Normal menstrual cycle/menstrual problems

Question 1

What are the four tanner stages for both breast and pubic hair

Answer 1

Breast

1. ) Breast buds form
2. ) Breasts and areola grow
3. ) Nipple and areola form separate mount
4. ) Areola rejoins breast contour

Pubic

1. ) Hair straight and fine
2. ) Hair become coarse, darkens, and spreads
3. ) Hair looks like an adult but limited to area
4. ) Inverted triangle forms

Question 2

What is the treatment for menopause

Answer 2

Vasomotor symptoms: OCPs, or SSRI/SNRI’s/clonidine
Vaginal atrophy: Topical estrogen
Osteoporosis: Daily calcium and vit D supplementation

Question 3

Primary amenorrhea is defined as absence of menses by age 16. It can be further categorized depending on whether or not secondary sexual characteristics formed. What are the causes for absence of secondary characteristics

Answer 3

Primary amennorhea
Absence of secondary sexual characteristics
1.) Constitutional growth delay
2.) Primary ovarian insufficiency
3.) Central hypogonadism

Question 4

Primary amenorrhea is defined as absence of menses by age 16. It can be further categorized depending on whether or not secondary sexual characteristics formed. What are the causes for presence of secondary sexual characteristics

Answer 4

1. ) Mullerian agenesis
2. ) Imperforate hymen
3. ) Complete androgen insensitivity - androgens can still be converted from testosterone to estrogen for breast development, but not enough for ovaries

Question 5

What are the steps for the work up of primary ammenorrhea

Answer 5

1. ) Get a pregnancy test
2. ) Bone age radiograph - if less than 12yo radiograph and short stature, it means its constitutional growth delay
3. ) If bone age > 12yo, then get LH/FSH levels now to determine if problem is on central axis or peripheral
4. ) If peripheral, ultrasound the ovaries

Question 6

What are the treatments for primary amenorrhea

Answer 6

1. ) Constitutional growth delay - no treatment
2. ) Hypogonadism: Start with estrogen, proceed to estrogen/progesterone
3. ) Anatomic - surgery

Question 7

What is the diagnostic algorithm for secondary amenorrhea

Answer 7

1. ) Get pregnancy test (same as primary)
2. ) This time, get TSH and prolactin
3. ) If prolactin elevated - get MRI
4. ) Do the progestin challenge to find out if PCOS is present

Other things to consider

• If hyperglycemia and hypotension are present, consider CAH, cushing’s, and addisons and do cortisol levels
• If virilizatoin is present, check testosterone and DHEAS and consider same three diseases

Question 8

What is the treatment for secondary amenorrhea

Answer 8

1. ) Hypothalamic - Reverse underlying cause, induce ovulation with gonadotropins
2. ) Tumors - Excision or dopamine antagonists
3. ) Premature ovarian failure - start giving combination estrogen/progesterone

Question 9

What is the definition of primary dysmenorrhea

Answer 9

What every female experiences - pain with ovulatory cycles associated with prostaglandin (PGF2)

Treatment: NSAIDs (PG), combined OCP’s

Question 10

What is the definition of secondary dysmenorrhea and what are the causes

Answer 10

Definition: Menstrual pain for which organic cause exists

Causes

1. ) Endometriosis
2. ) Adenomyosis
3. ) Fibroids
4. ) Adhesions
5. ) Polyps
6. ) PID

Question 11

What is the work up for secondary dysmenorrhea

Answer 11

First obtain B-HCG to rule out ectopic pregnancy which can be a cause of the pain

Then you check for STD’s, UTI’s, CBC, etc

Question 12

Contrast the symptoms of endometriosis to adenomyosis

Answer 12

Endometriosis: Cyclical pain and dyspareunia
Adenomyosis: Non-cyclical pain with menorrhagia and enlarged uterus

Question 13

Compare the diagnosis of endometriosis to adenomyosis

Answer 13

Endometriosis: Direct visualization by laparoscopy
Adenomyosis: Difficult, requires pathologic diagnosis

Question 14

Compare the treatment of endometriosis to adenomyosis

Answer 14

Medical

1. ) Endometriosis - inhibit ovulation by giving OCP’s (first line), GnRH analogs (leuprolide)
2. ) Adenomyosis - only fix symptoms - NSAIDs with OCPs

Surgical - definitive

1. ) Endometriosis - 20% of patients can become pregnant after ablation
2. ) Hysterectomy for both which is definitive