Week 1- The Menstrual Cycle Flashcards
What does the HPA axis stand for?
Hypothalamus pituitary ovarian loop
The function of the HPA axis is important for:
Ovulation and menstrual cycle regulation
The HPA axis system is regulated by what kind of system?
Positive and negative feed-back loops
Hormones that are produced to regulate the menstrual cycle start at the ____ which releases what?
Hypothalamus
GnRH
When GnRH is released from the hypothalamus what happens next?
It tells the anterior pituitary to secrete FSH and LH
When the anterior pituitary secretes FSH and LH, this tells what to secret what?
Ovaries
Estrogen and progesterone
FSH stimulates the ovaries to release:
Estrogen
When a woman ovulates, what is stimulated to be produced?
LH
The LH allows the follicle/egg to ___ which in turn allows for ___.
Rupture
Ovulation
If pregnancy/ conception does not occur, and the egg does not become fertilized, what happens? What hormone is secreted as a result?
Produces the corpus luteum
Progesterone
What happens when the corpus let run degenerates completely?
Progesterone is withdrawn and there is a withdrawal bleed
What starts the menstrual cycle?
Progesterone withdrawal
In a woman with AUB, what are the minor causes?
Stress
Nutritional deficiencies
Too frequent cycles are called what and these cycles are closer than every ___ days.
Hypermenorrhea or polymenorrhea
24
Periods that are infrequent are called what and are how far apart?
Oligomenorrhea
38 days
How many days are considered a normal cycle?
24-38
Normal menstrual flow last how long?
4-8 days
Normal menstrual flow volume is:
5-80ml
Average= 30-35ml
Menorrhagia is flow greater than:
80ml
What is the term for heavy or prolonged periods?
Menorrhagia
What is the term for periods that irregular?
Metorrhagia- t stands for trouble regulating periods
What is a condition that presents as endometrial overgrowth glandular tissue that you may see protruding from outside of the cervix or higher up in the uterus seen on an ultrasound?
Polyp
What is the difference between primary and secondary dysmenorrhea?
Primary- starts within the first couple years of menarche and happens most of their life (starts in younger women)
Secondary is a pathologic condition like endometriosis, adenomyosis, fibroids, and is a sudden onset after not having painful periods.
Are we more concerned with primary or secondary dysmenorrhea?
Secondary
If a woman complains of dysmenorrhea, what is important in the subjective history?
Gynecologic history Menstrual history Contraceptive history Social-abuse-somatic symptoms Diet Stress
Why is getting the contraceptive history important in a woman with dysmenorrhea?
IUD or progestin only method?
What is the first line treatment for dysmenorrhea?
NSAIDS- decrease prostaglandin secretion that causes pain
COC
How does COC help with dysmenorrhea?
Suppresses ovulation- decreases pain due to decrease in hormone influence on the ovaries
Patient is sexually active with heavy menstrual bleeding, primary dysmenorrhea, work-up for heavy bleeding. What are you concerned about with a 19-year-old?
1st r/o pregnancy
STD- speculum or urine- gonorrhea and chlamydia
Look for cervicitis
R/o anemia
What if a patient comes in for a work-up for heavy bleeding and it’s day 10 of heavy bleeding. What can we do in the office that day to help with acute heavy bleeding?
High dose of COC-monophasic- double up 1 pill BID until bleeding slows down or progestin
What do you give for estrogen therapy for acute bleeding i.e. long heavy menstrual flow?
Conjugated equine estrogen (CEE) 2.5 mg PO QID for 2-3 days and then add medroxyprogesterone acetate (MPA) provera 10mg for 10-14 days while continuing CEE.
COCs 2-3 times a day and then taper
What do you give for progestin therapy for acute bleeding i.e. long heavy menstrual flow?
All of the following for 3 weeks then once a day for 7-10days
- Medroxyprogesterone acetate 10-20mg BID
- Megestrol 20-40 mg BID
- Norethindrone 5 mg BID
If sexually active with heavy bleeding what’s the first thing you r/o?
- Pregnancy
- Cervicitis
- STIs
- Coagulation problems- Von Wildebrands
What age does secondary dysmenorrhea start?
30 and older
Which dysmenorrhea do you look at PALM COIEN for?
Secondary
What do you look at besides the waist down if someone is having irregular bleeding?
Thyroid gland- hypothyroidism can cause heavy or irregular bleeding
Pituitary gland
Bruising- coagulation disorder
Woman on 3rd day of menses and has fever and rash. What is going on?
TSS
If a woman has malaise, fever, rash on period, what would you suspect?
TSS
Main organism what causes TSS?
Staph aureus
What items can cause TSS?
High absorbency tampons
Diaphragm- not changing like should
What do you do if a patient comes in with TSS?
Send to ED- need IV antibiotics and hydration
What’s the difference between PMS and PMDD?
PMS is more mild and ends with end of menstruation
PMDD severely impairs daily function
What part of the cycle does PMS and PMDD occur?
PMS- ovulatory to Luteal phase second half
PMDD- ovulatory to luteal phase second half
If a woman has PMS symptoms and it does not end with the luteal phase, what is it?
Depression
How do you treat PMDD?
COC suppress ovulation- NOT progestin only
Zaz
SSRI begin day 14 (luteal phase)
Paxil, Prozac, Zoloft
Acupuncture, vitamin b6 and calcium, stress reduction
What is PALM COIEN?
Polys Adenomyosis Lyemyoma Malignancy Coagulopathy Ovulatory dysfunction Iatrogenic Endometrial abnormalities Not yet classified
A 40 year old female presents with irregular vaginal bleeding after a history of regular menses, besides palm coien what would you look at?
Thyroid- TSH, FSH
Could be premenopausal
CBC
R/o cancer
What do you want to r/o in thin women with no menses?
Eating disorders, dehydration, signs of vomiting
What do you look for in a breast exam with a woman not having periods?
Tenders- r/o pregnancy
Gylacteria-discharge
What test do you order if a women is having gylacteria?
Prolactin level- could be a tumor
If a woman has gylacteria with a HA, they could have what?
Pituitary tumor- adenoma
What do you order if the prolactin level is up?
MRI of the head or CT to look at the pituitary gland for tumor- can happen with secondary amenorrhea
What other labs might you order for a 30 year old female with a BMI of 17 who reports no menses in 5 months?
FSH, LH, r/o premature menopause
In PCOS, what would the FSH and LH look like?
Elevated
What are some causes of amenorrhea?
PCOS Malnutrition Hyperprolactinemia Cushing syndrome Congenital adrenal hyperplasia
Are you more concerned with primary or secondary amenorrhea?
Primary
What is considered primary amenorrhea?
No period by 16 regardless of sex characteristics
No menses by 14 and absence of sex characteristics
What is considered secondary amenorrhea?
Had period before then stopped for 3 cycles or 6 months
What do we work up in someone with primary amenorrhea?
Thyroid- TSH
Pituitary- FSH, LH
Outflow problems- obstruction for blood to come out
Asherman syndrome-scarring
If a women has amenorrhea, what is a good test to perform to see if it’s and outflow tract problem?
Progesterone challenge
How do you perform a progesterone challenge?
10 mg of progesterone- provera for 10 days
What is a positive progesterone test? What does it indicate?
Bleeding
No outflow problem
What do you do if they don’t bleed?
Send to endo
22 year old overweight female presents with irregular menses and excessive facial hair, what does she have?
PCOS
PCOS causes menstrual irregularities due to the:
Hyperandrogens that affect the lining of the uterus and puts the woman into estrogen excess
What tests do you conduct to diagnose PCOS?
Diagnosis of exclusion
What do you r/o to conclude diagnosis of PCOS?
Cushing syndrome
Congenital adrenal hyperplasia
Adrenal secreting tumors
Hyperprolactemia
You can diagnose PCOS if you r/o what with what symptoms?
Androgen secreting syndrome
Irregular periods
Androgen excess symptoms like excessive hair growth or acne or hirutism
Women with PCOS can be at increased risk for what kinds of conditions?
DM2
CV dx- lipid panel
Ovulatory dysfunction- infertility- order HCG
Hyperplasia, uterine CA, they make excessive testosterone and estrogen
If you are worried about PCOS patient being at risk for DM2, what labs do you order?
One of 2 hour fasting glucose
What labs would you want to order if you suspect PCOS?
1-2 hour glucose tolerance test Lipid panel TSH Thyroid level HCG
What is the term for heavy, prolonged menstrual flow?
Menorrhagia
What are the terms for light menstrual flow?
Oligomenorrhea
Hypomenorrhea
What are the terms for frequent menstrual bleeding?
Polymenorrhea
Hypermenorrhea
What is the term for irregular menstrual bleeding?
Metorrhagia
What is the term for irregular, heavy menstrual bleeding?
Metomenorrhagia
Any post-menopausal woman with uterine/vaginal bleeding should be considered as having:
Endometrial hyperplasia or endometrial cancer until proven otherwise.
Is a common condition that typically affects women who are multiparous and older than 40 (4-5th decade). It is characterized by a small area of endometrial tissue within the myometrium (burrows deep into the uterine muscle in the uterine wall and is a variant of endometriosis).
Adenomyosis
Commonly occurring benign growths on the cervix that are easily visualized with a speculum, appearing smooth, deep to bright red growths that are fragile and bleed easily.
Endocervical polyp
Are usually benign growths on the endometrium consisting of connective, glandular, or muscular tissue; usually asymptomatic and found of transvaginal US.
Endometrial polyps
What can be given to shrink large endometrial polyps prior to hysteroscopic resection?
GnRH agonists
What may prevent endometrial polyps in high-risk women?
Levonogestrel IUD
These are commonly known as fibroids, and are fibromuscular benign tumors in the myometrium. Most common benign pelvic tumors in women and the leading indication for hysterectomy.
Leiomyomas
What are the most common symptoms of endometrial cancer are:
AUB
Postmenopausal women
What tests should coagulopathy be ruled out with?
PT/PTT/platelet count
This includes amenorrhea as well as light or heavy menses that can be frequent, infrequent, or occurring in regular patterns and is a diagnosis of exclusion.
Ovulatory dysfunction
This usually occurs in predictive and cyclical manner and includes heavy menstrual bleeding. May also present with intermenstrual or prolonged bleeding patterns.
Endometrial AUB
Medications that can cause iatrogenic AUB:
Anticoagulants Digitalis Dilantin Progestin-containing contraceptives Antidepressants
Primary amenorrhea is typically:
Hormonal in nature.
Secondary amenorrhea is typically:
Due to lifestyle
Asherman syndrome causes?
Mechanical obstruction of the endometrium, vagina, or cervix that results in amenorrhea
This occurs after conization of the cervix, LEEP, cryotherapy, and D& C. Scar tissue causes a plug that doesn’t allow bleeding to drain (amenorrhea)
Cervical stenosis
Causes of amenorrhea:
- Disorders of the genital outflow tract
- Disorders of the ovary (PCOS)
- Disorders of the anterior pituitary (hyperprolactemia caused by a prolactin-secreting tumor or hypothyroidism)
- Disorders of the hypothalamus or CNS (due to excessive exercise, grieving, anorexia)
Hypothalamic lesions, tuberculosis, sarcoid, and encephalitis can result in ___ secretion of GnRH and ___ levels of FSH and estrogen causing amenorrhea.
Decreased
Reduced
What medications affect prolactin levels?
Antihypertensives
Psychotropic drugs
H2 blockers
Oral contraceptives
With amenorrhea if the FSH/LH is high it is:
An ovarian problem
In amenorrhea If FSH/LH is low it is:
Pituitary or CNS problem
Normal FSH level:
5-30 IU/L
Normal LH level:
5-20 IU/L
Occurs when ovary becomes resistant to FSH or LH stimulation or lacks sufficient eggs to ovulate?
Ovarian amenorrhea
Related to deficiency of FSH and LH combined hypothalamic and pituitary amenorrhea (central amenorrhea).
Pituitary amenorrhea
A single episode of heavy menstrual bleeding is likely caused by:
Pregnancy
Infection
Chronic, cyclic heavy menstrual bleeding can be managed with:
IUD- levonorgestrel IUD can be used to treat heavy menstrual bleeding
Monophasic OCPs- Low dose OCPs will help stabilize the endometrium and help with heavy bleeding.
Patch or ring
Heavy menstrual bleeding treatment medications include:
- Progestin- Limits endometrial growth and regulates flow- depo May do same
- GnRH agonist- creates a state similar to menopause- May result in bone loss
- NSAIDs- blocks synthesis of prostaglandins
- Danozol- synthetic steroid used to treat endometriosis
For PCOS you must rule out these other causes of hyperandrogenism:
- Androgen-secreting tumors- May cause elevated levels of testosterone
- Adrenal gland tumor- dheas level
- Adult onset non-classical congenital adrenal hyperplasia- accompanied by amenorrhea
- Cushing syndrome- 24 hour urine cortisol
PCOS management:
COCs- suppress enlarged ovaries and inhibit LH secretion and androgen production
Progesterone- LNG-IUD, mini pill, subdermal implant, progestin therapy only
Treating the hirsutism of PCOS:
Antiandrogens in combo with COCs
Spironolactone- inhibits testosterone
Finasteride-reduces DHT and blocks conversion of testosterone
