Menstruation and Related Problems Flashcards
Menarche typically occurs within 2-3 years after _____
thelarache (breast budding)
The average age of menarche is
12-13 years old
Menstruation is a normal physiologic process that results in: (2 items)
1- a cyclically recurring maturation
2- slough renewal of the endometrium
Menarche occurs ____ months earlier in African American girls
5.5
What can lead to an earlier onset of puberty (5 items)?
1- Higher body mass index 2- environmental factors 3- socioeconomic factors 4- nutrition 5- access to preventative health care
Under complex regulation by the _______, _______, and the _______, cyclic changes induce developmental of a dominant follicle that results in ovulation and corpus luteum formation.
hypothalamus, pituitary gland, ovaries
What is the frequency of the normal menstrual cycle?
24-38 days
The ovarian cycle is further divided into (2 phases)
1- Follicular phase
2- Luteal phase
What is the average amount of blood loss that takes place during menstruation?
5-80mls
What is the average length of the mensural cycle?
4.5-8 days
Describe the Follicular phase
1- Gonadotropin-releasing hormone (GnRH) is released by the hypothalamus
2- GnRH stimulates the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland
3- FSH and LH stimulates a number of follicles to begin developing. The follicles produce estrogen, therefore there will be increases in estrogen levels
4- One of the follicles will become the dominant follicle, producing the most estrogen, and the remaining follicles will undergo atresia
5- Estrogen levels will reach their peak 24 hours before ovulation
6- LH will then surge, and ovulation will occur within 24-36 hours
What phase does the start of ovulation indicate?
Luteal phase
During the luteal phase, there is a shift from ______ dominance, to ________ dominance
estrogen; progesterone
What days does the follicular phase take place in?
days 1-14
What days does the luteal phase take place in?
days 15-28
Describe the Luteal phase
1- The follicle ruptures causing the corpus luteum to develop
2- The corpus luteum produces large amounts of progesterone
3- Progesterone suppresses further follicular growth and causes secretory changes in the endometrium
4- If the woman does not become pregnant, the corpus luteum will deteriorate 9-11 days after ovulation
5- The deterioration of the corpus luteum results in a sharp decline in progesterone and estrogen and triggers menstruation
_______ causes an elevation in basal body temperature, therefore daily measurement of basal body temperature usually can determine whether ovulation has occurred
Progesterone
What are the phases of the uterine cycle?
1- proliferate phase
2- secretory phase
What phase of the ovarian cycle does the proliferate phase correspond with?
Follicular
What takes place during the proliferate phase?
Estrogen stimulates the endometrium to thicken and form progesterone receptors to increase blood flow to the endometrium
What phase of the ovarian cycle does the secretory phase correspond with?
Luteal phase
What takes place during the luteal phase?
progesterone causes the endometrium to differentiate and secrete proteins that are important in supporting implantation of the embryo if fertilization of the egg occurs
What does decrease of estrogen and progesterone result in?
Sloughing of the endometrium and a restart of the menstrual cycle
Absence of menses for at least three usual cycle lengths
amenorrhea
Infrequently occurring menses at intervals greater than 38 days
Oligomenorrhea
Menses at intervals of 21-24 days or fewer
polymenorrhea
Regular bleeding in less than normal amount
hypomenorrhea
Bleeding excessive in duration and flow that is greater than 80ml/cycle greater than 7 days, or irregular, heavy bleeding (2 names)
Menorrhagia, Heavy menstrual bleeding (HMB)
Bleeding at any time between otherwise normal menses or light bleeding occurring irregular
Intermenstrual bleeding (IMB)
Irregular, heavy bleeding
Menometrorrhagia
Light bleeding, occurring irregular
Metrorrhagia
What is considered as primary amenorrhea?
Absence of menses by age 16
What are the additional guidelines for primary amenorrhea? (3 items)
1- patient has not reached menarche by 15 or has not done so within 3 years of thelarche
2- no menses by age 14 and signs of hirsutism
3- absence of breast development by age 13
What are the causes of primary amenorrhea? (4 items)
1- Obstructed flow
2- Mullerian agenesis
3- Androgen insensitivity
4- Chromosomal abnormalities
What are some common causes of secondary amenorrhea? (6 items)
1- pregnancy 2- lactation 3- menopause 4- Hyperandrogenism 5- hypothyroidism 6- pituitary adenoma
What are some uncommon causes of secondary amenorrhea? (10 items)
1- tumors 2- Eating disorders 3- Excessive exercise 4- Medications 5- Gyn surgery injury 6- Systemic illness 7- Autoimmune disease 8- Chemo/radiation 9- Defective enzyme systems 10- Anatomic deviations
What are some common diagnostic tests used when a patients presents with amenorrhea? (6 items)
1- Pregnancy test
2- Assessment of TSH and Prolactin levels
3- Evaluation of hypothalamic-pituitary-ovarian (HPO) axis
4- Progesterone Challenge test
5- Endometrial stripe
6- Ovarian/adrenal function tests
Thyroid-stimulating hormone and prolactin hormone levels are recommended in the assessment of amenorrhea because _______ and _________ can cause amenorrhea.
hypothyroidism (elevated TSH), hyperprolactinemia (>50ng/mL)
_______ levels are stimulated by breast stimulation, eating and stress.
Prolactin
What does the evaluation of hypothalamic-pituitary-ovarian (HPO) axis involve?
Assessment of the hypothalamus, pituitary, ovaries and uterus
What blood work is ordered in the assessment of hypothalamic-pituitary-ovarian (HPO) axis?
FSH, LH, estrogen
An elevated FSH and LH with a low estradiol level indicates ________.
Ovarian insufficiency
Low FSH, LH and estradiol indicates ________.
hypogonadotropic hypogonadism
Low-to-normal FSH, LH and estradiol indicate _______.
hypothalamic amenorrhea
What does a progesterone challenge test confirm?
confirms the presence of estrogen and the intactness of the outflow tract
What is an indication for Ovarian/adrenal function tests?
Ruling out PCOS
What are the differential diagnosis of amenorrhea? (11 items)
1- pregnancy 2- thyroid dysfunction 3- pituitary dysfunction 4- drug related 5- hypothalamic amenorrhea 6- chronic disease 7- stress 8- congenital syndromes 9- primary ovarian insufficiency 10- adrenal function abnormality 11- anatomical abnormalities
What types of drugs can cause amenorrhea?
1- antipsychotics 2- cocaine 3- antidepressants 4- opiates 5- antihypertensive. 6- Combined or progestin only contraceptives
What types of patients is hypothalamic amenorrhea seen in? (3 items)
women with:
1- increased exercise
2- intense athletics
3- eating disorder or extreme weight loss
What types of chronic diseases can cause amenorrhea? (4 items)
1- celiac dx
2- depression
3- anxiety
4- poorly controlled iddm
What types of anatomical abnormalities can cause amenorrhea?
1- imperforate hymen
2- transverse vaginal septum
3- absent ovaries or uterus
4- asherman’s syndrome
What are the different ways to initiate a progesterone challenge test? (3 items)
1- 5 to 10mg oral medroxyprogesterone
Is given for 7-10days
2- 300mg oral micronized progesterone for 7-10days
3- 100-200mg of progesterone in oil IM for one dose
When doing a progesterone challenge test, if bleeding occurs in 2-7days after completing
medication what does it show?
it shows that the cervix is patent, estrogen is being produced and the endometrium is functional
An alternative to progesterone challenge test is to
perform a pelvic ultrasound to measure the endometrial strip. A thickness of _____ indicates adequate production of estrogen
> 6.0mm
If no bleeding occurs with a progesterone challenge test, what diagnosis is likely?
endometrial scarring
What diagnostic test is used to confirm endometrial scarring? (2 items)
1- hysterosalpingogram
2- direct visualization of the endometrial cavity
The main indication for pharmacological treatment is to prevent , amenorrhea induced _______ _____which left untreated can lead to endometrial cancer.
endometrial hyperplasia
What are the 3 types of pharmacological therapies used to treat amenorrhea?
1- low dose combination contraceptives
2- progesterone therapy
3- Hormone replacement therapy
_______ _______ is a progesterone therapy that is used to prevent endometrial hyperplasia in anovolatory clients who do not need contraception
medroxyprogesterone acetate
_____-_____ is the new terminology used to better describe AUB when there is structural and non structural causes of abnormal uterine bleeding
Palm-coein
What is the term that defines the structural causes of abnormal uterine bleeding (AUB) and what are some examples of structural causes? (4 items)
Palm; 1- polyps 2- adenomyosis 3- leiomyoma 4- malignancy and hyperplasia
What is the term that defines the non-structural causes of abnormal uterine bleeding (AUB), and what are some examples of these non structural causes? (4 items)
Coein; 1- coagulopathy 2- ovulatory dysfunction 3- endometrial dysfunction 4- iatrogenic
What is the most common cause of dysmenorrhea?
Overproduction of prostaglandins within the endometrium
A key defining factor in secondary dysmenorrhea is the presence of:
symptoms of pain and bleeding that persist beyond the normal menstrual cycle
The most established initial therapy for dysmenorrhea is:
NSAIDs
Irregular uterine bleeding is commonly related to anovulatory cycles and most often
seen in conjunction with: (4 items)
1- adolescence
2- obesity
3- PCOS
4- perimenopause
________ ______ is the presence of crampy, lower abdominal pain that occurs just before and/or during menses in the absence of pelvic diagnosis.
Primary dysmenorrhea
What two substances may be overproduced in the presence of primary dysmenorrhea?
prostaglandin and vasopressin
This is the diagnosis when there is painful menses in the presence of a pelvic pathology including: endometriosis, adenomyosis, uterine leiomyomas
and pelvic inflammatory disease
secondary dysmenorrhea
Common cyclic disorder that is characterized by emotional and physical symptoms consistently occurring during luteal phase
PREMENSTRUAL SYNDROME AND PREMENSTRUAL
DYSPHORIC DISORDER
What is the diagnostic criteria used for Premenstrual syndrome (PMS)? ( 3 items)
1- One or more affective or somatic symptoms
present in the 5 days prior to menses
2- symptoms end within 4 days after menses
3- Cause significant impairment not accounted
for by another diagnosis
What is the diagnostic criteria used for Premenstrual dysphoric disorder (11 items)?
At least 5 of the following, with at least 1 of the first 4 listed:
- Markedly depressed mood, feelings of hopelessness, or self deprecating thoughts
- Marked anxiety, tension
- Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)
- Persistent and marked anger or irritability, or increased interpersonal conflicts
- Decreased interest in usual activities
- Subjective sense of difficulty in concentrating
- Lethargy, easy fatigability, or marked lack of energy
- Marked change in appetite, overeating, or specific food cravings
- Hypersomnia or insomnia
- A subjective sense of being overwhelmed or out of control
- Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” or weight gain
When PMS or PMDD is suspected, patients should be instructed to:
keep a premenstrual daily symptom diary for at least 2 months to confirm luteal-phase symptoms
What are some lifestyle modifications that can be initiated to treat PMS or PMDD?
1- regular exercise
2- good amount of sleep
3- healthy diet including eating complex carbohydrates in luteal phase
4- take vitamin B6 100mg and calcium 1000mg daily
For women who do not respond to conservative therapy in the treatment of PMS and PMDD, what is the first line treatment?
Selective serotonin reuptake inhibitors (SSRIs) (can be given during the luteal phase or continuous)
What are three examples of SSRIs
fluoxetine, sertraline, paroxetine
_____ _____ _____ is a systemic disease marked by acute onset of fever, hypotension, myalgia, rash, multiple organ failure and late desquamation of hands and feet.
Toxic shock syndrome
What are the antibiotic choices that can be used to treat toxic shock syndrome?
Clindamycin and anti-staphylococcal PCN
What is the treatment used for MRSA caused toxic shock syndrome?
Clindamycin plus either vancomycin or linezolid
