Menstruation Disorders

Question 1

Amenorrhea definition

Answer 1

Primary: absence of menses by age 15 years in the presence of normal sexual development
Secondary: absence of menses for 3 cycles for 6 months ina prev menstruating woman
may also present with infertility, vaginal dryness and decreased libido, weight loss/gain, acne, hirsutism, hair loss due to androgen excess

Question 2

1 cause of amenorrhea

Answer 2

unrecognized pregnancy

Question 3

Amenorrhea causes

Answer 3

unrecognized pregnancy, anorexia, hyperprolactinemia, PCOS

Question 4

lab tests in amenorrhea

Answer 4

pregnancy test
hypothyroidism suspected- TSH
hyperprolactinemia susp - prolactin
if PCOS susp - total testosterone, 17-hydroxyprogesterone, FBG, FLP

Question 5

amenorrhea present, - preggo test, underlying cause is anorexia; excessive exercise
tx?
what if it isnt effective?

Answer 5

inc weight, dec exercise, consider psychotherapy

if ineffective, consider estrogen (CHC)

Question 6

amenorrhea present, - preggo test, underlying cause is hyperprolactinemia
tx?

Answer 6

Dopamine agonist (Bromocriptine)

Question 7

amenorrhea present, - preggo test, underlying cause is anovulation secondary to PCOS
tx?

Answer 7

if pregnancy is immediate goal: weight loss and letrozole to stimulate ovulation

if pregnancy is not immediate goal: weight loss, CHC with progesterone or antiandrogenic effects

Question 8

amenorrhea present, - preggo test, underlying cause is other/unknown
tx?

Answer 8

progestin to reduce withdrawal bleeding followed by estrogen/progestin therapy

Question 9

menorrhagia/heavy menstrual bleeding

s/sx

Answer 9

heavy prolonged menstrual flow, fatigue, lightheaded, pallor, +/- dysmenorrhea
acute distress

Question 10

menorrhagia lab tests

Answer 10

CBC, ferritin

Question 11

menorrhagia tx

Answer 11

NSAIDs can dec blood loss by 20-50% in 75% of women
CHC or POP
LNG IUD: reduce menstrual flow up to 90%

Question 12

if NSAIDs ineffective for menorrhagia, what is the next option

Answer 12

tranexamic acid OR leuteal phase progesterone or x 21d on day 5

Question 13

If tranexamic acid or luteal phase progesterone ineffective for menorrhagia, what is next option

Answer 13

consider CHC (LNG-IUD OR conservative endometrial ablation surgery

Question 14

Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
patho
s/sx

Answer 14

ovulatory dysfunction, corpus luteum nor formed, ovary does not secrete progesterone, CL doesnt differentiate so implantation can occur; unopposed estrogen causes noncyclic bleeding, hyperplasia, precancerous state

irregular, heavy prolonged vaginal bleeding, perimenopausal sx (hot flashes, night sweats, vaginal dryness), acne, hirsutism, bleeding

Question 15

Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
lab tests

Answer 15

PCOS sussy - total testosterone, 17-hydroxyprogesterone, FBG, FLP
perimenopause sussy - FSH
hypothyroidism sussy - TSH

Question 16

Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
tx

Answer 16

NSAIDs to dec BF
CHCs (any form), estrogens inc endometrial growth and stabilization, prevent anovulatory bleeding by suppressing ovulatory hormones

Medroxyprogesterone acetate (po, parental), suppresses pituitary gonadotropins (LH and FSH) to dec E and P, prevents anovulatory bleeding

Estrogen modulators: Clomiphene or Letrozole (if goal is to induce ovulation)

Question 17

Dysmenorrhea s/sx

Answer 17

Primary: complaints with normal pelvic anatomy
Secondary: complaints with abnormal pelvic anatomy (PID, cysts, tumors, fibroids, cervical stenosis, IBD, congenital abnormalities, IUD)

all: crampy pelvic pain, beginning before or at menses onset, usually lasting 1-3d
acute distress

Question 18

Dysmenorrhea lab tests

Answer 18

Pelvic exam to screen for STI

Question 19

Dysmenorrhea tx

Answer 19

non-pharm: rest, heat, loose clothing, exercise, massaging, smoking cessation
NSAIDs
CHCs: inhibit prolif of endometrial tissue and dec PGs
Progestin (Depo MPA or LNG IUD)

Question 20

Premenstrual Syndrome (PMS)
sx

Answer 20

mild mood disturbances, physical sx during luteal phase prior to menses, 75% of menstruating women

Question 21

Premenstrual Dysphoric Disorder (PMDD) definition

Answer 21

complex psychiatric disorder with multiple biological, psychological and sociocultural determinants (3-8% of women, “severe PMS”)

Question 22

PMS/PMDD sx and how many of these sx is PMS? PMDD?

Answer 22

Mood sx: fatigue, irritability, labile mood, depression, oversensitivity, social withdrawal, crying spells, forgetfulness, difficulty concentrating

physical sx: abdominal bloating, breast tenderness, acne, appetite changes/cravings, swelling of extremities, HA, GI upset

PMS = at least 1 mood, + 1 physical
PMDD = at least 5 + markedly depressed mood, anxiety, irritability, affective labiality, interfere with QOL, separate from another psychiatric disorder

Question 23

PMS or PMDD tx

Answer 23

non pharm - diet, exercise, cognitive behavioral techniques

pharm PMS- NSAIDs, diuretics (midol)
pharm PMDD: SSRIs, SNRIs, CHCs, GnRH ag

Question 24

PMDD tx

Answer 24

SSRIs (sertraline, fluoxetine, citalopram, escitalopram) in luteal phase or continuous

SNRIs (venlafaxine)

CHCs : continuous hormone levels preventing fluctuations that cause ntm changes (use as littel hormone as possible), Drosperinone containing agents (diuretic activity)

GnRH agonist in severe cases, shut down HPO axis and dec E + P

Question 25

PMS/PMDD dx and tx algorithm

Answer 25

PMS or PMDD documented over 2 consecutive cycles

if sx moderate to severe…

1. do COC or SSRI depending on if wants contraception or not
2. if no improvement switch to the other
3. if sx persist switch to GnRH agonist with add back therapy