menstrual disorders

Question 1

what is primary amenorrhea

Answer 1

Absence of menarche (first menses) by age 15 despite normal growth and secondary sexual development

Absence of menarche by age 13 in absence of normal growth or secondary sexual development

Question 2

what is secondary amenorrhea

Answer 2

Absence of menses for more than 3 months (previously regular cycles), or 6 months (previously irregular cycles) in women who were previously menstruating

Question 3

primary amenorrhea etiology

Answer 3

MC = Chromosomal abnormality causing gonadal dysgenesis

Hypothalamic hypogonadism

Absence of the uterus, cervix and/or vagina, mullerian agenesis

Transverse vaginal septum or imperforate hymen

Pituitary disease

Question 4

Turner’s syndrome (45, XO) and gonadal dysgenesis

Answer 4

Results in premature depletion of oocytes and follicles

assoc. w/short stature, widely spaced nipples, webbed neck, and sexual infantilism

Question 5

hypothalamic and pituitary causes primary amenorrhea

Answer 5

Hypogonadotropic hypogonadism

fx or hypothalamic amenorrhea, congenital GnRH deficiency (Kallmann syndrome), infiltrative dz/tumors, hyperprolactinemia, hypothyroidism

Question 6

uterine and vaginal causes of primary amenorrhea

Answer 6

Vaginal agenesis (Mullerian agenesis)

Imperforate hymen

transverse vaginal septum

Question 7

receptor abnormalities and enzyme deficiency causes for Primary amenorrhea?

Answer 7

Androgen Insensitivity Syndrome

Question 8

how do you dx androgen insensitivity syndrome

Answer 8

Dx: absent upper vagina, uterus and fallopian tubes on physical exam and pelvic ultrasound; high serum testosterone concentrations; and male (46,XY) karyotype

Question 9

when to initiate clinical eval for primary amennorrhea?

Answer 9

Age 15 if no uterine bleeding has occurred

Age 13 if no evidence of breast development
(Breast development = thelarche)

Age 13 if patient has failed to menstruate within 2 years of thelarche

Question 10

hx q’s for primary amenorrhea?

Answer 10

Timeline of other stages of puberty

Time of menarche in pt’s mother and sisters

Symptoms of virilization

Stress, change in weight, diet, exercise habits, or illness

Galactorrhea

Headaches, visual field defects, fatigue, polyuria, polydipsia

Question 11

Lab studies for primary amenorrhea

Answer 11

Urine or Serum HCG
Serum FSH/LH:
- High FSH suggests gonadal dysgensis
-Low or normal FSH suggests hypogonadotropic hypogonadism

karyotype
serum prolactin and TSH
serum testosterone

Question 12

imaging for primary amenorrhea

Answer 12

Based on H&P findings

Pelvic sonogram: if suspected pelvic anomalies

CT or MRI: If suspected pituitary pathology

Question 13

Tx for primary amenorrhea

Answer 13

Goals: est. firm dx
Restore ovulatory cycles and achieve fertility (if desired)
Prevent complications of disease process

counseling
referral to endocrine/gyn
surgical referral if necessary

Question 14

secondary amenorrhea causes

Answer 14

PREGNANCY!!!!!

Ovarian dysfunction

Hypothalamic dysfunction

Pituitary dysfunction

Uterine dysfunction

Question 15

hypothalamic/pituitary causes for secondary amenorrhea

Answer 15

Functional or hypothalamic amenorrhea: wt. loss, stress, celiac dz

Pituitary disease: high prolactin, Sheehan’s syndrome

Hypothyroidism

Head Trauma

Question 16

Ovarian dysfx reasons for secondary amenorrhea

Answer 16

Polycystic Ovary syndrome

Primary Ovarian Insufficiency (premature ovarian failure)

Autonomous hyperandrogenism

Question 17

uterine reasons for secondary amenorrhea

Answer 17

Asherman’s syndrome- acquired scarring of the endometrial lining

Question 18

secondary amenorrhea hx q’s

Answer 18

Previous menstrual hx
Previous pregnancies
Meds
Weight loss or gain
Galactorrhea
Symptoms of estrogen deficiency

Question 19

PE secondary amenorrhea

Answer 19

vitals, skin, HEENT (parotid gland swelling, dental enamel erosion for balemia), cardiac, pulm, breast (axillary hair, galactorrhea, pelvic exam (estrogen deficiency, clitorimegaly)

Question 20

Lab studies for secondary ameorrhea

Answer 20

Urine or serum HCG
TSH
Prolactin
FSH and LH
Total testosterone

Question 21

what is the progestin challenge test

Answer 21

for secondary amenorrhea

Performed to assess estrogen status when initial lab studies are WNL

Medroxyprogestone

If pt has adequate levels of estrogen, should experience withdrawal bleeding within 2 weeks

Question 22

imaging for secondary amenorrhea

Answer 22

Pelvic sonogram

CT of adrenal glands
If significant virilization and elevated testosterone

CT or MRI
If suspected pituitary pathology

Question 23

Tx for secondary amenorrhea

Answer 23

Based on underlying etiology

Goals: Establish firm dx, restore ovulatory cycles and treat infertility, tx hypoestrogenemia and hyperandrogenism

Counseling:
If hypothalamic failure due to anorexia, excessive exercise, abuse, stress

Possible referral to Endocrinology and/or GYN

Question 24

etiology of abnormal uterine bleeding?

Answer 24

anovulation

Question 25

what is Polymenorrhea

Answer 25

Abnormally frequent menses at intervals <24 days

Question 26

what is Menorrhagia (Hypermenorrhea)

Answer 26

Excessive and/or prolonged menses (>80mL and/or >7 days) occurring at normal intervals

Question 27

what is Menometrorrhagia

Answer 27

Heavy & irregular uterine bleed

Question 28

what is Metrorrhagia

Answer 28

Irregular episodes of uterine bleeding

Question 29

what are some causes for AUB? PALM - COIEN stand for?

Answer 29

``` Polyp Adenomyosis Leiomyoma Malignancy and Hyperplasia - Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified ```

Question 30

what is included on Ddx for AUB?

Answer 30

``` systemic disorders (hepatic dz, renal dz, thyroid dz) trauma pregnancy, endometritis, cervicitis ```

Question 31

what is dysfunctional uterine bleeding?

Answer 31

When all identifiable causes for abnormal uterine bleeding are ruled out dx of exclusion

Question 32

initial eval for AUB

Answer 32

Confirm the uterus is the source of bleeding Determine if the patient is premenarchal or postmenopausal Exclude pregnancy

Question 33

further eval for AUB

Answer 33

Determine the bleeding pattern, if endometrial sampling is needed, if a coagulation evaluation is needed, if the bleeding is related to a contraceptive method, consider concurrent factors

Question 34

hx questions to ask for AUB

Answer 34

- Age of menarche and menstrual hx - Detailed description of menstrual bleeding/Bleeding pattern - Normal cyclic ovulatory symptoms - Current birth control method(s) (CBM) - Meds - Personal and family history of bleeding disorders Weight changes - Sxs of anemia

Question 35

PE for AUB

Answer 35

exclude all causes check for pallor, tachycardia, hypotension, excessive bruising Pelvic exam: verify source of bleeding is uterine, check for IUD strings, uterine size

Question 36

Lab/diagnostic studies for AUB

Answer 36

labs based on H&P: HCG, CBC, Iron studies +/- coag, bleeding time, TSH, LFTs, FSH Pap smear and vaginal/cervical cultures Pelvic sonogram Endometrial biopsy (In-office sampling vs. D&C)

Question 37

management of AUB

Answer 37

Obs: for less significant bleeding Hormonal tx's Endometrial ablation: Amenorrhea rate of ~50% and relief of excessive bleeding in most of the remaining 50% Hysterectomy (extreme cases)

Question 38

what is dysmenorrhea? what is primary and secondary?

Answer 38

painful menstruation Primary: no readily identifiable cause exists Secondary: due to organic pelvic disease

Question 39

what age range is typical for dysmenorrhea?

Answer 39

17-22yo typical age for primary dysmenorrhea secondary MC as woman ages

Question 40

what % of women are affected by dysmenorrhea?

Answer 40

50% of menstruating women | 10% have sxs needing time off from school/work

Question 41

primary dysmenorrhea?

Answer 41

Regression of corpus luteum Prostaglandins released from endometrium at time of menstruation as a result of cell lysis Occurs during ovulatory cycles Uterine contractions with ischemia

Question 42

clinical presentation for primary dysmenorrhea?

Answer 42

Begins few hours before or just after onset of menstruation and lasts ~12-72 hours Pain typically = cramp-like, intermittent most intense in lower abd. and may radiate to lower back, upper thighs assoc. sxs = N/V/D, HA, LBP, fatigue pelvic exam normal

Question 43

lab/diagnostic studies for primary dysmenorrhea?

Answer 43

HCG Possible pap smear and vaginal cultures If H&P consistent, other lab studies or imaging not typically indicated

Question 44

conservative Tx for primary dysmenorrhea

Answer 44

``` Decrease caffeine intake Apply heat Gently massage lower abd Adequate sleep Exercise Yoga, acupuncture Nutritional supplements: Calcium, Mg, B-complex Smoking cessation ```

Question 45

Pharm Tx for primary dysmenorrhea

Answer 45

NSAIDS 1st line therapy (Ibuprofen 400mg, 1 po q6hrs x 3-4 days) If not desiring pregnancy, hormonal contraceptives reduce menstrual flow and inhibit ovulation (COCs, ECOCs, Depo-Provera) Resistant cases: CCB's (nifedipine)

Question 46

management and referral for primary dysmenorrhea?

Answer 46

required if: Pain worsening with each menses Pain lasts longer than first 2 days of menses Meds patient has used in the past is no longer controlling the pain Menstrual bleeding has become increasingly heavy Pain is accompanied by fever There is abnormal dc or bleeding The pain occurs at times unrelated to menses

Question 47

secondary dysmenorrhea clinical presentation

Answer 47

Pain depends on an underlying cause Pain not limited to menses, but may worsen at this time Usu. assoc. w/ other sxs: dyspareunia, infertility, abnl uterine bleeding Less related to first day of menses Usually develops in women aged 30-40yo

Question 48

potential underlying causes for secondary dysmenorrhea?

Answer 48

``` Pelvic inflammatory disease Uterine fibroids Ovarian cysts Pelvic congestion Endometriosis ```

Question 49

Tx for secondary dysmenorrhea?

Answer 49

Can use COCs for almost all cases -- if they can't take estrogen, try progestins or NSAIDs Complicated cases may require pelvic surgery: Diagnostic laparoscopy Hysterectomy Oophorectomy Myomectomy

Question 50

what is PMS

Answer 50

A group of physical, mood-related, & behavioral changes that occur in a regular, cyclic relationship to the luteal phase that interfere with some aspect of the patient’s life occur in most cycles, resolves with onset of menses

Question 51

what is PMDD

Answer 51

PMS with more severe emotional symptoms

Question 52

incidence for menstrual cycle assoc. disorders

Answer 52

Premenstrual sxs occur in ~75% Premenstrual syndrome causing significant disruption in daily life occurs in ~3-8% PMDD affects ~2% both can present at menarche or later in life

Question 53

physical manifestations of menstrual cycle assoc. disorders

Answer 53

Abdominal bloating Fatigue Breast tenderness Headaches

Question 54

behavior sxs for menstrual cycle assoc. disorders

Answer 54

``` Labile mood, irritability Depressed mood Increased appetite Forgetfulness Difficulty concentrating ```

Question 55

what is the DRSP?

Answer 55

Self rating questionnaire which helps distinguish PMS from PMDD depressed, sad, hopeless? anxious or tense? mood swings, sensitive? angry or irritable?

Question 56

PMS dx criteria?

Answer 56

1-4 symptoms physical, behavioral or affective/psychological in nature ≥ 5 symptoms physical or behavioral -- If ≥ 5 symptoms and one is an affective symptom then think PMDD

Question 57

PMDD DSM-5 dx criteria

Answer 57

Documentation of sxs for most of preceding year ≥ 5 symptoms present during week prior to menses, resolving with a few days after menses one or more sxs: mood swings, anger, hopelessness, anxiety one or more for total of 5: difficulty concentrating, diminished interest, change in appetite, feeling overwhelmed, etc.

Question 58

Management of menstrual cycle assoc. disorders

Answer 58

based on sxs Nonpharm tx's: Aerobic exercise & Stress reduction techniques Pharm tx: SSRI's --> fluoxetine, sertraline, citalopram, paroxetine, escitalopram +/- ovulation suppression (ECOCs, GnRH agonists)