Menstrual Disorders Flashcards
(87 cards)
1
Q
Variability in length of the menstrual cycle is greater in what ages of women?
A
Under 25
Over 40
2
Q
Variability in length of the menstrual cycle is less in what ages of women?
A
35-39 yo
3
Q
Two cycles of menstruation and their phases
A
- Ovarian (follicular, ovulation, luteal)
- Uterine (menstruation, proliferative, secretory)
4
Q
Describe follicular phase of ovarian cycle
A
- Most variable phase of menstruation
- Ovarian follicles mature within the ovary and get ready to release an egg
- Only 1 dominant follicle will grow to maturity (containing the egg)
- Overlaps with uterine proliferative phase
5
Q
What do ovarian follicles secrete as they mature?
A
Estradiol (form of estrogen)
6
Q
Describe ovulation phase of ovarian cycle
A
- Estradiol stimulates LH surge which starts around day 12
- Mature egg released from follicle
7
Q
What is Mittelschmerz?
A
Ovarian follicle that ruptures fills with blood and there may be some bleeding into abdominal cavity causing peritoneal irritation and lower abdominal pain
8
Q
Describe how fraternal twins occur
A
Both ovaries release and egg and both eggs are fertilized
9
Q
What happens after the egg is released from ovarian follicle?
A
- Travels to Fallopian tube
- If not fertilized within 1 day, it will disintegrate
- If fertilized, embryo will take 3 days to reach uterus and another 3 days to implant into endometrium
10
Q
Describe luteal phase of ovarian cycle
A
- FSH and LH cause remaining parts of follicle that released the egg to transform into corpus luteum
- Corpus luteum secretes progesterone which induces the production of estrogen
- Estrogen/progesterone suppress FSH/LH
11
Q
What does the corpus luteum secrete?
A
Progesterone (which induces production of estrogen)
12
Q
If fertilization occurs, what happens to the corpus luteum?
A
Corpus luteum persists because the embryo produces hCG (similar to LH and preserves the corpus luteum)
13
Q
If fertilization does NOT occur, what happens to the corpus luteum?
A
It degenerates because of low levels of LH/FSH which triggers menstruation
14
Q
Describe menstruation phase of uterine cycle
A
- First phase
- Average duration 3-5 days
15
Q
Describe proliferative phase of uterine cycle
A
- 2nd phase (length is variable!)
- Restoration of endometrium from preceding menstruation
- Lining of uterus proliferates/grows
- Ovarian follicles secrete estrogen which initiates formation of new layer
16
Q
Describe secretory phase of uterine cycle
A
- 3rd phase (corresponds to luteal phase of ovarian cycle)
- Preparation of uterus for implantation of fertilized egg
- Corpus luteum produces progesterone to increase BF to uterus, increase uterine secretions, raises body temp (all for proper environment for pregnancy)
17
Q
The proliferative phase of the uterine cycle corresponds to which phase of the ovarian cycle?
A
Follicular
18
Q
The secretory phase of the uterine cycle corresponds to which phase of the ovarian cycle?
A
Luteal
19
Q
Patient A has a cycle length of 24 days. When does she ovulate?
A
Day 10 (subtract 14 days to account for luteal/secretory phase)
20
Q
What is required to have regular spontaneous menstruation?
A
- Functional hypothalamic-pituitary-ovarian endocrine axis
- Competent endometrium
- Intact outflow tract from internal to external genitalia (uterus, cervix, vagina)
21
Q
What are the cervical mucus changes that occur within menstrual cycle?
A
- Estrogen makes mucus thinner and more alkaline (promotes transport and survival of sperm)
- Progesterone makes mucus thicker
- Mucus is thinnest at ovulation and more elastic
22
Q
When is cervical mucus thinnest in menstrual cycle?
A
At ovulation (to promote survival of sperm)
23
Q
How does progesterone affect cervical mucus?
A
Makes mucus thicker
24
Q
How does estrogen affect cervical mucus?
A
Makes mucus thinner and more alkaline (promotes transport and survival of sperm)
25
Breast changes that occur within the menstrual cycle?
- Estrogen causes proliferation of mammary ducts
- Progesterone causes growth of lobules and alveoli
- Brest swelling, tenderness, pain may occur 10 days before menstruation
26
How does estrogen affect breasts during menstrual cycle?
Causes proliferation of mammary ducts
27
How does progesterone affect breasts during menstrual cycle?
Causes growth of lobules and alveoli
28
How is body temperature affected during menstrual cycle?
Small increase during luteal phase (due to progesterone)
29
Define menorrhagia
Heavy or prolonged menstrual flow (greater than 80 mL per cycle)
30
Define polymenorrhea
Bleeding at less than 21 day intervals
31
Define oligomenorrhea
Bleeding at greater than 35 day intervals
32
Define metrorrhagia
Bleeding that occurs anytime b/w menstrual cycles
33
Define menometrorrhagia
Bleeding that occurs at irregular intervals
34
Define dysmenorrhea
Painful menstruation
35
Define dysfunctional uterine bleeding (DUB)
Bleeding secondary to anovulation
36
Define primary amenorrhea
- Absence of menses by age 13 in absence of normal growth or secondary sex development
- Absence of menses by age 15 in setting of normal growth and secondary sex development
37
Define secondary amenorrhea
Absence of menses for more than 3 cycle intervals or 6 consecutive months in previously menstruating woman
38
What is the MC cause of secondary amenorrhea?
Pregnancy
39
Uterine causes of amenorrhea
- Pregnancy
| - Asherman's syndrome
40
Cervical causes of amenorrhea
Stenosis/scarring
41
Vaginal causes of amenorrhea
- Mullerian aplasia (vaginal agenesis)
- Transverse vaginal septum
- Imperforate hymen
42
Ovarian causes of amenorrhea
- Menopause
- Premature ovarian failure
- PCOS
- Turner's syndrome
- Testicular feminization
43
What is Asherman's syndrome?
- Uterine scarring that causes amenorrhea
- MC occurs after surgery
- Tx by surgical removal of scar tissue
44
What is Mullerian aplasia?
- Congenital absence of uterus and upper 2/3rd's of vagina causing amenorrhea
- May have normal external genitalia OR only a small dimple at vaginal introitus
- Normal functioning ovaries
45
What is imperforate hymen?
- Vaginal cause of amenorrhea
- Hymen does not perforate as it should in late fetal life
- Hereditary component
46
How does imperforate hymen present in infants?
Mucocolpos (accumulation of vaginal secretions behind hymen makes it appear shiny, thin bulge)
47
How does imperforate hymen present in adolescents?
- Primary amenorrhea
- Cyclic pelvic pain
- Difficulty w/defecation or urination
- Purplish-red hymenal membrane bulging outward
- Hematometra (accumulation of blood above it)
48
What is a transverse vaginal septum?
- Vaginal cause of amenorrhea
- MC in upper vagina
- Presents similar to imperforate hymen
49
What conditions can cause premature ovarian failure?
- Fragile X syndrome
- Surgery
- Autoimmune disorder
- Mumps
50
How does Turner's syndrome cause amenorrhea?
Ovaries fail to develop
51
What is testicular feminization?
- Phenotypically female, but lacking a uterus and complete vagina
- May have non-functioning testes
52
Pituitary causes of amenorrhea
- Acquired dysfunction (Sheehan's syndrome)
- Surgical ablation and irradiation
- Thalassemia major
- Hyperprolactinemia
- Hypothyroidism
53
What is Sheehan's syndrome?
Amenorrhea resulting from postpartum pituitary necrosis 2/2 severe hemorrhage and hypotension (RARE)
54
What is Thalassemia major?
- Pituitary cause of amenorrhea
- Hematologic condition
- Iron deposits in pituitary result in destruction of the cells that produce LH and FSH
55
Hypothalamus causes of amenorrhea
- Defects in GnRH transport
- Defects in GnRH pulse production (female athletes)
- Congenital GnRH deficiency
56
Causes of menorrhagia
- Pregnancy
- IUD
- Uterine fibroids
- Cancer
- DUB (MC is PCOS)
- Endometrial hyperplasia
- Hyperthyroidism
- Bleeding disorders
57
How to treat moderate menorrhagia?
Exclude pregnancy first then one of following options:
- OCP at 2-4x usual dose
- Conjugated estrogen until bleeding stops then medroxyprogesterone acetate
- Medroxyprogesterone acetate until bleeding stops
58
How to treat severe menorrhagia?
- Dilation and curretage
| - Emergency hysterectomy
59
What is endometrial ablation?
- Another tx option for menorrhagia
- Results in amenorrhea or reduced menses
- Must be certain that pt does not want more children
60
Causes of metrorrhagia
- Midcycle or ovulatory
- Endometrial polyps
- OCP
- Endometritis (occurs after pregnancy or with use of IUD)
- Cancer
- Endometrial hyperplasia
61
Causes of postcoital bleeding
- Cervical polyps
- Cervicitis
- Cervical cancer
- Atrophy in menopausal female (due to low estrogen)
62
Causes of oligomenorrhea
- Pregnancy
- Hypogonadotropic hypogonadism (stress, wt loss, excessive exercise)
- Anovulation
- Hypothyroidism
63
Causes of polymenorrhea
- Anovulation
- Incorrect use of OCPs
- Pregnancy
- Fibroids
- Polyps
64
Causes of hypomenorrhea
- Cervical stenosis
| - OCPs
65
Define dysmenorrhea
Painful menstruation that prevents normal activity and requires medication
66
Types of dysmenorrhea
- Primary (no organic cause)
| - Secondary (pathologic cause)
67
Physiology of dysmenorrhea
- A/w ovulatory cycles (later in adolescence)
- Secondary to abnormal and increased prostaglandins (induces contractions, reduces BF, leading to hypoxia)
- Psych component suspected as well
68
Treatment of dysmenorrhea
- NSAIDs or acetaminophen for mild discomfort (best if taken 1-2 days prior)
- Heating pad
- OCPs (synergistic with NSAIDs)
69
What makes up 60% of cases of abnormal uterine bleeding?
Dysfunctional uterine bleeding (DUB)
70
Describe DUB
- Bleeding not a/w ovulation after all other pathology has been excluded
- 60% of abnormal uterine bleeding cases
- Almost half are women over 40 yo
71
How is DUB mostly caused in young women 20-30 yo?
Pathological causes are uncommon
72
How does DUB mostly occur in postmenopausal women?
More likely secondary to a pathologic cause (requires further workup)
73
Possible causes of DUB in postmenopausal women
- HRT
- Vaginal atrophy
- Vulvar lesions
- Tumors
74
Work up for postmenopausal women with DUB
- Pelvic US
| - Endometrial sampling/biopsy
75
Define adenomyosis
Extension of endometrial glands into uterine musculature
76
How does adenomyosis present?
Severe secondary dysmenorrhea and menorrhagia OR may be asymp
77
How is adenomyosis treated?
- D&C
| - GnRH agonist or hysterectomy
78
Define endometriosis
Condition in which endometrial tissue grows outside endometrial cavity
79
Who is MC affected by endometriosis?
- Almost exclusively pre-menopausal
| - 25-35% of infertile women
80
Where is the MC site of implantation in endometriosis?
Ovary
81
Positive risk factors for endometriosis
- Fam hx
- Early menarche
- Long duration of menstrual flow
- Heavy bleeding during menses
- Shorter cycles
82
Negative risk factors for endometriosis
- Regular exercise
- Higher parity
- Longer duration of lactation
83
MC s/s of endometriosis
- Secondary dysmenorrhea
- Dyspareunia
- Infertility
84
What is required to diagnose endometriosis?
Direct visualization of lesions/implants by laparoscopy
85
1st line medical tx of endometriosis
6-9 month trial of:
- NSAIDs
- Hormonal (OCPs, progestins)
86
2nd line medical tx of endometriosis
- High dose progestin
- Danazol (induces a pseudomenopause)
- GnRH agonists
87
Surgical treatments for endometriosis
- Conservative (preserve fertility)
| - Definitive (total abdominal hysterectomy, BSO)
