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Clin Med - Repro > Lecture 4 - Menstrual Probs > Flashcards

Lecture 4 - Menstrual Probs Flashcards

1
Q

Amenorrhea

A

absence of menses

this is a symptom, not a dz

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2
Q

What are the stages of puberty?

A

Thelarche (breast development)
Pubarche (axillary and pubic hair growth)
Accelerated Growth
Menarche (first menses)

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3
Q

Primary Amenorrhea

A

absence of menarche by age 16 in presence of normal pubertal development
OR
absence of menarche by age 14 years in absence of normal pubertal development
OR
absence of menarche 2 years after completion of sexual maturation

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4
Q

When does typical menarche start?

A

11-13 years old

estrogen dependent

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5
Q

How much blood is loss during menstruation?

A

<80mL

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6
Q

What 3 three questions are you aiming to answer when examining a pt with primary amenorrhea?

A

1) Do they have secondary sexual characteristics?
2) Are all reproductive organs present?
3) Is there an obstruction to menstrual flow?

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7
Q

What history is important to ask about in regards to primary amenorrhea?

A

Childhood chemotherapy or radiation exposure

pubertal development
sexual activity
contraceptive use

athletic training
weight change

family hx - when family members started their menarche
autoimmune dz

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8
Q

Which labs should you run for pts with primary amenorrhea?

A 
B-hCG 
FSH (high indicates ovarian failure, low indicates hypothalamus/pituitary disorders) 
Prolactin 
TSH 
Karyotype
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9
Q

What is the most important step in evaluation of amenorrhea?

A

determine by PE or US if uterus is present

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10
Q

Poll everywhere questions

A

go back and panopto

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11
Q

What can cause ovarian failure?

A

Gonadal dysgenesis

Turner’s syndrome

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12
Q

What is the MC cause of primary amenorrhea?

A

Gonadal dysgenesis

decrease in estrogen
increase in LH and FSH

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13
Q

Gonadal Dysgenesis

A 
MC cause of primary amenorrhea
decrease in estrogen 
increase in LH and FSH 
underdeveloped ovaries 
normal internal and external female genitalia

Congenital - Turner’s Syndrome (45 XO)

Acquired - chemo/radiation

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14
Q

Turner’s Syndrome

A

45XO
partial/complete absence of X chromosome
no ovaries-fibrous band of tissues “gonadal streak”
Poor breast development
Primary amenorrhea
short stature, webbed neck, infertility, hear defects (coart of aorta), learning disabilities

dx: karyotype

management: estrogen replacement
cyclic progesterone to induce menses

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15
Q

How do you dx Turner’s syndrome?

A

Karyotype

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16
Q

How do you manage Turner’s syndrome?

A

estrogen replacement

cyclic progesterone to induce menses

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17
Q

Mullerian Ageneiss

A 
Congenital malformation of genital tract 
normal XX karyotype 
no uterus 
shortened vagina 
ovulation occurs
normal hormone levels

management: surgical reconstruction of vagina

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18
Q

AIS

A

androgen insensitivity syndrome

genetically male
testosterone is secreted - target cells lack receptors - no masculizing effects occur

46XY - X linked recessive
lack of androgen receptors
primary amenorrhea with normal breast development
absent uterus, short vagina, +testes present
complete (female external genitalia) vs partial
increase testosterone (to male levels)

tx: remove testes after puberty
estrogen replacement after puberty
gender assignment

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19
Q

What is the treatment for AIS?

A

remove testes after puberty
estrogen replacement after puberty
gender assignment

20
Q

Secondary Amenorrhea

A

Absence of menstruation for at least 3 cycles in pts who previously had regular menstrual cycles
or 6 months in females with irregular cycles

21
Q

What is the MC cause of secondary amenorrhea?

A

PREGNANCY

ovary (40%)
hypothalamus (35%) 
pituitary (7%) 
uterus (7%) 
other (1%)
22
Q

12 x 28 x 6

A

an example of how you document
12 years age of menarche
28 day cycles
6 days of bleeding

23
Q

What drugs of abuse can decrease GnRH?

A

heroin and methadone

24
Q

What are the initial labs you order for secondary amenorrhea?

A 
urine pregnancy test 
TSH 
prolactin 
FSH 
LH 
serum estradiol 
testosterone/DHEA-S (r/o PCOS) 
Pelvic US
25
Q

Progestin withdrawal test

A

Rx Provera 10mg daily for 10 days
estrogen vs ovulation problem –confirms the presence of estrogen

withdrawal bleeding occurs within 2-7 days after completion of meds

you are doing this test for pts with a hx of amenorrhea to determine cause

26
Q

What are the possible results of the progestin challenge?

A

you are doing this test for pts with a hx of amenorrhea

if they bleed after this test then they have normal estrogen levels, normal outflow tract, they are NOT ovulating right

if they don’t have withdrawal bleeding its because they dont have endometrial proliferation d/t estrogen deficiency or outflow tract abnormality

27
Q

Functional hypothalamic amenorrhea

A

no pathology

associated with: 
weight loss 
excessive exercise 
anorexia
stress

Female athlete triad: anorexia, amenorrhea, osteoporosis

tx: manage nutritional status
OCPs

28
Q

What is the treatment for functional hypothalamic amenorrhea?

A

manage nutritional status

OCPS

29
Q

Sheehan Syndrome

A

post partum pituitary necrosis
pituitary cell destruction
severe HTN secondary to massive hemorrhage
pituitary hormones GH, TSH, LH, FSH, ACTH

dx: MRI
Tx: replace pituitary hormones

30
Q

Premature ovarian failure

A

depletion of oocytes <40 y/o
high FST and LH
low estradiol
sx: hot flashes, vaginal dryness

concerns: ischemic heart dz, osteoporosis

tx: HRT
estrogen + progesterone
weight -bearing exercise
calcium and vitamin D supplement

31
Q

Polycystic ovaries

A 
hyperandrogenism 
obese; hirsute 
dx: polycystic ovaries on US 
signs of androgen excess (acne, hirsuitism) 
oligomenorrhea/amenorrhea

tx: OCPs
metformin

32
Q

Asherman Syndrome

A

intrauterine adhesions or fibrosis
most commonly secondary to scarring from pregnancy related D and Cs

dx: hysteroscopy
tx: hysteroscopic lysis of adhesions

33
Q

Dysmenorrhea

A

painful menstruation, normally occurring with ovulatory cycles

34
Q

What is the most commonly reported menstrual disorder?

A

dysmenorrhe

35
Q

Primary vs Secondary dymenorrhea

A 
Primary: 
prostaglandin -mediated 
pain during first 1-2 days of menses 
assoc with N/V/D
no identifiable pathology

Secondary:
new onset of pain in older women
endometriosis is MC cause of secondary dysmenorrhea
+ pathology

36
Q

What is the MC cause of secondary dysmenorrhea?

A

endometriosis

37
Q

What is the Ddx of secondary dysmenorrhea?

A 
endometriosis 
leiomyoma (fibroids) 
Adenomyosis 
PID 
UTI
ectopic pregnancy
38
Q

What is the treatment for dysmenorrhea?

A

NSAIDs and OCPs

39
Q

What is the function of OCPs?

A

estrogen -progestin combo
prevents ovulation
reduces endometrial growth
decreases PG production

40
Q

Endometriosis

A

MC cause of secondary dysmenorrhea
aberrant growth of endometrium outside the uterine cavity –pelvis and ovary MC locations

nulliparous women 20s-30s

infertility common

41
Q

What are the symptoms of endometriosis?

A 
3Ds 
Dysmenorrhea
Dyspareunia
Dyschezia 
Pelvic Pain

Signs:
tender nodularity of cul-de-sac and uterine ligaments
fixed uterus

42
Q

What is the gold standard dx for endometriosis?

A

laparoscopy

43
Q

What is the treatment for endometriosis?

A

based on severity of sx and desire for fertility
pain management
hormonal treatment
surgery

44
Q

What are the different behavior and somatic sxs seen with PMS?

A 
Behavioral: 
labile mood
irritability
anxiety/tension
sad or depressed mood 
increased appetite/food cravings 
diminished interest in activities 
Somatic: 
abdominal bloating 
fatigue 
breast tenderness
HA
hot flashes
dizziness

to dx: they must have 1 or more of these sxs 5 days before menses for at least 3 prior menstrual cycles

45
Q

PMDD

A

Premenstrual dysphoric disorder

46
Q

How do you dx PMDD?

A

5 of the 11 sxs occurring during the majority of cycles over the past year (must have 1 of the first 4 sxs)

1) depressed mood
2) anxiety, tension
3) affective lability
4) anger or irritability
5) decreased interest in usual activities
6) difficulty concentrating
7) lack of energy, fatigue
8) change in appetite, specific food cravings
9) hypersomnia or insomnia
10) overwhelmed or feeling “out of control”
11) physical sxs such as breast tenderness, HA, weight gain

47
Q

What is the treatment of PMDD?

A

mild:
lifestyle modifications - exercise, relaxation

moderate:
OCPS

severe:
SSRIs (fluozetine, sertraline)

Clin Med - Repro (18 decks)

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