Women's Health / Vaginal Bleeding and Dysmenorrhea Flashcards
In a normal ovulatory cycle, Cycle length is between ….
24 and 35 days
In a normal ovulatory cycle Menses last for….
2 to 7 days
In a normal ovulatory cycle blood loss is ……(volume)
less than 80 mL per cycle (5 tablespoons)
Define Menorrhagia
Excessive or prolonged bleeding that occurs at normal intervals, blood loss is greater than 80 mL per cycle, periods last for more than 7 days
Define Oligomenorrhea
Menstrual periods that occur at intervals greater than 35 days
Define Amenorrhea
Absence of bleeding for at least three usual cycles
Define Polymenorrhea
Bleeding that occurs at intervals less than 24 days
Define Menometrorrhagia
Bleeding at irregular intervals with heavy flow (>80 mL) or prolonged duration (>7 days)
Define Intermenstrual bleeding
Bleeding that occurs between menses
Define Postcoital bleeding
Vaginal bleeding within 24 hrs of vaginal intercourse
What term is used to describe bleeding from the uterus that falls outside the normal ovulatory criteria?
- Abnormal uterine bleeding (AUB).
- Physician visits for AUB commonly occur in the first 3 years following menarche or in the perimenopausal period.
Besides obtaining a detailed history and physical, what is the first step in evaluating AUB in a woman of childbearing age?
Determine pregnancy status
What are common causes of abnormal genital tract bleeding within the first 3 years following menarche?
- Anovulation (due to hypothalamic immaturity)
- coagulopathies
- stress (psychologic or exercise-induced)
- pregnancy
- infection (such as cervicitis)
What are common causes of abnormal genital tract bleeding during the reproductive years?
- anovulation
- pregnancy
- cancer (eg, endometrial or cervical)
- polyps (endometrial or cervical)
- leiomyomas
- adenomyosis (endometrium within the myometrium)
- infection (cervicitis, endometritis)
- endocrine dysfunction (eg, polycystic ovary syndrome [PCOS], thyroid disease, pituitary adenomas)
- coagulopathies
- medications (oral contraceptives)
- trauma
What are common causes of abnormal genital tract bleeding during perimenopause?
- anovulation
- polyps
- leiomyomas
- adenomyosis
- cancer
What are common causes of abnormal genital tract bleeding in postmenopausal women?
- atrophy
- polyps
- cancer
- endometrial hyperplasia
- medications (hormone replacement therapy)
What are signs and symptoms of ovulation?
- Thin vaginal discharge at mid-cycle andpremenstrual symptoms such as
- breast tenderness, bloating, and pelvic pain
What occurs to the endometrial lining during anovulatory bleeding?
Progesterone is produced by a corpus luteum after ovulation, and declining progesterone, in the absence of embryo implantation, contributes to cyclic menses. Without ovulation, estrogen, unopposed by progesterone, causes the endometrial lining to proliferate. Ultimately, the thickened endometrium outgrows its blood supply and undergoes partial shedding.
What is dysfunctional uterine bleeding?
Abnormal uterine bleeding in the absence of an anatomical lesion, systemic disease, or pregnancy; it is commonly secondary to anovulation
Which causes of AUB can be diagnosed using Pap smear?
Cervical cancer
Which causes of AUB can be diagnosed using Endometrial biopsy?
Endometrial cancer or hyperplasia
Which causes of AUB can be diagnosed using Pelvic ultrasound?
Leiomyomas
What causes of AUB can be diagnosed by TSH and free T4 testing?
Hyperthyroidism and hypothyroidsm
What causes of AUB can be diagnosed by Platelets, PT, and aPTT testing?
Coagulopathies
What causes of AUB can be diagnosed by Protactin testing?
Hyperprolactinemia, which can cause oligomenorrhea and galactorrhea
What causes of AUB can be diagnosed byTestosterone and dehydroepiandrosterone sulfate (DHEAS) testing?
PCOS and ovarian or adrenal tumors
What are the medical options for treating menorrhagia in nonpregnant, hemodynamically stable women?
- Treatment of the underlying disorder
- estrogen-progestin contraceptives (with 30-35 mcg of ethinyl estradiol)
- levonorgestrel intrauterine device (reduces blood loss by 74%-97% after 1 year of use),
- NSAIDs (decrease prostaglandin synthesis leading to uterine vasoconstriction)
Your 19-year-old female patient is admitted to the hospital with a hemoglobin of 6.2 and menorrhagia. She has active uterine bleeding but is hemodynamically stable. What hormonal therapies can be used to reduce menstrual flow?
- Combination oral contraceptive pills with 50 mcg of estradiol and 0.5 mg of norgestrel (or 1 mg of norethindrone)
- given every 4 hours until the bleeding decreases
- then four times per day for 4 days
- then three times per day for 3 days
- then two times per day for 2 weeks
Progestin-only pills (norethindrone acetate 5-10 mg or micronized progesterone 200 mg) can be given to patients in whom high dose estrogen is contraindicated
- Itravenous (IV) conjugated equine estrogen (25 mg IV every 4-6 hours until the bleeding stops but not exceeding six doses) is typically reserved for unstable patients.
What is dysmenorrhea?
Painful menstruation
What is the differential diagnosis of dysmenorrhea?
- Primary dysmenorrhea
- endometriosis
- adenomyosis
- uterine leiomyomas
- chronic pelvic inflammatory disease
What is primary dysmenorrhea?
- Recurrent, lower abdominal pain occurring during menses without evidence of underlying pelvic pathology
When does primary dysmenorrhea typically begin?
Adolescence (with the prevalence decreasing with age)
What causes primary dysmenorrhea?
Frequent and prolonged uterine contractions from increased prostaglandins leading to myometrial ischemia
What are the clinical manifestations of primary dysmenorrhea?
- midline, suprapubic, crampy pain
- beginning before or with the onset of menses and lasting for 12-72 hours
- only occurs with ovulatory cycles
- can be associated with malaise, fatigue, and headache
What can be used to treat primary dysmenorrhea?
- heat to the lower abdomen
- nonsteroidal anti-inflammatories (which inhibit prostaglandin synthesis)
- combination oral contraceptives
