Menstrual Disorders -> Flashcards
(140 cards)
1
Q
What part of the female reproductive system is shed during menstruation?
A
Lining of uterus (endometrium)
2
Q
What is menarche?
A
Onset of menses (10-15 y/o)
3
Q
What is menorrhagia?
A
Heavy/prolonged menstrual bleeding (>80mL)
4
Q
What does menorrhagia frequently cause?
A
Anemia
5
Q
What is metrorrhagia?
A
Bleeding between periods
6
Q
What is polymenorrhea?
A
Frequent menses (interval <21 days)
7
Q
What is oligomenorrhea?
A
Infrequent menses (interval >35 days)
8
Q
What is amenorrhea?
A
Absence of menses
9
Q
What axis is a tightly regulated system for reproduction/menstrual cycle regulation via hormonal control?
A
HPO (hypothalamic-pituitary-ovarian) axis
10
Q
What is GnRH (Gonadotropin Releasing Hormone) released from?
A
Hypothalamus
11
Q
FSH (follicle stimulating hormone) stimulates the development of what?
A
Ovarian follicle
12
Q
___________ secretion from ovarian follicles are dependent on ______ and _______
A
Estrogen dependent on FSH & LH
13
Q
Which hormone stimulates estrogen and progesterone production from the ovary, triggers ovulation, and stimulates the corpus luteum to produce progesterone?
A
LH (luteinizing hormone)
14
Q
Average cycle length?
A
28-35 days (day 1=first ay of period, last day of cycle = day before next period starts)
15
Q
Normal length of menstrual bleeding?
A
5 days
16
Q
Mean blood loss per cycle?
A
40mL
17
Q
What is the ovarian cycle?
A
prepares for release of egg from ovary/builds lining of uterus
18
Q
What is the uterine cycle?
A
prepares uterus/body to accept fertilized egg or start of next cycle if pregnancy does not occur
19
Q
Follicular phase (proliferative) of cycle?
A
Days 1-14, estrogen predominates, includes menses (day 1) and ovulation (days 12-14)
20
Q
Luteal phase (secretory) of cycle?
A
Days 14-28, progesterone predominates
21
Q
Phase 1- follicular phase?
A
estrogen/progesterone levels low –> menstruation, FSH levels slightly inc/stimulate development of several follicles in ovaries (each follicle contains an egg), later FSH levels decrease & only one follicle continues to develop (this follicle produces estrogen), endometrium thickens under estrogen influence, in the ovaries –> dominant follicle matures leading to ovulation, GnRH from the hypothalamus increases causing FSH/LH release from pituitary to stimulate ovaries
22
Q
Ovary response in phase 1 - follicular phase?
A
Inc. FSH causes follicle/egg maturation in ovary, Inc. LH stimulates maturing follicle to produce estrogen
23
Q
Uterus response in phase 1 - follicuar phase?
A
Estrogen builds endometrium
24
Q
What does estrogen cause in the HPO axis during phase 1 - follicular phase?
A
Negative feedback
25
Phase 2 - luteal phase?
After ovulation, ruptured follicle becomes corpus luteum, secreting progesterone which enhances lining of uterus to prepare for implantation, if it does not occur --> corpus luteum degenerates (steep inc. in estrogen and progesterone) --> menstruation
26
Ovarian cycle contains what phases?
Follicular phase, Ovulation, Luteal phase
27
Uterine cycle contains what phases?
Menstruation, Proliferative, Secretory phases
28
The follicular phase is variable in length from cycle to cycle, causing what?
Overlap w/ uterine proliferative phase
29
What happens in the follicular phase?
One ovarian follicle containing an egg matures w/in ovary
30
Hormones responsible for follicular phase?
Rise in FSH during first few days, cycle stimulates one dominant follicle
Follicles secrete estradiol as maturing
31
Length of ovulation phase?
One day
32
What happens in ovulation phase?
Follicle maturation is complete and estrogen is released from mature follicle --> swithces from positive feedback on GnRH causing increased estrogen/FSH/LH
*LH surge
33
What causes ovulation?
LH surge (causes egg to mature, weakens wall of follicle in ovary, follicle ruptures/releases oocyte), ovulation spotting may occur due to hormone changes
34
What is Mittelschmerz?
Lower abdominal pain w/ ovulation due to follicle filling with blood/bleeding into abdominal cavity causing peritoneal irritation
35
How many eggs normally release from one ovary?
1
36
What occurs if both ovaries release an egg and both eggs are fertilized?
Fraternal twins
37
What decides which of the two ovaries ovulate every month?
occurs at random
38
How long does an egg live after leaving the ovary?
12-24 hrs
39
When the egg is released/enters the fallopian tube, what happens if it is not fertilized?
Disintegrates into fallopian tube/absorbs into uterine lining
40
When the egg is released/enters the fallopian tube, what happens if it is fertilized?
Implantation usually occurs 6-12 days after ovulation
41
Duration of luteal phase?
Consistent from cycle to cycle (overlaps w/ uterine secretory phase)
42
What happens to FSH/LH levels during luteal phase?
Decrease
43
What forms at the site of a ruptured follicle?
Corpus luteum (secretes progesterone and some estrogen)
44
How does the corpus luteum prepare the uterus for fertilization/implantation?
Causes endometrium to thicken, fills w/ fluids and nutrients to nourish potential embryo, mucus thickens in cervix to protect from sperm/bacteria entering, body temp slightly increases
45
What happens in the ovarian cycle if fertilization occurs?
Corpus luteum continues to produce progesterone and some estroge until placenta takes over, endometrium maintained
46
What happens in the ovarian cycle if fertilization does not occur?
Corpus luteum degenerates, causing dec in progesterone and estrogen levels, endometrium no longer maintained/sloughs off (menstruation), negative feedback on GnRH subsides (inc. GnHR secretion, inc. FSH/LH, starts maturation process all over again)
47
Menstruation can be affected by what?
Thickness of endometrium, meds, underlying disease, etc.
48
What happens in the proliferative phase?
Lining of uterus proliferates/grows (restores from prior menses)
49
Hormones responsible for proliferative phase of uterine cycle?
Estrogen (being secreted by ovarian follicle) initiates formation of new layer of endometrium in uterus/stimulates cervix to produce cervical mucus
50
How long is the secretory phase of the uterine cycle?
Consistently 14 days
51
What happens in the secretory phase of the uterine cycle?
Uterus preps for implantation of fertilized egg
52
Hormones responsible for the secretory phase?
Progesterone produced by corpus luteum increases BF to uterus, increases uterine secretions, reduces contractility of SM in uterus & raises body temp *helps promote favorable environment for pregnancy
53
If fertilization does not occur in the secretory phase of the uterine cycle, what takes place?
Corpus luteum regresses, endometrium cannot maintain itself, resulting in vascular spasms and endometrial ischemia (menstruation)
54
Levels of estrogen and progesterone are ____ during menstruation
Low
55
Follicular phase overview?
Time between first day of period & ovulation, estrogen inc. to prepare for egg release
56
Proliferative phase overview?
After period, uterine lining builds back up
57
Ovulation phase overview?
Release of egg from ovary mid cycle, estrogen peaks just before then drops, LH surge triggers ovulation
58
Luteal phase overview?
TIme between ovulation and before menstruation, body preps for possible pregnancy, Progesterone produced --> peaks --> drops
59
Secretory phase overview?
Uterine secretions that either help support or prepare lining to break
60
Regular spontaneous menstruation requires what?
1. functional HPO axis
2. competent endometrium
3. intact outflow tract from internal to external genitalia
61
When should absence of menses be a concern?
If persistently absent, one missed period is not a huge deal (sensitive to environmental stressors)
62
Cervical mucus changes during cycle?
Estrogen makes mucus thinner/more alkaline (promotes sperm), Mucus thinnest at ovulation/more elastic, progesterone makes mucus thicker
63
Breast changes during cycle?
Estrogen causes proliferation of mammary ducts, progesterone causes growth of lobules and alveoli, breast swelling/tenderness preceding menses
64
When does a small change in body temp occur in cycle?
Luteal phase d/t progesterone
65
Primary amenorrhea?
Failure of menarche by 13 in absence of normal growth/secondary sexual development or failure by age 15 in the presence of normal growth/secondary sexual development
66
Cause of primary amenorrhea?
Usually genetic/anatomy abnormality
67
Secondary amenorrhea?
Absence of menses for 3 consecutive months in previously menstruating woman
68
Most common cause of secondary amenorrhea?
Pregnancy
69
How can cervical stenosis cause amenorrhea?
obstruct flow, congenital or secondary to cervical surgery
70
Sx of cervical stenosis?
amenorrhea, pelvic pain, dysmenorrhea, infertility, endometriosis possible, or asx
71
Dx for cervical stenosis?
Clinical
72
What is Mallerian agenesis?
46 XX karyotype, congenital absence of uterus and upper 2/3 of vagina
73
Sx of Mallerian agenesis?
Amenorrhea, pelvic pain, or asx
May have small dimpling at vaginal introitus, normal ovary function
74
Tx for Mallerian agenesis?
Multidisciplinary
75
What causes an imperforate hymen?
Familial component, normal hymen covers part of vaginal opening but imperforate covers all
76
Appearance of imperforate hymen as infant?
Bulging, yellow-gray mass at or beyond introitus, may put pressure on urethra, may present as mucocolpos
77
Appearance of imperforate hymen as adolescent?
Primary amenorrhea, cyclic pelvic pain, difficulty defecating/urinating, blue-ish discoloration of hymen membrane (hematocolpos) and generally abdominal mass (vaginal pooling of blood)
78
Dx and tx for imperforate hymen?
Clinical dx, surgical resection of hymen
79
What is a transverse vaginal septum?
Congenital anomaly where horizontal wall of tissue blocks vaginal opening
80
Dx of
U/S and MRI
81
Tx of transverse vaginal septum?
Surgical resection of septal tissue
82
What is Ashermans syndrome?
Acquired endometrial scarring from postpartum hemorrhage, after D&C **MC, or endometrial infection
83
Sx of Ashermans?
Amenorrhea, +/- spotting, infertility
84
Tx of Ashermans?
Surgical removal of scar tissue
85
What is primary ovarian insufficiency (POI)?
Deplection of oocytes before 40/premature menopause (intermittent menses followed by amenorrhea)
86
What is tuners syndrome?
Chromosome 45 X genetic disorder, oocytes/follicles undergo apoptosis in utero, ovaries replaced w/ fibrous tissue
87
Signs of tuner syndrome?
Short stature, ovarian failure, shield chest, widely spaced nipples, short/webbed neck
88
What is androgen insufficiency syndrome?
Chromosome 46 XY genetic disorder, X linked recessive, complete or partial androgen insensitivity failure of normal masculinization but lacking uterus and complete vagina (phenotypically female, genotype male), normal testes and testosterone function/conversion
89
What is 46, XY-5-alpha reductase type 2 deficiency?
XY at birth, autosomal recessive sex-linked condition resulting in inability to convert testosterone to dihydrotestosterone, genetic males born w/ ambiguous genitals (uterus/fallopian tubes absent), testes intact and in inguinal canal or scrotum
90
What can cause acquired pituitary function leading to amenorrhea?
Previous local radiation or surgery, excess iron disposition, Sheehans syndrome (postpartum pituitary necrosis), hypothyroid (elevated prolactin)
91
Most common pituitary cause of amenorrhea?
Hyperprolactinemia (prolactinoma tumor)
92
Dx of Hyperprolactinemia (prolactinoma tumor)?
elevated prolactin level and imagine MRI/CT
93
Tx for Hyperprolactinemia (prolactinoma tumor)?
Bromocriptine or Cabergoline (dec tumor size) or surgery (resection if large and desiring conception or rapidly enlarging w/ mass effect)
94
Meds that can cause hyperprolactinemia?
Antipsychotics, antidepressants, Prokinetics (Reglan), anti-hypertensives, morphine, H2As
95
Causes of defects in GnRH transport of hypothalamus leading to menagorrhea?
Trauma, compression, radiation, tumors, infiltrative disorders (sarcoid, Tb)
96
Signs of defects in GnRH transport of hypothalamus?
Low LH and estradiol w/ normal FSH
stress, eating d/o, excessive exercise, wt loss
*at risk for osteoporosis d/t low estrogen
97
Dx of defects in GnRH transport of hypothalamus?
Progesterone challenge (Medoxyprogesterone acetate x5-7d)
if menses: ovarian secretion of estrogen
if none: no estrogen
98
What is the female athlete triad of defects in GnRH transport of hypothalamus?
Amenorrhea, eating disorder, ostopenia/osteoporosis
99
What is congenital GnRH deficiency?
Idiopathic lack of GnHR secretion w/ low serum gonadotropins
100
What is Kallman's syndrome?
Identical to congenital GnRH deficiency w/ anosmia (no smell)
101
PE for primary amenorrhea?
Assess breast development, growth, skin, physical features for turners syndrome, genital exam
102
Labs and diagnostics for primary amenorrhea?
Pelvic US, Initial labs: Serum hCG, FSH/LH, TSH, Prolactin, Karyotype testing, testosterone levels
103
PE for secondary amenorrhea?
Ht/wt/BMI, skin, breast exam, vulvovaginal exam for dryness, pelvic exam, parotid gland swelling/dental erosions
104
Labs/diagnostics for secondary amenorrhea?
Pregnancy test***, Serum CG, FSH (high --> POI, Low-norm --> hypothalamic-piruitary or PCOS), LH, TSH, Prolactin
105
Etiologies of abnormal uterine bleeding (AUB)?
PALM-COEIN:
Polyp, Adenomyosis, Leiomyoma, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, not yet classified
(other- pregnancy, structural lesions, hormonal contraception)
106
Menagorrhea?
heavy, >80mL loss for >7 days
107
Hypomenorrhea?
Unusually light flow, spotting
108
Metorrhagia?
Bleeding between periods
109
Polymenorrhea?
Frequent uterine bleeding menstrual interval <21 days
110
111
Oligomenorrhea?
Infrequent uterine bleeding menstrual interval >35 days
112
Contact bleeding?
Post-sex bleeding
113
Ovulatory dysfunction?
Irregular bleeding, non-ovulatory
114
Initial workup for AUB?
Serum hCG r/o preg, CBC esp w/ heavy bleeding and sx
115
Why do postmenopausal women require further workup for AUB?
More likely d/t secondary pathologic cause
116
Additional tests for AUB?
TSH, coagulation, androgen levels, prolactin, FSH/LH, Estradiol, pap/cultures, pelvic imaging (transvag US, hysteroscopy)
117
When is an endometrial bx recommended for AUB?
>45 w/ frequent heavy period, all postmenopausal bleeding, younger pts w/hx of unopposed estroigen, persistent AUB despite tx, <45 w/ obesity/DM/HTN
117
MC etiologies of menagorrhea?
Fibroids and adenomyosis
117
Acute hemorrhage management?
R/o pregnancy
if unstable: IV high dose estrogen, D&C, emergency hysterectomy last resort
if stable: PO estrogen until bleeding stops, Medoxyprogesterone acetate BID 7-10d (progestin if estrogen C/I), endometrial ablation
118
What can control hemorrhage in setting of malignancy?
Radiation
119
What is an irregular bleeding pattern?
Phases of no bleeding that may last 2+ months and other phases w/ either spotting or heavy bleedinf
120
How can ovulatory dysfunction AUB be treated?
Estrogen-progestein OCPs 1st line, Progesterone if estrogen C/I
121
When to admit for AUB?
Hemodynamic instability or acute hemorrhage (IV HIGH DOSE ESTROGEN GIVES RAPID RESPONSE)
122
Primary dysmenorrhea is dx more often in what population?
Adolescents and young women d/t increased prostaglandin release (triggering uterine wall contractions)
prevalence dec w/ age
123
Secondary dysmenorrhea (d/t underlying pelvic pathology) has what features?
Large uterus, dyspareunia, resistance to tx
*prevalence inc. w/ age
124
Sx of primary dymenorrhea?
Recurrent, crampy midline lower abd or pelvic pain 1-2 days before menses or at onset of menses, HA, N/V
*gradually diminishes over 12-72hrs
125
Signs of secondary dysmenorrhea?
Not resolved w/ NSAIDS or OCPS, vaginal d/c, dyspareunia, infertility, bloating, AUB
126
PE for primary dysmenorrhea?
Unremarkable
127
PE for secondary dysmenorrhea?
signs of PID, Fibroids, Adenomyosis
128
Diagnosis of primary dysmenorrhea?
Dx of exclusion, detailed H&P, +/- transvag US
129
If secondary suspicion for dysmenorrhea, what diagnostics?
HCG, CBC, GC/CHl screen, UA, guiac, US, laparoscopy
130
Tx for primary dysmenorrhea?
NSAIDS or hormonal OCPs 1st line
131
Tx for secondary dysmenorrhea?
Underlying cause (medical vs. surgical), sx relief w NSAIDS, heat, OCP
132
PMS occurs when?
2nd half of menstrual cycle (luteal phase)
133
PMDD prominent sx?
anger, irritability, internal tension (DSM V criteria for dx)
134
Lab tests for PMS?
Serum TSH r/o thyroid cause of sx
135
Patient should record a diary of PMS sx for how long?
>2 cycles
136
DSM-V criteria for PMDD?
1+ following:
mood swings, sudden sadness, increased sensitivity to rejection
anger, irritability
sense of hopelessness, depression
tension, anxiety, on edge
1+ follwing to reach 5 sx overall
difficulty concentrating
change in appetite
diminished interest in activities
easy fatigue
overwhlemed/out of control
breast tenderness, bloat, weight gain, aches
sleep changes
*must correlate w/ near menses, relieved at onset of menses, occurred in most menstrual cycles w/in the yr, not d/t other med condition
137
Mild PMDD/PMS tx?
Lifestyle mods
138
Mod/severe PMDD/PMS tx?
SSRIs 1st line, combined OCPs 1st line in women needing contraception (otherwise reserved for refractory), therapy, acupuncture, surgery is last resort
Other reserved for refractory: GnRH agonists
