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Women's Health EOR > Menstruation > Flashcards

Menstruation Flashcards

1
Q

What is primary amenorrhea?

A

the failure of menses to occur by age 15 years (some sources say 16 years) in the present of normal growth and secondary sexual characteristics (breast development, axillary or pubic hair)
-at age 13 years, if no menses have occurred and there is a complete absence of secondary sexual characteristics, evaluation for primary amenorrhea should begin

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2
Q

What are the causes of primary amenorrhea?

A
  • look for karyotype: (XX = normal female)
  • Turner’s syndrome: XO karyotype, webbed neck, broad chest, high FSH
  • Hypothalamic-Pituitary insufficiency: 46, XX, low FSH, LH
  • Androgen insensitivity: 46, XY, high testosterone, breast development only
  • Imperforate hymen: 46, XX, diagnosed on PE (patient with cyclic pelvis pain), observed on speculum exam
  • Anorexia: 46, XX, very low weight
  • Mullerian genesis - secondary sex characteristics, no uterus
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3
Q

What is secondary amenorrhea?

A

absence of menses for 3 months in a woman with previously normal menstruation or 6 months in a women with a history of irregular cycle

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4
Q

What is the most common cause of secondary amenorrhea?

A

Pregnancy

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5
Q

What also can cause secondary amenorrhea?

A
  • also caused by weight changes, hypothyroid, prolactinoma
  • always check beta HCG, TSH, and prolactin

-progesterone challenge test - medroxyprogesterone 10 mg PO x 7 days if bleeding occurs = anovulatory cycles

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6
Q

What is dysfunctional uterine bleeding?

A

excessive uterine bleeding and prolonged menses that is NOT caused by pregnancy or miscarriage, diagnosis of exclusion, look for an underlying endocrine disorder

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7
Q

What is polymenorrhea?

A

menses that occur more frequently (menses <21 days apart)

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8
Q

Wha is hemorrhagic or hypermenorrhea?

A

menses that involve more blood loss (>7 days or >80 mL) during menses

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9
Q

What is menorrhagia?

A

prolonged/heavy bleeding (>7 days or >80 mL); regular intervals

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10
Q

What is metrorrhagia?

A

uterine bleeding that occurs frequently and irregularly between menses

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11
Q

What is menometrorrhagia?

A

more blood loss during menses and frequent and irregular bleeding between menses

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12
Q

What is oligomenorrhea?

A

long intervals > 35 days

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13
Q

What is AUB?

A

in the absence of an anatomic lesion, caused by a problem with the hypothalamic-pituary-ovarain axis

  • polymenorrhea, menorrhagia and/or metorrhagia
  • unremarkable physical exam
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14
Q

How is dysfunctional uterine bleeding dx?

A

diagnosis of exclusion, Uterine Dilation and Curettage is the gold standard diagnosis

  • urinary Beta-hCG levels - r/o pregnancy
  • Labs: CBC, iron studies, PT, PTT, TSH, progesterone, prolactin, FSH, LFTs
  • Progestin trial - if the bleeding stops, anovulatory cycles confirmed
  • ovulation journal, Pap smear
  • Pelvic U/S, endometrial biopsy, HSG, hysteroscopy
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15
Q

What is the tx of dysfunctional uterine bleeding?

A

oral contraceptives and NSAIDs

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16
Q

What is dysmenorrhea?

A

refers to uterine pain around the time of menses, which can either be primary or secondary

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17
Q

What are the characteristics of dysmenorrhea?

A
  • reserved for women who pain prevents normal activity and requires medication, whether an over-the-counter or a prescription drug
  • pain occurs with menses or precedes menses by 1 to 3 days
  • pain tends to peak 24 hours after the onset of menses and subside after 2 to 3 days
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18
Q

How is dysmenorrhea dx?

A

pregnancy testing and pelvic ultrasonography

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19
Q

What is primary dysmenorrhea?

A

(no organic cause)

  • painful uterine muscle activity due to an excess of prostaglandins (F2a)
  • teens-early 20s, decline with age, no associated pelvic pathology
  • risk factors include menarche before age 12, nulliparity, smoking, family history, obesity
  • pain with menstruation, lower abdominal, intermittent, “labor-like” on days 1-3
  • nausea, vomiting, diarrhea (smooth muscle contraction), headache
  • normal pelvis exam
20
Q

What is the tx of primary dysmenorrhea?

A

NSAIDS and oral contraceptive pills

21
Q

What is secondary dysmenorrhea?

A

(pathologic cause)

  • painful menstruation caused by clinically identifiable cause
  • etiology: endometriosis, adenomyosis, polyps, fibroids, PID, IUD, tumors, adhesions, cervical stenosis/lesions, psych
  • pain with menstruation begins mid-cycle and increased in severity until end
  • common women age (20-40 s)
22
Q

What is the tx of secondary dysmenorrhea?

A

treat underlying cause

23
Q

What is menopause?

A

a retrospective diagnosis based on 12 or more months of amenorrhea occurring at a mean age of 51 years

24
Q

What is the average age of menopause?

A

average age 51.5 years (44-55 years)

-onset < 40 years old = premature ovarian failure

25
Q

How long does the average women spend in the postmenopausal state?

A

30+ years

26
Q

What is perimenopause?

A

the transition between reproductive capability and menopause hallmark is irregular menstrual function, lasts 3- 5 years

27
Q

What are the symptoms of menopause?

A
  • menstrual irregularity (more frequent), vasomotor symptoms (hot flashes, and night sweats), sleep disturbances, irritability, mood disturbances
  • vaginal dryness - dyspareunia, vaginal atrophy, loss of urogenital integrity, loss of skin elasticity
28
Q

What is the dx menopause?

A

one year of no periods (amenorrhea) after age 40 with no pathologic cause

  • cessation of menses for at least 12 months
  • FSH and estradiol levels (FSH> 30) with decreased estradiol (although no necessary for diagnosis)
  • onset < 40 years old = premature ovarian failure
29
Q

What is the tx of menopause?

A
  • estrogens are used to treat hot flashes
  • If uterus: HRT (estrogen + progesterone), if no uterus (ERT)
  • woman with an intact uterus should not use estrogen alone because the increased risk of endometrial cancer
  • progestins: hot flashes, increased risk of breast cancer
30
Q

What is the indication for hormone replacement therapy for menopause?

A

severe menopause symptoms (hot flashes, night sweats, vaginal dryness)

  • “smallest dose for shortest possible time and annual reviews of the decision to take hormones”
  • HRT should not be used to prevent cardiovascular disease due to slightly increased risk of breast cancer, MI, CVD, DVT
  • hormone therapy effect on lipid profile: HDL and TG levels increased, LDL levels decreased
31
Q

What are the known contraindications for HRT?

A
  • increase triglycerides
  • undiagnosed vaginal bleeding
  • endometrial cancer
  • history of breast CA or estrogen-sensitive cancers
  • CVD history
  • DVT or PE history
32
Q

What are the non-hormonal therapies for menopause?

A

cool temperatures, avoid hot, spicy foods or beverages, avoid ETOH, exercise, soy

  • alternative drugs for vasomotor symptoms
  • SSRIs (paroxetine)
  • SNRIs
  • clonidine
  • gabapentin
33
Q

What are characteristics of menstruation?

A

28-day menstrual cycle can be described by the ovulatory hormones in two phases: the follicular (proliferative) phase and the luteal (secretory) phase

34
Q

How long does the menstrual cycle last?

A

can vary in duration from 20 to 35 days, with an average 28 days

35
Q

When does menstrual cycle begin?

A

on the first day of menstruation, and this is referred to as day one of the cycle

36
Q

When does ovulation occur?

A

the release of the oocyte from the ovary, usually occurs 14 days before the first day of menstruation (14 day before the next cycle begins)

37
Q

What is the chance of fertilization highest?

A

between day 11 and day 15 of an average 28-day cycle

38
Q

What are the characteristics of the follicular (proliferative) phase?

A
  • the follicular phase is the first part of menstrual cycle
  • it goes from day 0 to day 14
  • first, GnRH (from the hypothalamus) stimulates FSH and LH release (from anterior pituitary)
  • a follicle grows, secreting estrogen
  • estrogen initially gives negative feedback
  • once estrogen levels are high enough from follicle secretion, it begins to give positive feedback on FSH and LH, which then surge
  • estrogen secretion is increased even more from the follicle, it induces an LH spike, which causes ovulation
39
Q

What are the characteristics of the luteal (secretory) phase?

A
  • typically, the luteal phase is days 15-28 of the cycle
  • after ovulation, the follicles becomes the corpus lute, which secretes progesterone and provide negative feedback to FSH and LH
  • if pregnancy does not occur, the corpus albicans is formed, which no longer secretes estrogen and progesterone
  • this decrease in hormones leads to endometrial sloughing or menses
  • to begin a new follicular phase of the menstrual cycle, GnRH is secreted
40
Q

What is premenstural dysphoric disorder (PMDD)?

A

a disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation

  • a severe, sometimes disabling extension of premenstrual symptoms (PMS)
  • causes marked disruption in functioning
41
Q

What is the DSM-5 diagnostic criteria for PMDD?

A

in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses

One (or more) of the following symptoms must be present:

  • marked affective lability (mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
  • marked irritability or anger or increased interpersonal conflicts
  • marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • marked anxiety, tension, and/or feelings of being keyed up or on

One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from above

  • decreased interest in usual activities (work, school, friends, hobbies)
  • subjetive difficulty in concentrations
  • lethargy, easy fatiguability, or marked lack of energy
  • marked change in appetite, overeating or specific food cravings
  • hypersomnia or insomnia
  • a sense of being overwhelmed or out of control
  • physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating” or weight gain
42
Q

What is the tx of PMDD?

A
  • SSRIs (fluoxetine 10 mg, sertraline 50 mg QD, etc) are useful for the treatment of PMDD
  • SNRIs such as venlafaxine may also be effective in women with predominantly psychological symptoms
  • birth control, low-dose estrogen, and diuretics may also be beneficial
  • gonadotropin-releasing hormone (GnRH) should be resolved only for patients unresponsive to first -and second-line agents
  • other useful agents are benzodiazepines (alprazolam 0.25 mg tid prn) and the tricyclic antidepressant clomipramine (25 mg qd as starting dose)
  • ovariectomy may be considered in severe refractory cases
43
Q

What is premenstrual syndrome?

A

a group of symptoms that occur in women, typically between ovulation and period (a week or two before their period)

44
Q

What is premenstrual syndrome caused by?

A

an imbalance of estrogen and progesterone along with excess prostaglandins production

45
Q

When are the symptoms of premenstrual syndrome present?

A

symptoms during the luteal phase (1-2 weeks before menses) - bloating, irritability

  • PMDD - causes marked disruption in functioning
  • symptoms resolve at the onset of mense
46
Q

How is the dx of premenstrual syndrome made?

A

is baed on history and physical exam

  • ACOG criteria: need one of the following symptoms is present during the 5 days before menses and abates within 4 days of the onset of menses
  • somatic: breast tenderness, abdominal bloating, headache, edema
  • affective: irritability, depression, angry outbursts, anxiety, social withdrawal, confusion
47
Q

What is the tx of premenstrual syndrome?

A

exercise and stress reduction are beneficial in general and should be recommended on this basis

  • SSRIs are first-line options for women with moderate to severe premenstrual symptoms who do not desire contraception
  • can be administered as continuous daily therapy or may be used clinically 2 weeks prior to the menstrual cycle
  • combined estrogen-progestin oral contraceptive as first-one therapy if contraception is a high priority (stops ovulation and stabilizes hormone levels)
  • starts with a 3 mg drospirenone (DRSP)/20 mcg ethinyl estradiol (EE) COC (Yazmin) with a four-day pill-free interval as the first-line pill
  • if symptom relief with the COC mono therapy is incomplete, an SSRI can be added
  • GnRH agonist therapy: for women who have not responded to or cannot tolerate SSRIs or OCs and continue to experience severe symptoms
  • surgery (bilateral oophorectomy/bilateral salpingoophorectomy [surgical menopause]) is considered only as a last resort

Women's Health EOR (10 decks)

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