruction
radiation/chemo

40
Q

Hypothalamic & pituitary causes of secondary amenorrhea

A

Functional hypothalamic amennorhea (weight loss, exercise, nutritional deficiencys, stress, inflammation, lesions, celiac, head trauma)

Pituitary disease - hyperprolactinemia - prolactinoma or med induced (antipsychotics)
Sheehan syndrome (postpartum pituitary necrosis due to hemorrhage and hypotension)
Iron deposition (hemosiderosis)
Primary hypothyroidism (thyrotroph/lactotroph)
41
Q

Meds causing prolactinemia

A

antipsychotics

42
Q

Sheehan syndrome

A

Postpartum amenorrhea resulting from postpartum pituitary necrosis secondary to severe hemorrhage and hypotension

43
Q

Asherman’s Syndrome (uterine dysfunction)

A

scarring of endometrial lining, usually secondary to postpartum hemorrhage or endometrial infection followed by instrumentation such as dilation and currettage

44
Q

Acanthosis nigricans

A

PCOS

45
Q

Exopthalmos, goiter, abnormal DTRs

A

Hypothyroidism

46
Q

Galactorrhea

A

Pituitary tumor

47
Q

Labs for secondary amenorrhea

A 
urine/serum HCG
FSH
Prolactin
TSH
Total Testosterone (if evidence of hyperandrogenism)
48
Q

Imaging for secondary amenorrhea

A

Pevlic US
Pituitary MRI
Adrenal CT (if significant virilization & elevated T)

49
Q

Progesterone challenge

A

no withdrawal bleed = no estrogen (low FSH) - functional hypothalamic amenorrhea

withdrawal: PCOS

50
Q

Abnormal uterine bleeding (AUB)

A

<24 or >38 days
bleed > 8 days
>80 mL blood loss
intermenstrual bleeding

51
Q

Types of AUM

A

AUM/HMB (heavy menstrual bleeding)

AUM/IMB (intermenstrual bleeding)

52
Q

Etiologies of AUM (PALM-COEIN)

A

Polyp
adenomyosis (endometrium into myometrium)
Leiomyoma (fibroids)
Malignancy & endometrial hyperplasia

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic (anticoags, hormonal contraceptives)
Not otherwise classified
53
Q

13-18 YO AUM

A 
anovulation
OCP
Pelvic infection
coagulopathy
tumor
MOST COMMON: immature HPO axis
54
Q

19-39 YO AUM

A 
pregnancy
lesions (leiomyoma, polyp)
Anovulatory cycles (PCOS)
OCP
endometrial hyperplasia
endometrial CA
55
Q

40-menopause AUM

A

anovulatory bleeding
endometrial hyperplasia/carcinoma
Endometrial atrophy
Leiomyoma

56
Q

Anovulation

A

immature HPO axis

57
Q

Menorrhagia

A

anovulation or bleeding disorder

58
Q

Amenorrhea

A 
pregnancy
chromosomal abnormality
hypothalamic hypogonadism
congenital absence of uterus
cervix/vagina
structural abnormalities
59
Q

Most common presentation of anovulatory AUB

A

UNPREDICTABLE, varying bleeding amounts & intervals

related to hypothalamic abnormalities or PCOS

60
Q

Ovulatory AUB presentation

A

regular cycle length; Mittelschmerz, PMS sx, changes in cervical mucus

Menorrhagia, polymenorrhea, oligomenorrhea, intermenstrual bleeding

61
Q

menorrhagia

A

lesions
coag disorder
liver failure
renal failure

62
Q

Polymenorrhea

A

luteal-phase disorder

short follicular phase

63
Q

Oligomenorrhea

A

prolonged follicular phase

64
Q

Intermenstrual bleeding

A

due to cervical pathology (dysplasia, infection) or an IUD

65
Q

Perimenopause age

A

47 years

66
Q

What is perimenopause

A

5-10 years before menopause (51); anovulation due to decliniing # of follicles

lengthened intermenstrual intervals, skipped cycles, episodes of amenorrhea

67
Q

When to get bx for intermenstrual bleeding

A

frequent, heavy or prolonged bleeding (hyperplasia or cancer)

68
Q

Postmenopausal bleeding

A

ABNORMAL!
endometrial carcinoma
assess w/ pelvic US or EMB

69
Q

Mittelschmerz

A

one sided pain in abdomen due to ovulation

70
Q

Molimina symptoms

A

breast tenderness
ovulatory pain
bloating

71
Q

Dx for anovulatory bleeding suspected

A

CBC, TSH, prolactin, fasting glucose w/ fasting insulin

Screen for eating disorders, stress, female athlete triad

72
Q

Suspect ovulatory bleeding dx

A

Menorrhage:
CBC: consider LFT, Bun/Creat, coag
Order pelvic US (exclude fibroids)
EMB to exclude endometrial hyperplasia

intermenstrual bleed: pap and cervical culture

73
Q

Who should get EMB?

A

postmenopause w/ any bleeding
45 YO - menopause w/ AUB: if ovulatory OR if bleeding is frequent, heavy or prolonged (>5 days)

Age <45 w/ AUB and:

  • risk factors of unopposed estrogen exposure (obesity, chronic anovulation, PCOS)
  • persistent bleeding
  • failed management for AUB
74
Q

Management for unstable bleeding

A

admit

IV estrogen or possible D&C

75
Q

Management of acute AUB in stable patients

A

outpatient

Hormonal:

  • COC (monophasic w/ 35 mcg ethinyl estradiol- 3 pills qd x 7 days)
  • medroxyprogesterone (provera) orally
  • High dose estrogen w/ antiemetic

Tranxemic acid (lysteda) IV or oral ( those who don’t wanna take hormones)

76
Q

Medical tx for chronic AUB

A

hormones:

  • levonorgesterel (mirena) IUD
  • depot medroxyprogesteron (depo-provera)
  • estrogen/progestin OCP

Tranexamic acid (lysteda) - 3x/day for up to 5 days during menstruation

NSAIDs - 1st day of bleeding til cease

77
Q

Surgery for chronic AUB

A

endometrial ablation
Hysterectomy (extreme cases)
Endometrial artery embolization/myomectomy (leiomyomas)

78
Q

Primary dysmenorrhea

A

painful mesntraution w/ no patho cause
occurs during ovulatory cycle
age 17-22 is typical age

79
Q

Secondary dysmenorrhea

A

painful menstruation due to underlying disease (endometriosis, adenomyosis, uterine fibroids)
More common as woman ages

80
Q

Cause of pain

A

uterine contractions and ischemia due to prostaglandin release

81
Q

Primary dysmenorrhea presentation

A 
few hours before or just after onset of menstruation 
Lasts 12-72 hours
cramp-like/intermittent
lower abdomen
radiate to back/thighs
N/V/D, h/a, LBP, fatigue
Pelvic exam normal
82
Q

Tx for primary dysmenorrhea

A

heat/massage/exercise/yoga
nutritional supplements (increase dairy consumption, B complex)
Smoking cessation
NSAIDS (first line: ibuprofen 400 mg PO q 4-6 hours x 3-4 days)
Hormonal contraceptives (COC, mini pill, depo, mirena IUD)

83
Q

Resistant cases of primary dysmenorrhea

A

laparoscopy and/or possible GnRH analogue

84
Q

F/u and referral needed if

A 
pain worse w/ each menses
last longer than 2 days of menses
meds don't help pain
menstrual bleeding becomes heavier
pain accompanied by fever
abnormal d/c or bleeding
pain occurs at time unrelated to menses
85
Q

Common causes of secondary dysmenorrhea

A 
endometriosis
adenomyosis
adhesion
PID
Leiomyomas
86
Q

Tx for secondary dysmenorrhea

A

treat underlying cause

Hormone (COCs) – progestin or NSAIDS if contraindicated for estrogen

87
Q

Complicated secondary dysmenorrhea tx

A

diagnostic laparoscopy
hysterectomy
oophorectomy
myomectomy

88
Q

PMS

A

A group of physical and behavioral changes that occur in a regular, cyclic relationship to the LUTEAL PHASE that interfere with some aspect of the patient’s life

89
Q

PMDD

A

PMS w/ more severe emotional sx

90
Q

Cause of PMS

A

unknown; due to hormone fluctuations triggering an abnormal serotonin response

Progesterone increases MAO –> MAO reduces serotonin availability –> serotonin is decreased in the progesterone-dominant luteal phase

91
Q

Dx criteria for PMA

A

1-4 sx that are physical/behavioral or affective/psych in nature OR
>5 sx that are physical or behavioral
- presence of at least one sx occuring in luteal phase
- leads to impairment in functioning
- sx remit @ menses

92
Q

Non-pharm tx for PMS

A 
decrease salt/caffeine/alcohol
aerobic exercise
supplement Mg, Ca (swelling/pain)
acupuncture, yoga
Cognitive therapy
93
Q

Pharm tx for PMS

A 
SSRI (1st line for PMDD)
- continuous or luteal phase
Oral contraceptives (Yaz)
NSAIDs
Spironolactone (bloating)
GnRH agonist (refractory)

Women's Health Exam 1 (5 decks)

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