week 8- gyn 1 Flashcards
• why are gyn exams necessary?
o Assess a problem: Pelvic pain, Vaginal bleeding, Vaginal d/c, etc
o Routine gyn eval: Yearly for women sexually active or >18 (21 for pap)
• What are some pt issues to keep in mind?
o Possible hx sexual abuse, rape o Previous bad experiences w gyn exams o Modesty and shame issues o Fear, sense of helplessness o Fear dz, preg o Denial o Poor body awareness o Sexual orientation – language usage very important
• What are some physician issues?
o Fear causing pain o Personal space issues o Respect for pt o Uninhibited pts o Support role when doing the exam o Confidentiality o Teenagers and their special needs: Mental or sexual (dt sexual abuse), contraception (pt consent as young as 10); Vaccines (15 if pt wants vaccine w/o parent knowledge (HPV is the big one))
• How do you take a gyn hx?
o Establish rapport o Identify primary complaint and get details (concurrent sxs): Pelvic pn, AbN vaginal bleeding, d/c o Menstrual hx o Sexual activity and hx o Possibility of pregnancy, attitudes and contraception (use of) o Hx of preg, outcomes o PMHx, surgery, hospitalization o Psych status: depression, anxiety, drugs o medications, OTC & supplements o ROS o Screen for Domestic Violence o FHx of dz (family member/age of dx)
• What do you need for menstrual hx?
o Age at menarche o Number of days of menses o Length and regularity of interval bw cycles o Last menstrual period (LMP) o Previous menstrual periods (PMP) o Color and volume of flow o Sxs w menses: Cramps, loose stools
• What is a normal menses like? Anovulation?
o N: Blood is medium to dark red, Flow lasts 5 (+/- 2) d, 21-35 d, avg blood loss 30mL (r 13-80), Most bleeding on 2nd d, Saturated pad or tampon absorbs 5-15mL, Cramping is common day before and 1st day
o A: mb vaginal bleeding, pnless, scant, dark, abn brief or prolonged, irregular
• What do you ask about sexual activity and hx?
o Freq
o # sexual partners
o Participation in unsafe sex
o Effects of sexual activity (pleasure, orgasm, dyspareunia)
o Orientation
o Types: vaginal, anal, oral, sex toys, etc.
• What do you ask about pregnancy and contraception?
o Possibility of pregnancy, along with attitudes and contraception (use of)
o Symptoms of pregnancy
o Morning sickness, breast tenderness, delayed menses
o History of pregnancy and outcomes
o Contraception: hx (why d/c certain types), currently using, Length of time used
• What ROS do you ask in gyn exam?
o GI sxs o Urinary sxs o Breast problems o Endocrine status o Bleeding hx (clotting issues, anemia) o Sxs of pelvic pain: location, duration, character, quality, triggering and relieving factors o Abn vaginal bleeding: quantity, duration, relation to cycle o Cardiac status
• How do you screen for domestic violence?
o Questionnaires and interview; Look for: o Inconsistent explanations for injuries o Delay in seeking tx for injuries o Unusual somatic complaints o Psychiatric sxs o Frequent ER visits o Head and neck injuries o Having given birth to low birth weight infants
• What FHX of dz do you ask for in gyn exam?
o family member/age of diagnosis
o CVD, DM, Breast CA, Other CA
o Osteoporosis, Endometriosis, PCOS, Infertility
• How do you begin the gyn exam?
o letting pt know what to expect, exams performed, she can let you know at any point if pain
o empty bladder prior
o Vitals, ht & wt, waist circumference
o Heart, lung, LN (cervical), Thyroid exams
o complete CBE; check axillary and clavicular LN
o Abd exam
o Pelvic exam: external inspection, speculum exam & specimen collection, bimanual, rectovaginal exam (in certain circumstances and at 40 annually)
• How do you do the external genital exam?
o LN: inguinal
o Hair (distribution, lesions, folliculitis, lice)
o Clitoral size
o Vulva and perineum (lesions, masses, swelling, excoriations, erythematous changes, AbN pigmentation)
o Vestibule
o AbN pigmentation
o D/c
o Inflammation and patency of introitus
o Rectocele (posterior bulge on bear down)
o Cystocele (anterior bulge on bear down)
o Optional: palpate bartholin & skene’s glands
o Palpate pelvic floor w lubed, gloved index finger: “squeeze as if stopping urine”, assess strength
• How is the speculum exam done?
o warm and lubricate speculum
o Insert, w downward pressure, slowly move forward, path of vagina (away from urethra, causes pain)
o fully inserted before opening blades (cervices are in all different positions!)
o Inspect: cervical changes, polyps, mucosal atrophy, tumors, cysts, masses, vaginal wall ruggae, bleeding, d/c (quantify & describe)
o collect pH, wet prep, culture, GC/CT, pap smear for cellular health and HPV DNA (if appropriate)
o Remove, don’t pinch cervix, allow blades to close, don’t press against urethra
• What are normal speculum exam findings?
o Cervix is pink, shiny, clear/white d/c, no masses, lesions
o Vagina has appropriate ruggae for her age, no masses, lesions
• How is the bimanual exam done?
o Insert lubed middle and index finger of dominant hand
o move cervix side to side, assess for cervical motion tenderness (CMT)
o move it up & down, assess for uterine mobility (should move some, not excessively or be fixed)
o Move your fingers under cervix, Top hand just above pubic symphysis, gently presses down to assess uterus (position, size, shape, consistency, mobility, tenderness)
o Adnexal structures
• What are normal uterus findings in bimanual? Abn w ddx?
o N: Anteverted (mc), anteflexed, retroflexed, retroverted; 6x4cm, Mobile, smooth, NT
o Irregular shape: uterine fibroids or tumor
o Enlargement: pregn, adenomyosis, malignancy, myomas
o Softening (bogginess): preg, malignancy, degenerating myoma, sarcoma, PID
o CMT: PID, ovarian cysts, endometriosis, adhesions
• How do you asses adnexal structures in bimanual?
o Palpate in lateral fornix, top hand gently pushing down, bring internal fingers up to meet the top hand to catch ovary bt them. Mb a bit pnful
o Note size, shape, consistency, mobility, tenderness
o Normal ovary (reproductive age): 3x2x2 cm
o Menopausal: 1x0.7x0.5 cm
• How is a rectovaginal exam done?
o Lubed index finger vaginally, middle finger rectally
o Assess septum, utero-sacral ligaments, uterus, cul-de-sac, adnexae, cervix
o > 40 y/o or if suspect endometriosis, CA
• What are common tests done in gyn exam?
o Preg: Urine BhCG: sp, ↑ sn, + in 1 wk; Serum qualitative BhCG: more sp, sn; Serum quantitative BhCG: specifically w miscarriages, ectopic pregnancy
o PAP smear: Can add on HPV DNA to liquid Paps, GC/CT, may detect uterine CA
o Wet Prep: Micro exam of vaginal secretions, identify infx (trich, BV, yeast, etc)
o Cervical Mucus Inspection: infertility, assess crystallization (Ferning), reflects levels of circulating estrogens
o Genital Culture: identify bacteria and fungus
o DNA probes or Urine Aptima test: For GC/CT
o pH of cervical secretions: Normal 3.5-4.5
o Other STI testing: Herpes (Viral PCR from lesion, Serum IgG HSV 1 & 2), HIV blood test, RPR for syphilis (serum), Hep B & C (serum)
• What imaging may be done w gyn exam?
o US mc for suspicion of masses; transvaginal (TVUS) and abd are mc
o MRI/CT less often
• What surgical procedures may be done with gyn exam?
o Laparoscopy: exploration of dz process & tx at same time
o Endometrial Bx (EMB): In office, unexplained vaginal bleeding, thickened endometrium on TVUS
o Colposcopy
o Vulvar Bx
o Hysteroscopy
• What is etio of a pelvic mass (mb found on routine gyn exam)? Hx?
o mb from gyn organs: cx, uterus, adnexae
o other pelvic organs: intestine, bladder, ureters, skeletal mm, bone
o PMHx, Complete gyn hx, menstrual hx, pelvic pain, irregular bleeding
o vaginal bleeding and pelvic pain suggest ectopic pregnancy
o dysmenorrhea suggests endometriosis/adenomyosis, uterine fibroids
• What are the types of pelvic masses, by age group?
o In utero: adnexal cysts dt maternal hormones (rare)
o Puberty: hematocolpos: accum menstrual blood forms vag mass dt obstruction (imperforate hymen, congenital malformations of uterus, cx, vagina)
o Reproductive age: preg, myoma, functional ovarian cysts, ectopic preg, benign teratoma, Hydrosalpinges, endometrioma
o Postmenopausal: more likely to be cancerous
• What PE, labs, imaging is done for a pelvic mass?
o PE: Vitals, Thyroid, Abd, Complete gyn
o TVUS
o CT/MRI: if TVUS doesn’t clearly identify size, location, consistency
o Bx, tumor markers: if masses have characteristics of CA
o Preg test: women of reproductive age
• What is pelvic pain? Common menstrual causes, ssx, dx?
o Common complaint, many causes, gyn or non-gyn organs, st unknown etio
o Dysmenorrhea: Sharp, cramping pn before or onset menses, h/a, N/D, constipation, urinary frequency; clinical eval
o Endometriosis: Sharp, cramping pn in early menses, dysmenorrhea, dyspareunia, painful defecation, eventual pn unrelated to menses, adv st uterine retroversion, tender, ↓mobility; clinical eval, st laparoscopy
o S/t a fixed pelvic mass (possibly an endometrioma) or tender nodules noted during bimanual and rectovaginal exam
o Mittelschmerz: Sudden severe, sharp pain, intense onset, 1-2 d, light, spotty vaginal bleeding; mid-cycle (ovulation), dt mild, brief peritoneal irritation dt ruptured follicular cyst; clinical eval, dx of exclusion
• What are some causes of pelvic pain, unrelated to menstrual cycle?
o PID, Ruptured ovarian cyst, Ruptured ectopic preg, Acute degeneration of uterine fibroid, Adnexal torsion, Adhesions, Uterine or ovarian CA, Spontaneous abortion (SAB)
• What is PID? Ruptured ovarian cyst?
o PID: Gradual onset BL pelvic pn, tender, mucopurulent cx/vag d/c, fever, dysuria, dyspareunia, CMT, adnexal, fundal tenderness; Rarely, an adnexal mass (abscess); Clinical eval, cx culture, st TVUS (if suspect abscess)
o ROC: Sudden onset pn, severe at onset, rapidly ↓ in hours, st slight vaginal bleeding, N/V, peritoneal signs, mb syncope or hemorrhagic shock; Clinical eval, st TVUS
• What is ruptured ectopic pg? acute degeneration of uterine fibroid?
o REP: Sudden onset localized, constant (no cramping) pn, vaginal bleeding, st syncope, hemorrhagic shock, Closed os, st acute abddistension, tender adnexal mass; Quant BhCG, TVUS, st laparoscopy, laparotomy
o Aduf: Sudden onset pn, vaginal bleeding, mc during 1st tri or after delivery, termination of pg; TVUS
• What is adnexal torsion (ddx)? Adhesions?
o AT: Sudden onset severe, unilat pn, colic (intermittent torsion), N/V (in sec-min), peritoneal signs, CMT, risk factors (pg, induced ovulation, ovarian enlarg >4cm); TVUS w color Doppler flow studies, st laparoscopy, laparotomy; ddx renal colic
o A: Gradual onset pelvic pn (→chronic) or dyspareunia, after abd surgery or pelvic infx, No vaginal bleeding or d/c, st N/V (suggest intestinal obstruction); Clinical eval, Dx of exclusion, st abd obstruction series (flat and upright abd x-rays)
• What is uterine or ovarian CA? spontaneous abortion (SAB)?
o CA: Gradual onset pain, vag d/c →AbN vag bleeding (pm bleeding, pre-menopausal recurrent metrorrhagia), Rarely, a palpable pelvic mass; TVUS, bx
o SAB: Vag bleeding, cramping low abd pn, back pain in early pg, breast tender, N, delayed menses; Clinical eval, pg test, TVUS to assess viability of pg, Quant BhCG
• what may have tender adnexal mass or CMT?
o Ectopic pregnancy, PID, ovarian cyst or tumor, or adnexal torsion
• In bimanual, what is ddx of uterine fixation? Tender anterior vag wall?
o Adhesions, endometriosis, or late-stage cancer
o Bladder or urethral pain dt lower urinary tract disorder
• What ssx indicate appendicitis, GI do, diverticulitis?
o A: N →anorexia, fever, right sided pain
o GI: Constipation, diarrhea, relief or worsening of pain w defecation; Gross or microscopic rectal blood
o D: LLQ pain in women > 40
• What are ssx of peritonitis? Causes?
o Generalized abd tenderness or peritoneal signs
o appendicitis, diverticulitis, GI do, PID, adnexal torsion, ruptured ovarian cyst or ectopic preg
• what is ddx of tender pubic bone in parous women?
o particularly if pain occurs during ambulation
o Diastasis of pubic symphysis
o ≥ 1cm on any imaging, occurs w preg, worse touch, movement, esp lifting leg
• How do you ddx perirectal abscess, severe endometriosis, late stage cx CA?
o abscess: Painful defecation, localized tender mass on internal or external rectal exam, w or w/o fever
o Other: Chronic painful defecation, localized firm woody mass on rectal; NO fever
• What are emergency situations that may require surgery, w pelvic pn?
o Tubo-ovarian abscess o Ectopic pregnancy o Ruptured or torsion of ovarian cysts o Appendicitis o Bowel perforation
• How do you take hx forpelvic pn?
o Complete gyn, GI, GU, musculoskeletal hx
o HPI: onset, severity, relation to menses, quality, radiation, location, assoc findings
o Concomitants: vag bleeding, d/c; sxs of hemodynamic instability
o Relation to various activities: sleep, vag penetration/intercourse, eating, BMs, urination
o Chronic pelvic pain (CPP): > 6 mos, 25%-40% have hx physical or sexual abuse
o ROS: seek symptoms suggesting possible cause: morning sickness, breast swell/tender, missed menses (pregn); fever, chills, N/V (infx); abd pain, N/V or change in stool habits (GI dos); urinary frequency, urgency, dysuria (Urinary dos)
o PMHx: Infertility, Ectopic preg, PID, Urolithiasis, Diverticulitis, GI/GU CA, abd or pelvic surgery
• What PE is done for pelvic pain cc? red flags?
o Vitals, orthostatic BP (important to determine immediate need for surgery)
o Abd exam, and r/o appendicitis, CVA tenderness
o Pelvic exam, pubic symphysis
o Rectal exam: tenderness, mass or occult blood
o Red Flags: Syncope or hemorrhagic shock, Peritoneal signs (rebound, rigidity, guarding), PM vag bleeding, fever/chills, Sudden, severe pn w N/V, diaphoresis, agitation
• What labs are done for pelvic pn cc?
o UA complete & culture
o Wet prep, genital culture, GC/CT DNA probe
o CBC
o Preg test – if (+) ectopic is assumed → TVUS, quant HCG
o TVUS: if can’t examine pt (pain), or suspect mass → if results indeterminate MRI, CT
o Laparoscop: if cause of severe, persistent pn unidentified
• What are key points to remember w pelvic pain cc?
o Common, mb gyn or non-gyn cause
o Always r/o Preg in women of childbearing age
o Quality, severity, location, relationship to menstrual cycle can suggest the most likely causes
o Dysmenorrhea is common cause of pelvic pain but is a Dx of exclusion
• What is abn vag bleeding? Types?
o prolonged, painful, excessive or irregular bleeding
o Menorrhagia: excessive duration (> 7 d) or amount (> 80 ml) of bleeding
o Polymenorrhea – too frequent menses (less than 21 days)
o Metrorrhagia: unrelated to menses; freq & irregularly bw menses
o Oligomenorrhea: too few periods (> 35 days)
o Amenorrhea: no menses
o PM bleeding: 6 mos (or 12) after LMP needs to be evaluated
• What is etio of abn vag bleeding?
o Most AUB (abnormal uterine bleeding) dt abn hormonal HPO (hyp-pit-ovarian) axis
o Anovulation →no progesterone, unopposed E, stimulation of endometrial glands sloughs irregularly, incompletely, st excessively or > duration
o Mb dt structural, inflammatory, other gyn do (tumors)
o Rarely dt bleeding do (mc adolescents)
• What could cause bleeding in infants, children?
o I: In utero endometrial stimulation by placental estrogens (causing minimal bleeding)
o C: Trauma, vag foreign body w vaginitis, prolapse of urethral meatus, precocious puberty w premature menses; Tumors, sarcoma, botryoides; Cervical adenocarcinoma dt DES exposure; Warts (cx or vag)
• What could cause abn vag bleeding in women of reproductive age?
o W syncope, hemorrhagic shock: Ruptured ectopic preg
o W (+) preg test: Spontaneous complete or incomplete abortion, ectopic preg, gestational trophoblastic dz, endometritis 2nd to retained products of conception
o W (-) preg test: Hormonal: Dysfxn uterine bleeding (mc), brain lesions, contraceptives, hypothyroid, adrenal or ovarian tumors
o Structural: Vag dos: CA, adenosis, trauma, granulomas 2nd to surgery).
o Cervical: CA
o Uterine: adenomyosis, benign invasion of myometrium by endometrium, endometrial polyps, submucous, pedunculated fibroids; st delayed endometritis 2nd to retained products of conception
o Ovarian: tumors
• What could cause vag bleeding in PM women?
o Structural dos of vagina (CA, atrophic vaginitis), cervix (CA, polyps), uterus (endometrial CA, atrophy, hyperplasia [endometrium >5mm], polyps), ovaries (tumors)
• How do you take a hx for abn vag bleeding cc?
o Complete gyn hx
o Sxs of bleeding: quality, duration, quantity (# pads/tampons, size per hr/d), relation to menses and vag penetration, r/o trauma
o Menstrual: date LMP, age menarche/menopause, cycle length/regularity, quantity/duration of typical menstrual bleeding
o Any prior hx AbN bleeding, details
o Sxs of blding do: easy bruising, gingival, excessive w cuts or venipuncture
o Sxs of preg, pelvic pain
o Sxs of hemorrhagic shock: light-headedness, syncope
o Sxs of infx related to: Retained products of conception (POC) or endometritis, recent SAB or TAB w blding, pelvic pain, fever, vag d/c
o PCOS: hirsutism, obesity, hx irregular menses
o CA: Chronic pn, wt loss
o Structural dos: uterine fibroids, endometrial polyps, ovarian cysts
• What are risk factors for endometrial CA?
o Obesity, DM, HTN
o Prolonged unopposed estrogen use
o PCOS
o > 35
• What PE is done for abn vag bleeding? Red flags?
o Vitals, BMI, waist circumference
o Skin: signs of bleeding do, jaundice, hirsutism, acne
o Thyroid exam
o Abdominal exam: look for HSM (liver do)
o Complete gyn exam: Speculum exam (determine if bleeding from vagina, cx, uterus. If no blood → do DRE to r/o GI bld; Bimanual (may palpate mass, tender pelvic mass suggests ruptured ectopic preg or ovarian cyst, NT uterine mass commonly uterine fibroids)
o if pregnant in 3rd tri bimanual exam is C/I as it mb placenta previa)
o RF: Hemorrhagic shock; Premenarchal, pregnant, postmenopausal vag bleeding
• What labs are done for abn vag bleeding cc?
o Preg test: ALL reproductive age women
o CBC: if heavy, > 1 pad/tampon/hr, lasted several d, ssx of anemi, hypovolemia
o Ferritin, iron panel
o Thyroid panel
o Prolactin (w oligomenorrhe, amenorrhea, rarely in other bleeding presentations)
o TVUS : > 35, risk factors for endometrial CA, bleeding continues despite empiric tx); or sonohysterogram (saline infused US): identify submucosal or intracavitary pedunculated myomas, endometrial polyps, endometrial hyperplasia
o EMB: if >35 and TVUS & exam do not detect AbN, risk factors for CA, or TVUS shows thickened endometrium (> 4mm)
o PT & PTT, vWF: if suspect bleed do
o Vulvar bx: if source of bleeding is from vulva
o Pap smear/HPV: r/o cx CA
o If suspect PCOS: serum testosterone, DHEAS, fasting glucose/insulin, FSH/LH (day 3 of cycle)
• What are key points to remember w cc of abn vag bleeding?
o Always exclude preg in women of reproductive age even when hx does not suggest it
o DUB (dysfunctional): mc cause of AUB during reproductive years
o Vaginitis, foreign bodies, trauma, sexual abuse are common causes before menarche
o PM needs further eval to r/o CA
• What is Tanner staging?
o Stage I: prepubertal
o Stage II: palpable subareolar breast buds, presexual pubic hairs, short, light, straight & not obvious on exam at 1st
o Stage III: enlargement & elevation of whole breast, sexual pubic hairs – long, dark, curly, & appearing on labia majora
o Stage IV: areolar mounding (transient), progression of pubic hair on pubis, but not to medial surface of thighs.
o Stage V – attainment of mature breast contour, progression to mature female escutcheon (inverted triangle pattern)
• What mechanisms initiate puberty?
o Childhood: a state of GnRH deficiency dt CNS restraint dev in infancy
o Pubertal gonadotropin secretion is diarunal, sleep-assoc onset, cyclic in girls from beginning LH more predictive of pubertal maturation of neuroendocrine sys than FSH
o CNS permits pubertal GnRH & gonadotropin production when a certain somatic (skeletal) maturity is reached – more so than chronological age
o Adrenarche= ↑ production of DHEA and DHEAS, several yrs before puberty (sex hair growth)
• What are relative hormone levels throughout life stages?
o Birth: LH and FSH very high
o Childhood: LH and FSH very low; very sensitive to low E → neg feedback
o Puberty: less sensitive, ↑E, T → growth, sex characterisitics
o After menopause: E and inhibin ↓ → ↑FSH, LH dt lack of feedback from P
• What is role of GnRH? Downstream effects of LH, FSH, E, P?
o produced in the hypothalamus, Stimulates pituitary production of FSH and LH
o FSH and LH → stimulate ovarian follicles to produce E and P
o Ovulation occurs after midcycle surge of LH
o E and P exert both positive and negative feedback control on the pituitary and HTH
o Hormones are produced in roughly hourly pulses
• What happens in ovarian follicular development?
o At birth there is a finite number of eggs
o After the fourth month of gestation oocytes are lost through atresia
o During each menstrual cycle 3-30 follicles are recruited, only 1 grows for ovulation
o dominant follicle releases its oocyte for ovulation and promotes atresia of other recruited follicles
• why does LH surge happen right before ovulation?
o follicles produce E (estradiol, E2) (from granulosa cells) suppresses FSH slightly but not LH, surges right before ovulation
• what are the menstrual cycle phases of the ovary?
o Follicular phase (Day 1-14): during menses E and P are low, lack of feedback allows FSH and LH to rise, stimulates follicles
o Ovulation Phase: begins making P=thermognic, BBT ↑ after ovulation
o Luteal Phase (Day 15-28): wo implantation corpus luteum collapses → discontinuation of progesterone. Estrogen also declines, menstruation begins
• What does the endometrium consist of?
o glands and stroma; basal, intermediate spongiosa, and layer of compact epithelial cells line uterine cavity
o Functionalis: transient layer, sloughed during menses, composed of spongiosa and epithelial layers
o After menstruation, generally < 2mm thick
• What are the 2 phases of the endometrium?
o Proliferative (follicular): E → proliferation, vascularization; fertile cx mucus from endocervical columnar cells, ↑ pH nice place for sperm; EM max thickness of 11mm late in follicular phase; **if >11mm, that is too thick, would suggest hyperproliferative o Secretory: luteal phase of ovary; Secretory glands develop, stabilize EM, Thickening cx mucus; necessary for embryonic implantation; ↑ to 14mm thick, right before menses; After ovulation: cervical mucus gets thick and white = plug; to keep everything inside uterus, nothing else can get in; Flora in vagina: normally, predominantly lactobacillus, keeps vagina safe
• What are vaginal changes throughout cycle?
o Early follicular phase: vag epithelium thin and pale
o Late follicular: w E ↑, vag epithelium thickening
o Luteal phase: shed ature squamous cells
• What additional hormones are produced in the ovary, and when are they seen?
o In stroma: androgens, precursors, androstenedione, testosterone, dehydroeiandrosterone (DHEA); Stromal hypertrophy in dz like PCOS w a hyperandrogen state & menstrual dysfxn o 3 types of estrogen: E1, E2, E3 o Estrone (E1): ↑ in menopause, persists after menopause in small amounts via conversion of androstenediol in fat & muscle cells o Estradiol (E2): ↑ in childbearing years, produced by ovary follicles o Estriol (E3): ↑ in preg, produced by placenta, also a liver breakdown product of E1 & E2
• Describe a normal menstrual cycle? Age of menarche?
o Day 1: bleeding starts; interval 28 +/- 3 days for 65% of women
o Normal range 21-35 day cycle, longer in puberty & perimenopause
o Avg duration bleeding: 5 days +/- 2
o Blood loss average: 30 mL (13-80), usu greatest on day 2
o Usu no clot, dt fibrinolysin & other fxs inhibiting clotting
o Menarche: average age of onset 12.5 years in US (range 12-15)
• What is needed for normal periods to occur?
o Healthy hypothalamus, needs routine, regularity: food, sleep, stress management
o Pulsatile discharge of LH and FSH
o Ovary capable of responding with appropriate E and P production
o Normal levels of other hormones: thyroid, prolactin, androgens
o Anatomically correct and responsive reproductive organs (Uterus)
