The Menstrual Cycle & Abnormalities Flashcards
1
Q
pelvic anatomy is form from what embryologically?
A
Muellerian ducts
2
Q
layers of the uterus?
A
peritoneum, myometrium, endometrium
3
Q
2 sub-layers of the endometrium?
A
the basal layer and functional layer
- basal layer closests to the myometrium
- functional layer sheds during menses
4
Q
what layer of the endometrium shed during menses?
A
functional layer
5
Q
what is the site of implantation of an embryo?
A
the uterus - endometrium layer
6
Q
what are the Fallopian tubes?
A
Passageways through which oocytes travel from ovaries to uterus
7
Q
what do the fallopian tubal fluids provide for the embryo?
A
nutrients - crucial to the embryo’s survival and development
8
Q
what does the cervix consist of?
A
internal os, cervical canal, and external os
9
Q
what changes in the cervix throughout menstrual cycle d/t hormones?
A
Cervical mucus changes throughout menstrual cycle in response to hormones
10
Q
how does the cervical mucus change throughout menstrual cycle? (HINT: in middle of cycle and after ovulation)
A
in middle of cycle, estrogen levels are high -> cervical mucous becomes permeable to sperm, thin and allows fertilization to occur
after ovulation, estrogen levels are low and cervical mucous thickens and becomes impermeable to sperm
11
Q
how are ovaries attached to uterus?
A
via ovarian ligament (aka suspensory ligament)
12
Q
what are the functions of ovaries? (HINT: 3)
A
Storage, maturation, and release of oocytes (eggs)
Formation of the corpus luteum
Production and secretion of hormones including estrogen and progesterone
13
Q
what factors DON’T impact rate of decline of follicles & oocytes in a woman?
A
Age of menarche, number of pregnancies or births, use of contraceptives, or number of IVF cycles
14
Q
what is the functional unit of an ovary? what is it exactly?
A
the follicle - sac that contains the egg
15
Q
how long is the cycle from a primordial follicle to a dominant follicle?
A
120 days
16
Q
what is another name for a dominant follicle?
A
Graafian follicle (egg that’s ovulated during menstrual cycle)
17
Q
what is the corpus luteum? what does the corpus luteum secrete?
A
sac that is left over from the ovulated egg -> the follicular sac
it secretes progesterone
18
Q
what hormone is very important for a pregnancy to develop? what does this hormone keep active and why?
A
progesterone - keeps the corpus luteum active to support the pregnancy (make it keep secreting progesterone)
19
Q
where in the brain does the whole menstrual process start?
A
hypothalamus and pituitary
20
Q
elevated TRH stimulates the pituitary gland to produce what?
A
prolactin
21
Q
what does prolactin do? what’s the result?
A
prolactin inhibits GnRH -> shuts off whole HPO axis, so no menstruation
22
Q
what is menarche?
A
first menstruation
23
Q
mean age of menarches? abnormal ages?
A
12-13 y/o (abnormal if < 8 or > 15 y/o)
24
Q
what pubertal changes come before menarche by 2-3 years?
A
growth/height spurt, breast development (thelarche) and pubic hair development (pubarche)
25
what is average cycle length? normal cycle length? abnormal cycle length?
average cycle length = 28 days
normal cycle length = 21-35 days
abnormal cycle length = <21 or >35 days
26
what is average duration of menstrual cycle? normal duration? abnormal duration?
average duration of cycle = 4 days
normal duration of cycle = 1-8 days
abnormal duration of cycle = >8 days
27
what is average blood loss during menstruation? normal blood loss? abnormal blood loss?
average blood loss = 35ml
normal blood loss = 20-80ml
abnormal blood loss = >80ml
28
what is menorrhagia?
Abnormally heavy bleeding at regular intervals (ex: 1-2 pads an hours)
-Regular periods, but are very heavy
29
what is metrorrhagia?
Bleeding at irregular intervals
| -Menses not every 28 days
30
what is polymenorrhea?
< 21 day cycle intervals -> short cycle intervals
31
what is oligomenorrhea?
>35 day cycle intervals -> long cycle intervals
32
what is hypomenorrhea?
Extremely light menstrual flow
33
what is Mittelschmerz?
Ovulation or mid-cycle pain
34
what are the 2 phases of the ovarian cycle?
(1) follicular phase (Correspond to the proliferative phase of the uterine cycle)
(2) luteal phase (Corresponds to the secretory phase of the ovarian cycle)
35
what are the 2 phases of the uterine (endometrial) cycle?
(1) proliferative phase (corresponds to follicular phase of ovarian cycle)
(2) secretory phase (corresponds to the luteal phase of the ovarian cycle)
36
what is the length of the follicular phase? what is occurring in it?
Follicular phase can vary in length of days í first 14 days, but can be 7 days, 21 days
Follicles and eggs are growing and developing in this phase
37
what is the length of the luteal phase? does it always occur? what forms in luteal phase?
Luteal Phase is ALWAYS 14 days in ovulatory cycle
If no ovulation -> NO LUTEAL PHASE
Corpus luteum forms in luteal phase
38
what are oocytes surrounded by?
granulosa and theca cells
39
what do theca cells contain and what do they produce?
Theca cells contain LH receptors and produce androgens
| -LH from pituitary binds to receptors on theca cells -> produces androgens
40
what do granulosa cells contain and what do they produce?
Granulosa cells contain FSH receptors and produce estrogen as well as convert androgens to estrogens
-FSH is coming from the pituitary -> FSH binds to receptors on granulosa cells and prompts them to produce estrogen and convert androgens to estrogens
41
what is the proliferative phase of the uterine (endometrial) cycle?
1st half
endometrium is growing (proliferating)
estrogen that's produced from the ovaries causes endometrium to thicken
42
what is the secretory phase of the uterine (endometrial) cycle?
2nd half
begins after ovulation
progesterone is produced from the corpus luteum, which halts cell division of the endometrium and causes morphologic changes in the endometrium which stabilize the lining in order to allow the embryo or pregnancy to implant
43
if pregnancy doesn't occur in the secretory phase, what occurs
progesterone levels drop causing the lining to shed
44
what is amenorrhea? what may it result from?
absence of menstruation
may result from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina
45
what is primary amenorrhea?
failure of menarche onset by age 15y in the presence of secondary sex characteristics
OR
13y in the absence of secondary sex characteristics
46
what is secondary amenorrhea?
absence of menses for >3 cycles in women with previously normal menstruation
OR
>6 months in women who have irregular menstrual cycles
47
causes of primary amenorrhea?
gonadal dysgenesis, Mullerian genesis, constitutional delay of puberty, GnRH deficiency, transverse vaginal septum, weight loss/anorexia nervosa, hypopituitarism
48
what is the MOST COMMON cause of secondary amenorrhea?
Pregnancy
49
what is constitutional delay of puberty? common/uncommon in who? dx of what? dysfunction of what?
delay of normal puberty, but have completely normal development, but at a later age
uncommon in females, more common in males
DX OF EXCLUSION
HYPOTHALAMIC DYSFUNCTION
50
what is isolated GnRH deficiency?
HYPOTHALAMIC DYSFUNCTION
congenital lack of GnRH
51
what is functional hypothalamic amenorrhea?
HYPOTHALAMIC DYSFUNCTION
REVERSIBLE
d/t stress, over exercising, anorexia (nutritional deficiencies) -> all of these increase cortisol levels which shuts down secretion of GnRG from hypothalamus -> amenorrhea
52
what causes pituitary dysfunction?
anything that causes an elevated prolactin level
-hyperprolactinemia, prolactinomas, drugs (antipsychotics), stress, breast stimulation, sex, etc.
53
what does prolactin prevent the secretion of?
prolactin prevents the secretion of GnRH -> amenorrhea
54
what diseases cause ovarian dysfunction, thus causing amenorrhea?
Turner syndrome, 46 XY gonadal dysgenesis, primary ovarian insufficiency, ovarian tumors, PCOS
55
what is Turner's syndrome?
45X
missing 1X chromosome
-ovaries replaced with fibrous tissue, but everything else develops normally
56
what is 46XY gonadal dysgenesis? what must they be started on early in life? chance of what later in life?
RARE; 46 XY
Genotypically male karyotype, but the way it is expressed is female phenotype, but gonads are non-functional b/c are fibrous tissue
chance of gonads becomes cancerous later in life
MUST BE STARTED ON HORMONE THERAPY EARLY IN LIFE
57
what is primary ovarian insufficiency?
development of menopause before the age of 50, but pts have a normal karyotype
may have other genetic abnormalities (ex: Fragile X syndrome)
can be caused from chemo, radiation, autoimmune
CAUSES SECONDARY AMENORRHEA
58
what amenorrhea cause primary ovarian insufficiency cause?
secondary amenorrhea
59
ovarian tumors and amenorrhea
rare cause of SECONDARY AMENORRHEA
ovarian tumors that secrete inhibit (gives the negative feedback)
60
what amenorrhea does PCOS cause?
secondary amenorrhea, but most commonly causes oligomenorrhea (long cycles)
ovaries have increased androgen production, which arrests growth of the follicles -> follicular phase isn't followed by a secretory phase
61
sx's of PCOS?
signs of androgen excess, insulin resistance, obesity, facial hair
62
what are the criteria to dx PCOS?
2 out of 3 criteria to dx PCOS:
| -hyperandrogenism, oligomenorrhea or amenorrhea, polycystic ovaries on US
63
what are intrauterine adhesions? what amenorrhea do they cause? caused by what?
i.e. Asherman syndrome
adhesions of the uterus/scarring of lining of uterus (endometrium) - caused by postpartum hemorrhage or infection of endometrium after instrumentation
causes SECONDARY AMENORRHEA
64
what is Mullerian agenesis or Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome?
defect in development of Mullerian
causes PRIMARY AMENORRHEA
- absence/defect in vagina and variable uterine development
- usually no vagina, but may/may not have uterus and if do have uterus it is small
65
what is imperforate hymen?
hymen is still intact and needs to be surgically excised
causes PRIMARY AMENORRHEA
66
what is transverse vaginal septum?
septum b/w hymen and cervix -> structural defect
causes PRIMARY AMENORRHEA
67
labs for amenorrhea?
hCG, FSH (send on cycle day 3 when it's the highest), TSH, Prolactin (PRL), testosterone if indicated
68
primary amenorrhea workup evaluated most efficiently by focusing on the presence or absence of what?
of breast development, uterus, and FSH level
69
when do you do US for primary amenorrhea?
if need to determine whether uterus is present
70
treatment for primary/secondary amenorrhea?
psychological counseling (esp for Mullerian agenesis to see if ready for fake vagina surgery)
surgery may be required in some pts
constitutional delay resolves itself
GnRH deficiency -> give supplement
71
what is dysmenorrhea?
recurrent crampy lower abdominal pain that occurs during menstruation in the absence of pelvic pathology
72
what is dysmenorrhea caused by?
Caused by excess production of endometrial prostaglandin F2 alpha
73
dysmenorrhea signs and sx's? when can it not happen?
diffuse pelvic pain right before or with the onset of menses (cramps last 1-3 days)
CAN'T HAPPEN IN MIDDLE OF MENSTRUAL CYCLE B/C THEN NOT DYSMENORRHEA
74
history of pt for dysmenorrhea?
```
menstrual hx (want full hx)
-age at menarche, duration of cycle, menstrual flow assessment
```
sexual hx
-active? contraception? STIs? PID?
75
physical exam of pt for dysmenorrhea? if have endometriosis where do you have pain?
normal, may have uterine tenderness midline
| if endometriosis pain then have pain in other areas of abdomen
76
FIRST LINE tx for dysmenorrhea?
NSAIDs - ibuprofen, naproxen
-inhibit the prostaglandins
Mefenamic acid if ibuprofen, naproxen don't work
TAKE WITH FOOD
77
2nd line tx for dysmenorrhea?
hormonal OCPs
- can use for first line tx if pt is sexually active
- prevent dysmenorrhea by preventing ovulation
78
what is PMS?
physical, emotional, behavioral, and cognitive symptoms that occur repetitively in the second half of the menstrual cycle, resolve after onset of menses, and interfere with some aspects of the women's life
MUST OCCUR IN THE 5-7 DAYS BEFORE THE ONSET OF MENSES AND BE PRESENT IN AT LEAST 3 CONSECUTIVE MENSTRUAL CYCLES
79
what is PMDD?
severe form of PMS in which symptoms anger, irritability, and internal tension are prominent
Use DSM to help diagnose this
80
pathogenesis of PMS/PMDD?
thought to result from the interaction b/w cyclic changes in ovarian steroids and the functioning of central neurotransmitters
Changes in gonadal steroids during the Luteal phase -> steroids are affecting the functioning of the NTs in the brain
81
signs and sx's of PMS/PMDD?
Must begin during the end of the Luteal phase and subside with the beginning of menses (have sx free period during follicular phase of the menstrual cycle)
affective/behavioral sx's:
-mood swings, angry, irritability, depression, food cravings
physical:
breast tenderness/pain, bloating, constipation, HOT FLASHES
82
what sx is highly suggestive of PMS/PMDD?
HOT FLASHES
83
what is important to assess for PMS/PMDD?
their impact on quality of pts life and suicide risk
PMDD associated with increased risk of suicidal ideation and attempts
84
have PMS/PMDD pts keep what?
a symptom diary for 2 months
85
FIRST LINE tx for PMS/PMDD?
SSRIs
| -can take all the time or only in Luteal phase
86
other meds for PMS/PMDD that aren't first line?
OCPs (2nd line), Benzo's, GnRH agonist with low-dose estrogen-progestin replacement (3rd line), surgery (4th line)
87
what is dysfunctional uterine bleeding?
Abnormal uterine bleeding unrelated to anatomical lesions of the uterus, pelvic pathology, pregnancy, or systemic disease -> usually caused by a problem with the HPO axis
88
key component to evaluation of dysfunctional uterine bleeding?
to determine whether ovulation is occurring
89
when does dysfunctional uterine bleeding occur? dx of what?
Commonly occurs after menarche and during perimenopause b/c have more anovulatory cycles on those time
Dx of exclusion
