Menstruation Flashcards
Average menarche age
12-13 YO
Average age of menopause
51
normal cycle
24-38 days
<8 dyas long
5-80 mL blood (30 mL = average)
Primary amenorrhea is considered
absence of menstruation by 15 YO w/ secondary characteristics
OR
absence by age 13 w/o secondary characteristics
secondary amenorrhea is considered
no period for 3 cycles
OR
6 consecutive months in women who were previously menstruating
Causes of primary amenorrhea
gonadal dysgenesis/ POI (most common)
Hypothalamic or pituitary
Outflow tract disorders
receptor abnormality or enzyme deficiency
Dysgensis results in
hypergonadotropic hypogonadism
Turner syndrome
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
Presentation of turners
short, webbed neck, wide nippl
“streak ovaries” and sexual infantilism
Swyer syndrome
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
POI
46, XX w/ menopause before age 40
usually presents as secondary amenorrhea but can present as primary
Causes of POI
chemo
radiation
FX (FMR1 gene mutation)
autoimmune oophoritis
PCOS
rarely causes primary amenorrhea
ovulatory dysfunciton
hyperandrogenism w/ amenorrhea in absence of other causes
Hypogonadotropic hypogonadism
low FSH due to:
- abnormal hypothalamic GnRH secretion (leaing to decreased gonadotropin pulse d/c)
- congenital absence of GnRH
Hypothalamic amenorrhea
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)
Causes of hypothalamic amenorrhea
stressors (eating disorders, physical or psychological stress, weight loss, excessive exercise – female athletes triad)
Kallmann’s syndrome
idiopathic hypogonadotropic hypogonadism (congenital GnRH deficiency) + anosmia
Pituitary causes of primary amenorrhea
- 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)
Outflow tract disorders
Uterine- Mullerian Agenesis (vaginal agenesis)
Vagina- Imperforate hymen & transferse vaginal septum
Mullerian agenesis
46, XX w/ congenital absence of oviducts, uterus and upper vagina (normal gonad function: estrogen - breasts)
Imperforate hymen & transferse vaginal septum presentation
cyclic pelvic pain & perirectal mass from sequestration of blood in vagina
Androgen insensitivity syndrome (receptor/enzyme abnormality)
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
Dx for AIS
Pelvic US- absent upper vagina, uterus & fallopian tube; tests remain in intra-abdominal or partially descended (mistaken for hernia)
Tx for AIS
remove testes (risk of testicular CA)
5-alpha reductase deficiency
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
Ambiguous genitalis
5-alpha reductase deficiency
17-alpha hydroxylase deficiency
46, XX or XY
lack enzyme to produe cortisol or sex steroids; overproduction of mineralcorticoids (high ACTH)
Presentation of 17-alpha deficiency
female w/ HTN and lack of pubertal development
OR
46, XY w/ incompletely developed external genitalia
HTN
17-alpha hydroxylase deficiency
When to initiate eval for amenorrhea
15 w/ no bleeding
13 w/ no menses or thelarche
No menarche w/i 3 years of thelarch
Order of sexual development
thelarche > pubarche > growth spurt > menarche
“boobs, pubes, grow, flow”
Anosmia
Kallman Syndrome
Virilization/hirsutism
PCOS
Labs for primary amenorrhea
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)
Tx for primary amenorrhea
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
Causes of secondary amenorrhea
PREGNANCY
Ovarian dysfunction
Hypothalamic dysfunction
Pituitary dysfunction
Uterine dysfunction
PCOS
2/3 to diagnose:
- androgen excess (acne, hirsutisim, elevated T)
- ovulatory dysfunction (amenorrhea or oligomenorrhea
- polycystic ovaries
Causes of ovarian dysfunction
PCOS
POI
Hyperandrogenism (tumors secreting androgens- lead to pronounced virilization)
Etiologies of POI
turner
FX
autoimmune ovarian destruction
radiation/chemo
Hypothalamic & pituitary causes of secondary amenorrhea
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)
Meds causing prolactinemia
antipsychotics
Sheehan syndrome
Postpartum amenorrhea resulting from postpartum pituitary necrosis secondary to severe hemorrhage and hypotension
Asherman’s Syndrome (uterine dysfunction)
scarring of endometrial lining, usually secondary to postpartum hemorrhage or endometrial infection followed by instrumentation such as dilation and currettage
Acanthosis nigricans
PCOS
Exopthalmos, goiter, abnormal DTRs
Hypothyroidism
Galactorrhea
Pituitary tumor
Labs for secondary amenorrhea
urine/serum HCG FSH Prolactin TSH Total Testosterone (if evidence of hyperandrogenism)
Imaging for secondary amenorrhea
Pevlic US
Pituitary MRI
Adrenal CT (if significant virilization & elevated T)
Progesterone challenge
no withdrawal bleed = no estrogen (low FSH) - functional hypothalamic amenorrhea
withdrawal: PCOS
Abnormal uterine bleeding (AUB)
<24 or >38 days
bleed > 8 days
>80 mL blood loss
intermenstrual bleeding
Types of AUM
AUM/HMB (heavy menstrual bleeding)
AUM/IMB (intermenstrual bleeding)
Etiologies of AUM (PALM-COEIN)
Polyp
adenomyosis (endometrium into myometrium)
Leiomyoma (fibroids)
Malignancy & endometrial hyperplasia
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic (anticoags, hormonal contraceptives) Not otherwise classified
13-18 YO AUM
anovulation OCP Pelvic infection coagulopathy tumor MOST COMMON: immature HPO axis
19-39 YO AUM
pregnancy lesions (leiomyoma, polyp) Anovulatory cycles (PCOS) OCP endometrial hyperplasia endometrial CA
40-menopause AUM
anovulatory bleeding
endometrial hyperplasia/carcinoma
Endometrial atrophy
Leiomyoma
Anovulation
immature HPO axis
Menorrhagia
anovulation or bleeding disorder
Amenorrhea
pregnancy chromosomal abnormality hypothalamic hypogonadism congenital absence of uterus cervix/vagina structural abnormalities
Most common presentation of anovulatory AUB
UNPREDICTABLE, varying bleeding amounts & intervals
related to hypothalamic abnormalities or PCOS
Ovulatory AUB presentation
regular cycle length; Mittelschmerz, PMS sx, changes in cervical mucus
Menorrhagia, polymenorrhea, oligomenorrhea, intermenstrual bleeding
menorrhagia
lesions
coag disorder
liver failure
renal failure
Polymenorrhea
luteal-phase disorder
short follicular phase
Oligomenorrhea
prolonged follicular phase
Intermenstrual bleeding
due to cervical pathology (dysplasia, infection) or an IUD
Perimenopause age
47 years
What is perimenopause
5-10 years before menopause (51); anovulation due to decliniing # of follicles
lengthened intermenstrual intervals, skipped cycles, episodes of amenorrhea
When to get bx for intermenstrual bleeding
frequent, heavy or prolonged bleeding (hyperplasia or cancer)
Postmenopausal bleeding
ABNORMAL!
endometrial carcinoma
assess w/ pelvic US or EMB
Mittelschmerz
one sided pain in abdomen due to ovulation
Molimina symptoms
breast tenderness
ovulatory pain
bloating
Dx for anovulatory bleeding suspected
CBC, TSH, prolactin, fasting glucose w/ fasting insulin
Screen for eating disorders, stress, female athlete triad
Suspect ovulatory bleeding dx
Menorrhage:
CBC: consider LFT, Bun/Creat, coag
Order pelvic US (exclude fibroids)
EMB to exclude endometrial hyperplasia
intermenstrual bleed: pap and cervical culture
Who should get EMB?
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
Management for unstable bleeding
admit
IV estrogen or possible D&C
Management of acute AUB in stable patients
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)
Medical tx for chronic AUB
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
Surgery for chronic AUB
endometrial ablation
Hysterectomy (extreme cases)
Endometrial artery embolization/myomectomy (leiomyomas)
Primary dysmenorrhea
painful mesntraution w/ no patho cause
occurs during ovulatory cycle
age 17-22 is typical age
Secondary dysmenorrhea
painful menstruation due to underlying disease (endometriosis, adenomyosis, uterine fibroids)
More common as woman ages
Cause of pain
uterine contractions and ischemia due to prostaglandin release
Primary dysmenorrhea presentation
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
Tx for primary dysmenorrhea
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)
Resistant cases of primary dysmenorrhea
laparoscopy and/or possible GnRH analogue
F/u and referral needed if
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
Common causes of secondary dysmenorrhea
endometriosis adenomyosis adhesion PID Leiomyomas
Tx for secondary dysmenorrhea
treat underlying cause
Hormone (COCs) – progestin or NSAIDS if contraindicated for estrogen
Complicated secondary dysmenorrhea tx
diagnostic laparoscopy
hysterectomy
oophorectomy
myomectomy
PMS
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
PMDD
PMS w/ more severe emotional sx
Cause of PMS
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
Dx criteria for PMA
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
Non-pharm tx for PMS
decrease salt/caffeine/alcohol aerobic exercise supplement Mg, Ca (swelling/pain) acupuncture, yoga Cognitive therapy
Pharm tx for PMS
SSRI (1st line for PMDD) - continuous or luteal phase Oral contraceptives (Yaz) NSAIDs Spironolactone (bloating) GnRH agonist (refractory)
