Lecture 4 - Menstrual Probs

Question 1

Amenorrhea

Answer 1

absence of menses

this is a symptom, not a dz

Question 2

What are the stages of puberty?

Answer 2

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

Question 3

Primary Amenorrhea

Answer 3

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

Question 4

When does typical menarche start?

Answer 4

11-13 years old

estrogen dependent

Question 5

How much blood is loss during menstruation?

Answer 5

<80mL

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

Which labs should you run for pts with primary amenorrhea?

Answer 8

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

Question 9

What is the most important step in evaluation of amenorrhea?

Answer 9

determine by PE or US if uterus is present

Question 10

Poll everywhere questions

Answer 10

go back and panopto

Question 11

What can cause ovarian failure?

Answer 11

Gonadal dysgenesis

Turner’s syndrome

Question 12

What is the MC cause of primary amenorrhea?

Answer 12

Gonadal dysgenesis

decrease in estrogen
increase in LH and FSH

Question 13

Gonadal Dysgenesis

Answer 13

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

Question 14

Turner’s Syndrome

Answer 14

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

Question 15

How do you dx Turner’s syndrome?

Answer 15

Karyotype

Question 16

How do you manage Turner’s syndrome?

Answer 16

estrogen replacement

cyclic progesterone to induce menses

Question 17

Mullerian Ageneiss

Answer 17

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

management: surgical reconstruction of vagina

Question 18

AIS

Answer 18

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

Question 19

What is the treatment for AIS?

Answer 19

remove testes after puberty
estrogen replacement after puberty
gender assignment

Question 20

Secondary Amenorrhea

Answer 20

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

Question 21

What is the MC cause of secondary amenorrhea?

Answer 21

PREGNANCY

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

Question 22

12 x 28 x 6

Answer 22

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

Question 23

What drugs of abuse can decrease GnRH?

Answer 23

heroin and methadone

Question 24

What are the initial labs you order for secondary amenorrhea?

Answer 24

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

Question 25

Progestin withdrawal test

Answer 25

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

Question 26

What are the possible results of the progestin challenge?

Answer 26

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

Question 27

Functional hypothalamic amenorrhea

Answer 27

no pathology ``` associated with: weight loss excessive exercise anorexia stress ``` Female athlete triad: anorexia, amenorrhea, osteoporosis tx: manage nutritional status OCPs

Question 28

What is the treatment for functional hypothalamic amenorrhea?

Answer 28

manage nutritional status | OCPS

Question 29

Sheehan Syndrome

Answer 29

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

Question 30

Premature ovarian failure

Answer 30

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

Question 31

Polycystic ovaries

Answer 31

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

Question 32

Asherman Syndrome

Answer 32

intrauterine adhesions or fibrosis most commonly secondary to scarring from pregnancy related D and Cs dx: hysteroscopy tx: hysteroscopic lysis of adhesions

Question 33

Dysmenorrhea

Answer 33

painful menstruation, normally occurring with ovulatory cycles

Question 34

What is the most commonly reported menstrual disorder?

Answer 34

dysmenorrhe

Question 35

Primary vs Secondary dymenorrhea

Answer 35

``` 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

Question 36

What is the MC cause of secondary dysmenorrhea?

Answer 36

endometriosis

Question 37

What is the Ddx of secondary dysmenorrhea?

Answer 37

``` endometriosis leiomyoma (fibroids) Adenomyosis PID UTI ectopic pregnancy ```

Question 38

What is the treatment for dysmenorrhea?

Answer 38

NSAIDs and OCPs

Question 39

What is the function of OCPs?

Answer 39

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

Question 40

Endometriosis

Answer 40

MC cause of secondary dysmenorrhea aberrant growth of endometrium outside the uterine cavity --pelvis and ovary MC locations nulliparous women 20s-30s infertility common

Question 41

What are the symptoms of endometriosis?

Answer 41

``` 3Ds Dysmenorrhea Dyspareunia Dyschezia Pelvic Pain ``` Signs: tender nodularity of cul-de-sac and uterine ligaments fixed uterus

Question 42

What is the gold standard dx for endometriosis?

Answer 42

laparoscopy

Question 43

What is the treatment for endometriosis?

Answer 43

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

Question 44

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

Answer 44

``` 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

Question 45

PMDD

Answer 45

Premenstrual dysphoric disorder

Question 46

How do you dx PMDD?

Answer 46

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

Question 47

What is the treatment of PMDD?

Answer 47

mild: lifestyle modifications - exercise, relaxation moderate: OCPS severe: SSRIs (fluozetine, sertraline)