Women's Health / Vaginal Bleeding and Dysmenorrhea

Question 1

In a normal ovulatory cycle, Cycle length is between ….

Answer 1

24 and 35 days

Question 2

In a normal ovulatory cycle Menses last for….

Answer 2

2 to 7 days

Question 3

In a normal ovulatory cycle blood loss is ……(volume)

Answer 3

less than 80 mL per cycle (5 tablespoons)

Question 4

Define Menorrhagia

Answer 4

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

Question 5

Define Oligomenorrhea

Answer 5

Menstrual periods that occur at intervals greater than 35 days

Question 6

Define Amenorrhea

Answer 6

Absence of bleeding for at least three usual cycles

Question 7

Define Polymenorrhea

Answer 7

Bleeding that occurs at intervals less than 24 days

Question 8

Define Menometrorrhagia

Answer 8

Bleeding at irregular intervals with heavy flow (>80 mL) or prolonged duration (>7 days)

Question 9

Define Intermenstrual bleeding

Answer 9

Bleeding that occurs between menses

Question 10

Define Postcoital bleeding

Answer 10

Vaginal bleeding within 24 hrs of vaginal intercourse

Question 11

What term is used to describe bleeding from the uterus that falls outside the normal ovulatory criteria?

Answer 11

• Abnormal uterine bleeding (AUB).
• Physician visits for AUB commonly occur in the first 3 years following menarche or in the perimenopausal period.

Question 12

Besides obtaining a detailed history and physical, what is the first step in evaluating AUB in a woman of childbearing age?

Answer 12

Determine pregnancy status

Question 13

What are common causes of abnormal genital tract bleeding within the first 3 years following menarche?

Answer 13

• Anovulation (due to hypothalamic immaturity)
• coagulopathies
• stress (psychologic or exercise-induced)
• pregnancy
• infection (such as cervicitis)

Question 14

What are common causes of abnormal genital tract bleeding during the reproductive years?

Answer 14

• 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

Question 15

What are common causes of abnormal genital tract bleeding during perimenopause?

Answer 15

• anovulation
• polyps
• leiomyomas
• adenomyosis
• cancer

Question 16

What are common causes of abnormal genital tract bleeding in postmenopausal women?

Answer 16

• atrophy
• polyps
• cancer
• endometrial hyperplasia
• medications (hormone replacement therapy)

Question 17

What are signs and symptoms of ovulation?

Answer 17

• Thin vaginal discharge at mid-cycle andpremenstrual symptoms such as
  
  • breast tenderness, bloating, and pelvic pain

Question 18

What occurs to the endometrial lining during anovulatory bleeding?

Answer 18

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.

Question 19

What is dysfunctional uterine bleeding?

Answer 19

Abnormal uterine bleeding in the absence of an anatomical lesion, systemic disease, or pregnancy; it is commonly secondary to anovulation

Question 20

Which causes of AUB can be diagnosed using Pap smear?

Answer 20

Cervical cancer

Question 21

Which causes of AUB can be diagnosed using Endometrial biopsy?

Answer 21

Endometrial cancer or hyperplasia

Question 22

Which causes of AUB can be diagnosed using Pelvic ultrasound?

Answer 22

Leiomyomas

Question 23

What causes of AUB can be diagnosed by TSH and free T4 testing?

Answer 23

Hyperthyroidism and hypothyroidsm

Question 24

What causes of AUB can be diagnosed by Platelets, PT, and aPTT testing?

Answer 24

Coagulopathies

Question 25

What causes of AUB can be diagnosed by Protactin testing?

Answer 25

Hyperprolactinemia, which can cause oligomenorrhea and galactorrhea

Question 26

What causes of AUB can be diagnosed byTestosterone and dehydroepiandrosterone sulfate (DHEAS) testing?

Answer 26

PCOS and ovarian or adrenal tumors

Question 27

What are the medical options for treating menorrhagia in nonpregnant, hemodynamically stable women?

Answer 27

• 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)

Question 28

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?

Answer 28

• 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.

Question 29

What is dysmenorrhea?

Answer 29

Painful menstruation

Question 30

What is the differential diagnosis of dysmenorrhea?

Answer 30

• Primary dysmenorrhea
• endometriosis
• adenomyosis
• uterine leiomyomas
• chronic pelvic inflammatory disease

Question 31

What is primary dysmenorrhea?

Answer 31

• Recurrent, lower abdominal pain occurring during menses without evidence of underlying pelvic pathology

Question 32

When does primary dysmenorrhea typically begin?

Answer 32

Adolescence (with the prevalence decreasing with age)

Question 33

What causes primary dysmenorrhea?

Answer 33

Frequent and prolonged uterine contractions from increased prostaglandins leading to myometrial ischemia

Question 34

What are the clinical manifestations of primary dysmenorrhea?

Answer 34

• 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

Question 35

What can be used to treat primary dysmenorrhea?

Answer 35

• heat to the lower abdomen
• nonsteroidal anti-inflammatories (which inhibit prostaglandin synthesis)
• combination oral contraceptives