Menstruation: Amenorrhea, Dysfunctional uterine bleeding, Dysmenorrhea, Menopause Flashcards
2 types of amenorrhea
primary
secondary
mc cause of secondary amenorrhea
intrauterine pregnancy
first step in work up for amenorrhea
pregnancy test
primary amenorrhea is the failure of menses to occur by __ yo
15 yo (according to AAPA Blueprint)
but apparently some sources say 16 yo
in order for primary amenorrhea dx, amenorrhea must occur in the presence of (2)
normal growth
secondary sexual characteristics
primary eval of amenorrhea should occur at age 13 if there is
complete absence of secondary sexual characteristics
6 causes of primary amenorrhea
turner’s syndrome
hypothalamic-pituitary insufficiency
androgen insensitivity
imperforate hymen
anorexia
mullerian agenesis
XO karyotype
webbed neck
broad chest
elevated FSH
turner’s syndrome
46 XX
elevated testosterone
breast development only
hypothalamic-pituitary insufficiency
46 xy
cyclic pelvic pain
diagnosis via speculum exam
imperforate hymen
46 xx
very low weight
anorexia
secondary sex characteristics present
no uterus
mullerian agenesis
secondary amenorrhea is absence of menses for _ months
in a woman w. previously normal menstruation
OR
_ months in a woman w. a hx of irregular cycles
3
6
4 causes of secondary amenorrhea
pregnancy
weight changes
hypothyroid
prolactinoma
lab work up for secondary amenorrhea
beta HCG
TSH
prolactin
work up for secondary amenorrhea should include what challenge test
progesterone challenge test
what is the progesterone challenge test
medroxyprogesterone/progestogen x 7-10 days - if bleeding occurs = anovulatory cycles
what do you think when you see a 35 yo woman w. heavy and irregular menstrual periods x 1 year - she is in a stable/monogamous relationship, no hx of abnormal paps, and no hx STI’s - elevated BMI, normal vitals and pelvic exam
dysfunctional uterine bleeding
excessive uterine bleeding and prolonged menses that is NOT caused by pregnancy or miscarriage
dysfunctional uterine bleeding/AUB
6 types of dysfunctional uterine/AUB
polymenorrhea
hemorrhagic/hypermenorrhea
menorrhagia
metorrhagia
menomethorrhagia
oligomenorrhea
menses that occur more frequently (< 21 days apart)
polymenorrhea
menses that involve more blood loss (> 7 days OR > 80 mL) w. irregular intervals
hemorrhagic/hypermenorrhea
prolonged/heavy bleeding (> 7 days OR > 80 mL) w. regular intervals
menorrhagia
uterine bleeding that occurs frequently AND irregularly btw regular intervals
metrorrhagia
more blood loss during menses AND frequent and irregular bleeding btw menses
menometrorrhagia
long intervals btw menses
oligomenorrhea
oligomenorrhea involves > _ days btw menses
35
AUB in the absence of an anatomic lesion caused by a problem w. the hypothalamic-pituitary-ovarian axis
polymenorrhea
menorrhagia
metrorrhagia
gs dx for abnormal uterine bleeding
uterine dilation and curettage
work up for AUB
r/o pregnancy
labs
progestin trial
ovulation journal
pap smear/pelvic exam
endometrial bx
HSG (hysterosalpingography)
tx for AUB
OCP
NSAIDs
dull, throbbing cramping/lower abdominal pain during menses w. n/v - normal length and bleeding amount
dysmenorrhea
dysmenorrhea pain peaks _ days after the onset of menses and subsides after _ days
peaks: 24 hr
subsides: 2-3 days
t/f: dysmenorrhea can be primary or secondary
t!
in order for dysmenorrhea dx, pain must (2)
prevent normal activity
require medication (OTC vs rx)
t/f: dysmenorrhea pain can occur w. menses OR 2-3 days before onset
t!
work up for dysmenorrhea (2)
pregnancy test
US
cause of primary dysmenorrhea
excessive PG’s (not pinot grigio, which actually helps)
what PG is associated with dysmenorrhea
any from Sonoma County
… jk
real talk: F2a
dysmenorrhea mc affects what age group
teens - early 20’s
declines w. age
rf for dysmenorrhea (5)
menarche before 12 yo
nulliparity
smoking
fam hx
obesity
how might primary dysmenorrhea pain be described
“labor-like” on days 1-3
dysmenorrhea may be associated by what symptoms (3)
n/v
diarrhea
HA
causes of secondary dysmenorrhea (lots!)
pathologic/clinically identifiable cause:
endometriosis
adenomyosis
polyps
fibroids
PID
IUD
tumors
adhesions
cervical stenosis
cervical lesions
psych
how might secondary dysmenorrhea pain be described
begins mid-cycle
increases in severity until the end
secondary dysmenorrhea is mc in what age group
20s-40s
dx of menopause is based on _ or more months of amenorrhea
12
mean age of menopause
51
(44-55 yo)
on average, women spend _ years in the postmenopausal state
30+
regular menstrual fxn that marks the transition btw reproductive capability and menopause
perimenopause
perimenopause lasts _ years
3-5
symptoms of menopause (6)
menstrual irregularity
vasomotor sx
sleep distrubances
irritability
mood disturbances
vaginal dryness
what are vasomotor symptoms (2)
hot flashes
night sweats
4 sx associated w. vaginal dryness
dyspareunia
vaginal atrophy
loss of urogenital integrity
loss of skin elasticity
menopause onset before 40 yo
premature ovarian failure
hallmark labs for menopause
FSH > 30
decreased estradiol
tx for vasomotor sx
HRT - estrogen
HRT for women with a uterus
estrogen + progesterone
HRT for women with no uterus
ERT (estrogen replacement therapy)
unopposed estrogen HRT in women w. a uterus increases the risk of
endometrial ca
progestin HRT increases the risk of (2)
hot flashes
breast ca
when should HRT be used for menopause
severe sx:
hot flashes
night sweats
vaginal dryness
how should you dose HRT for menopause
smallest dose for shortest possible time
annual review of decision to use HRT
t/f: HRT should be used to prevent CVD
f!
dt increased risk of breast ca, CVD, DVT
effect of HRT on lipid profile
increases: HDL and TG
decreases: LDL
contraindications for HRT (6)
elevated TG
undiagnosed vaginal bleeding
endometrial ca
hx breast ca OR estrogen sensitive ca
CVD hx
DVT/PE
non hormonal tx for vasomotor sx of menopause (3)
SSRI’s/SNRI’s
clonidine
gabapentin
what SSRI is used for vasomotor sx of menopause
paroxetine
2 phases of the 28 day menstrual cycle
follicular (proliferative)
luteal (secretory)
normal menstrual cycle can vary in duration from _ to _ days
20-35
each menstrual cycle begins on
the first day of ovulation
ovulation occurs _ days before teh first day of menstruation
14
chance of fertilization is highest btw days _ and _ of the menstrual cycle
11-15
days 0-14 of menstrual cycle
follicular (proliferative) phase
during the luteal phase, _ from the hypothalamus stimulates _ and _ to be released from the anterior pituitary
hypothalamus: GnRH
anterior pituitary: FSH, LH
FSH and LH stimulate _ growth,
which secretes _
follicle
estrogen
increasing estrogen levels during the follicular phase cause _ feedback, which causes a surge in _ (2)
positive
FSH, LH
what causes ovulation
LH spike (caused by increasing estrogen release from the follicle)
days 15-28 of the menstrual cycle
luteal (secretory) phase
after ovulation, the follicle become the _
which secretes _
corpus luteum
progesterone
increased progesterone in the luteal/secretoy phase causes _ feedback and a decrease in _ (2)
negative
LH/FSH
in the absence of fertilization during the luteal phase, the corpus luteum becomes the _
corpus albicans
the corpus luteum does not produce estrogen or progesterone, which leads to _
endometrial sloughing -> menses
after menses, _ secretion marks the beginning of a new follicular phase
GnRH
26 yo f c/o dpn and anxiety x 1 year just prior to menses - this interferes w. her relationships and work productivity - also c/o poor sleep, feeling overwhelmed, easily fatigued - PE and labs are normal
premenstrual dysphoric d.o
repeated episodes of significant dpn and related sx during the first week before menstruation
premenstrual dysphoric d.o (pmdd)
difference btw pmdd and pms
pmdd is a severe disabling extension of pms -> causes marked disruption in functioning
dsm 5 for pmdd
at least 5 sx in the final week before onset of menses, which improve/become absent a few days after onset of menses:
affective lability/mood swings
interpersonal conflict
dpn
anxiety
decreased interest in activities
difficulty concentrating
lethargy
change in appetite
hypersomnia OR insomnia
sense of being overwhelmed
physical sx: ex breast tenderness, bloating, joint pain
tx for pmdd (3)
SSRIs: fluoxetine, sertraline
SNRIs: venlafaxine
OCP + diuretics
tx for severe/refractory pmdd (4)
GnRH
TCAs
benzos
ovariectomy
25 yo c/o abd bloading, HA, irritability, dpn, poor sleep, breast tenderness 5 days before menses - sx greatly improve w.in 4 days of menses onset
premenstrual syndrome
when do sx of pms typically occur
btw ovulation and menses
what causes pms sx
-imbalance of estrogen and progresterone
-excess PG’s
what pms sx typically occur during the luteal phase (3)
bloating
irritability
pmdd
what criteria is used to for pms dx
ACOG:
one of the following sx is present during the 5 days before menses and abates w.in 4 days of menses:
-somatic: breast tenderness, abd bloating, HA, edema
-affective: irritability, dpn, angry outbursts, anxiety, social w/d, confusion
tx for pms
exercise
stress reduction
SSRIs
combined OCP
t/f: for pms, SSRI’s can be dosed cyclically
t!
tx for resistant/severe PMS
GnRH
oophrectomy
