Menstruation Flashcards
Define amenorrhea. Initial work-up components
Absence of menses Workup: Pregnancy test Serum prolactin FSH, LH TSH
Define primary amenorrhea
Failure of menarche onset:
- By age 15 in the presence of secondary sex characteristics
- By age 13 in the absence of secondary sex characteristics
Etiologies?
>15y/o with amenorrhea
Breast present, uterus present
Outflow obstruction
Transverse vaginal septum
Imperforate hymen
Etiologies?
>15y/o with amenorrhea
Breast present, uterus absent
Mullerian agenesis (46 XX) Androgen insensitivity (46 XY)
Etiologies?
13y/o with amenorrhea
Breast absent, uterus present
Elevated FSH/LH -> Ovarian causes Premature ovarian failure (46 XX) Gonadal dysgenesis (ex. Turner’s 45 XO) Normal-low FSH/LH: hypothalamus-pituitary failure Puberty delay Athletes Illness Anorexia
Etiologies?
13y/o with amenorrhea
Breast absent, uterus absent
Breast absent, uterus absent-> Rare. Usually caused by a defect in testosterone synthesize. Presents like a phenotypic immature girl w/ primary amenorrhea (will often have intra-abdominal testes)
Etiologies?
Secondary amenorrhea
Pregnancy -> MC
Hypothalamus dysfunction (35%) Path: disruption of normal pulsatile hypothalamic secretion of GnRH that directly leads to subsequent dec FSH and/or dec LH secretion by the pituitary gland
Pituitary Dysfunction (prolactin-secreting pituitary adenoma; 19%)
Ovarian Disorders Path: Polycystic Ovarian Syndrome Premature Ovarian Failure Follicular failure or follicular resistance to LH or FSH Turner’s syndrome
Uterine Disorders
Path:
Scarring of the uterine cavity
Asherman’s syndrome = acquired endometrial scarring secondary to postpartum hemorrhage, s/p D&C or endometrial infection
Secondary amenorrhea due to hypothalamus dysfunction
Path
Dx
Tx
Path: disruption of normal pulsatile hypothalamic secretion of GnRH that directly leads to subsequent dec FSH and/or dec LH secretion by the pituitary gland
- Hypothalamic disorders
- Anorexia/weight loss 10% below ideal body weight)
- Exercise
- Stress
- Nutritional deficiencies
- Systemic disease (Celiac)
Dx:
Normal-low FSH & LH
Low estradiol, normal prolactin
Tx: stimulate gonadotropin section
Clomiphene
Menotropin
Secondary amenorrhea due to pituitary dysfunction
Path
Dx
Tx
Path: prolactin-secreting pituitary adenoma
Dx:
Dec FSH, LH
Inc prolactin (galactorrhea)
MRI of pituitary sella; prolactin inhibits GnRH
Tx: transsphenoidal surgery (tumor removal)
Secondary amenorrhea due to ovarian disorders
Path
Pt
Dx
Path: Polycystic Ovarian Syndrome Premature Ovarian Failure Follicular failure or follicular resistance to LH or FSH Turner’s syndrome
Pt: sx of estrogen deficiency (similar to menopause)-> Hot flashes, Sleep and mood disturbances, Dyspareunia, dry/thin skin, Vaginal dryness/atrophy
Dx:
Inc FSH, LH and dec estradiol -> ovarian abnormalities (primary disorder)
Normal-dec FSH, LH -> pituitary or hypothalamus abnormalities (secondary or tertiary)
Progesterone Challenge Test: 10mg medroxyprogesterone x10 days
+withdrawal bleeding -> ovarian (pt is anovulatory or oligoovulatory) and there is enough estrogen present (which built up endometrial lining)
No withdrawal bleeding:
Hypoestrogenic: ex-> Hypothalamus-pituitary failure
Uterine: ex-> Asherman’s or uterine outflow tract (imperforate hymen)
Secondary amenorrhea due to uterine disorders
Path
Dx
Tx
Path:
Scarring of the uterine cavity
Asherman’s syndrome = acquired endometrial scarring secondary to postpartum hemorrhage, s/p D&C or endometrial infection
Dx:
Pelvic U/S: absence of normal uterine stripe
Hysteroscopy: to dx and tx
Tx:
Estrogen tx to stimulate endometrial regeneration and the denuded area
Cryptomenorrhea
light flow or spotting
Menorrhagia
heavy or prolonged bleeding @ normal menstrual intervals
Metrorrhagia
irregular bleeding between expected menstrual cycles
Menometrorrhagia
irregular, excessive bleeding between expected menstrual cycles
Oligomenorrhea
infrequent menstruation (prolonged cycle length >35 days but <6m)
Polymenorrhagia
frequent cycle interval (<21 days)
Define dysfunctional uterine bleeding
abnormal frequency/intensity of menses due to non-organic causes. Normal cycle: 24-38 days w/ menstruation lasting 4.5-8 days
Dysmenorrhea
Path
Pt
Tx
Painful menstruation that affects normal activities
Path:
-Primary: not due to pelvic pathology
Inc prostaglandins -> painful uterine muscle wall activity.
Pain usually starts 1-2 yrs after onset of menarche in teens
-Secondary: due to pelvic pathology
endometriosis, adenomyosis, leiomyomas, adhesions, PID
Inc incidence as women age (>25 yrs)
Pt: Diffuse pelvic pain right before or with the onset of menses (+/- lower abdomen, suprapubic or pelvic pain that may radiate to lower back and legs) May be associated with HAs, N/V Cramps usually last 1-3 days PE: normal
Tx:
NSAIDs
Ovulation suppression
Laparoscopy
Menopause
Path
Pt
Tx
Path:Cessation of menses >1yr due to loss of ovarian dysfunction
~50-52 year old
Pt
Estrogen deficiency changes: menstrual cycle alterations, vasomotor instability (hot flashes), mood changes, skin/nail/hair changes, inc CV events, HLD, osteoporosis, dyspareunia (due to vaginal atrophy), urinary incontinence
Atrophic vaginitis: thin, yellow discharge, vaginal pH >5.5, pruritus
Irregular menstrual cycles but no premenstrual symptoms
Dx
PE: dec bone density, skin-> thin, dry, decreased elasticity, vaginal-> atrophy thin mucosa
FSH assay most sensitive initial test (inc serum FSH >30 IU/mL)
Inc serum FSH, Inc LH, Dec estrogen
-Due to depletion of ovarian follicles
-Androstenedione levels don’t change
-Estrone is the predominant estrogen after menopause
Tx
Vasomotor insufficiency/hot flashes: estrogen, progesterone, clonidine, SSRIs, gabapentin
Vaginal atrophy: estrogen (transdermal, intravaginal)
Osteoporosis prevention:
-Calcium + Vitamin D
-Weight bearing exercise
-Bisphosphonates
-Calcitonin
-Estrogen (+/- progesterone)
-SERM-> raloxifene, tamoxifen
Hormone Replacement therapy (RCT):
Estrogen only, estrogen + progesterone
Define premature menopause and associated factors
Premature menopause: menopause before the age of 40. May occur sooner in pts w/: DM Smokers Vegetarians Malnourished pts
Complications for menopause
Inc osteoporosis (inc fractures)
Inc CV risks
Inc lipids
HRT risk and benefits of
Estrogen only
Benefits:
most effective sx tx (mood, hot flashes, vaginal atrophy)
Transdermal or vaginal preferred vs PO
No increased risk of breast cancer
Risks:
Inc risk of endometrial cancer (unopposed estrogen) so often used in pts w/ no uterus (s/p hysterectomy)
Thromboembolism (CVA, DVT, PE)
Liver disease
HRT risk and benefits of
Estrogen + Progesterone
Continue dose daily doesn’t cause menstrual-like bleeding
Sequential (cycling): dose changes- can cause menstrual like bleeding but less often than normal cyclical bleeding
Benefits: Sx relief Dec heart and stroke risk Dec osteoporosis Dec dementia Protective against endometrial cancer-> often used if pt still have intact uterus (progestin protect against unopposed estrogen that may lead to endometrial cancer)
Risks:
Venous thromboembolism
+/- slightly inc risk of breast cancer (controversial)
Etiologies for abnormal uterine bleeding
PALM-COEIN Structural causes for abnormal uterine bleeding: -Polyp -Adenomyosis -Leiomyoma -Malignancy and hyperplasia Non-structural causes for abnormal uterine bleeding: -Coagulopathy -Ovulatory -Endometrial -Iatrogenic -Not yet classified
Polyps
path
dx
Path:
-Epithelial proliferations composed of endometrial glands and fibrotic stroma
-Common; 10-30% women with AUB have polyps
-Usually benign
Dx:
TVS (transvaginal U/S)
SIS (saline infused sonography) “saline hyst”
Hysteroscopy
Color flow doppler-> visualization of a single feeding vessel
Adenomyosis
Path
Pt
Dx
Path:
-Direct extension of endometrial glands and stroma beyond the basalis
-Incidence may >60% of women 30-35, most are parous
-Diffuse type MC, focal involvement is termed adenomyoma
Pt:
-Secondary dysmenorrhea
-enlarged, globular uterus
Dx:
-U/S: Globular uterine enlargement not explained by leiomyomata, Uterine wall thickening w/ anteroposterior asymmetry, Obscure endometrial/myometrial border
-MRI
-Histopathologic (up to 1/3 of hysterectomy specimens)
Leiomyoma
Path:
Types:
Tx:
Path: -Benign fibromuscular tumors of the myometrium -When symptomatic, AUB MC sx -Proposed etiology: venous congestion within uterus Types: -Pedunculated -Intracavitary -Submucosal -Intramural -Subserosal Tx: -Observation -Medical therapy -Myomectomy -Hysterectomy -Alternatives: uterine artery embolization, high intensity focused U/S
Abnormal uterine bleeding
malignancy and hyperplasia
Path:
Endometrial cancer risk factors:
Path: -Most endometrial cancers arise from progression of endometrial hyperplasia-endometrial thickening with proliferation of irregularly sized and shaped glands with increased gland to stroma ratio -Hyperplasias are designated atypical if they demonstrate nuclear atypia Endometrial cancer risk factors: -Unopposed estrogen (#1 risk factor) -Obesity -Early menarche, late menopause -Nulliparity -Tamoxifen use (in postmenopausal women) -Hereditary nonpolyposis colorectal cancer, breast and ovarian cancer -DM, HTN -Age (post-menopausal women) -Prior pelvic irradiation
Abnormal uterine bleeding
Coagulopathy
Path:
Path:
- Coagulation defect-> Von willebrand disease MC
- Meds:Coumadin, heparin, ASA, NSAIDs
Abnormal uterine bleeding
Ovulatory
Path:
Absence of cyclic progesterone production from the corpus luteum every 22-35 days produces abnormal uterine bleeding Common endocrinopathies: -PCOS -Hypothyroidism -Hyperprolactinemia -Obesity -Mental stress -anorexia, weight loss, extreme exercise
Abnormal uterine bleeding
Endometrial
Path:
When heavy menstrual bleeding occurs in the context of predictable and cyclic bleeding typical of ovulatory cycles and no other identifiable cause is identified, the mechanism is probably a primary disorder of the endometrium
Examples:
-disorders of endometrial hemostasis
-deficiencies in local production of vasoconstrictors or vasodilators
-accelerated lysis of endometrial clot from overproduction of plasminogen activator
-disorders of endometrial repair
-inflammation
-infection
Abnormal uterine bleeding
Iatrogenic
Path:
Medical interventions or devices OCPs Patches DMPA? Mirena TCAs, phenothiazines, drugs that impact serotonin uptake may cause ovulatory dysfunction and result in AUB
Abnormal uterine bleeding
Not yet classified
Path:
Chronic endometritis
Arteriovenous malformations
Myometrial hypertrophy
