Menstruation Disorders Flashcards
Amenorrhea definition
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
1 cause of amenorrhea
unrecognized pregnancy
Amenorrhea causes
unrecognized pregnancy, anorexia, hyperprolactinemia, PCOS
lab tests in amenorrhea
pregnancy test
hypothyroidism suspected- TSH
hyperprolactinemia susp - prolactin
if PCOS susp - total testosterone, 17-hydroxyprogesterone, FBG, FLP
amenorrhea present, - preggo test, underlying cause is anorexia; excessive exercise
tx?
what if it isnt effective?
inc weight, dec exercise, consider psychotherapy
if ineffective, consider estrogen (CHC)
amenorrhea present, - preggo test, underlying cause is hyperprolactinemia
tx?
Dopamine agonist (Bromocriptine)
amenorrhea present, - preggo test, underlying cause is anovulation secondary to PCOS
tx?
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
amenorrhea present, - preggo test, underlying cause is other/unknown
tx?
progestin to reduce withdrawal bleeding followed by estrogen/progestin therapy
menorrhagia/heavy menstrual bleeding
s/sx
heavy prolonged menstrual flow, fatigue, lightheaded, pallor, +/- dysmenorrhea
acute distress
menorrhagia lab tests
CBC, ferritin
menorrhagia tx
NSAIDs can dec blood loss by 20-50% in 75% of women
CHC or POP
LNG IUD: reduce menstrual flow up to 90%
if NSAIDs ineffective for menorrhagia, what is the next option
tranexamic acid OR leuteal phase progesterone or x 21d on day 5
If tranexamic acid or luteal phase progesterone ineffective for menorrhagia, what is next option
consider CHC (LNG-IUD OR conservative endometrial ablation surgery
Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
patho
s/sx
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
Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
lab tests
PCOS sussy - total testosterone, 17-hydroxyprogesterone, FBG, FLP
perimenopause sussy - FSH
hypothyroidism sussy - TSH
Anovulatory bleeding/Abnormal uterine bleeding with ovulatory dysfunction
tx
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)
Dysmenorrhea s/sx
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
Dysmenorrhea lab tests
Pelvic exam to screen for STI
Dysmenorrhea tx
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)
Premenstrual Syndrome (PMS) sx
mild mood disturbances, physical sx during luteal phase prior to menses, 75% of menstruating women
Premenstrual Dysphoric Disorder (PMDD) definition
complex psychiatric disorder with multiple biological, psychological and sociocultural determinants (3-8% of women, “severe PMS”)
PMS/PMDD sx and how many of these sx is PMS? PMDD?
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
PMS or PMDD tx
non pharm - diet, exercise, cognitive behavioral techniques
pharm PMS- NSAIDs, diuretics (midol)
pharm PMDD: SSRIs, SNRIs, CHCs, GnRH ag
PMDD tx
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
PMS/PMDD dx and tx algorithm
PMS or PMDD documented over 2 consecutive cycles
if sx moderate to severe…
- do COC or SSRI depending on if wants contraception or not
- if no improvement switch to the other
- if sx persist switch to GnRH agonist with add back therapy
