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Summer FDTN Exam 3 > menstrual disorders > Flashcards

menstrual disorders Flashcards

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1
Q

What is primary amenhorrhea

A

absence of menarche by age 15 despite normal puberty

absence of menarche by age 13 without normal puberty

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2
Q

What is secondary amenorrhea

A

absence of menses for >3 months (if previously regular) or >6 months (if previously irregular) in women who were previously menstruating

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3
Q

First test you do for amenorrhea

A

PREGNANCY

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4
Q

If a woman comes in with complaints of no period for 3 months, what should you do

A

get a pregnancy test

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5
Q

A 24 year old woman presents to the ED with complaints of difficulty sleeping. She slips in that she hasn’t had period in 2 months, but she is not sexually active. What is your work up

A

PREGNANCY TEST! do not trust her, she is a fugly slut.

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6
Q

What are the possible causes of primary amenorrhea

A

chromosome abn causing gonadal dysgenesis
hypothalamic hypogonadism
No uterus, cervix, vagina, or mullerian agenesis
transverse vaginal septum, imperforate hymen
pituitary disease

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7
Q

What is mullerian agenesis

A

lacking the upper 1/3 of the vagina/uterus

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8
Q

What is Turner’s syndrome

A

45 XO genetic d/o causing gonadal dysgenesis
Causes premie depletion of oocytes and follicles (oavrian regression)
associated with short stature, widely spaced nipples, webbed neck, sexual infantilism

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9
Q

What lab abnormality will you see with Turner syndrome

A

high FSH and LH, because the ovaries cant respond to those hormones, so the pituitary tries to overstimulate and compensate

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10
Q

PCOS usually causes

A

Secondary amenorrhea

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11
Q

Hypothalamic and pituitary disorders are due to

A

GnRH transport dysfunction (tumors)
GnRH pulse discharge
Congenital absence of GnRH

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12
Q

What is Functional/Hypothalamic amenorrhea due to

A

Abnormal secretion of GnRH

MC 2/2 eating disorders, physical/psych stress, weight loss, excessive exercise

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13
Q

What are types of congenital GnRH deficiency (causing primary amenorrhea)

A 
Idiopathic hypogonadotropic hypogonadism 
Kallman Syndrome (w/ anosmia)
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14
Q

Other types of hypothalamic disorders causing primary amenorrhea include

A

Hyperprolactinemia
Hypothyroidism
Infiltrative disease

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15
Q

What are signs of an imperforate hymen

A 
Cyclic pelvic pain 
perirectal mass (blood sequestered in vagina)
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16
Q

What is androgen insensitivity syndrome

A

Testosterone is in the body, but receptors don’t respond to it;
Inside they are male (karyotype), but externally they are female (phenotype)

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17
Q

How do you diagnose androgen insensitivity syndrome

A

Absent upper vagina, uterus, and fallopian tubes
High serum testosterone
male 46 XY karyotype

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18
Q

Briefly describe the primary amenorrhea algorithm

A

Prior menstrual period? no
Recent sexual intercourse? (yes= bHCG) (no= delayed puberty, normal puberty, malnourished/low weight?)
Low weight= hypothalamic dysfunction
Normal puberty= outflow obstruction, HPO dysfxn
Delayed puberty= gonad dysgenesis, genetic

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19
Q

When do you initiate primary amenorrhea clinical evaluation

A

13 if no evidence of breast development
13 if patient has not menstruated w/in 2 years of thelarche
15 in no uterine bleeding (but with breast development)

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20
Q

Sexual activity questions important for primary amenorrhea evaluation

A

timeline of other stages of puberty
When mom and sisters had menarche
Patient’s height relative to other family
Symptoms of virilization (hirsutism, deep voice)
stress, weight change, diet, exercise, illness
Galactorrhea
Anosmia (kallman’s syndrome)
HA, visual field defects
Hx of head trauma
Sexual activity

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21
Q

PE for primary amenorrhea should include

A

vitals
skin
GEneral (female body shape, signs of abuse)
Cardiac (everyone)
Pulmonary (everyone)
Breast exam (development, axillary hair growth)
Pelvic (ext genitalia, pubic hair growth, presence of uterus)

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22
Q

Labs for primary amenorrhea should include

A 
beta HCG 
FSH (if high= gonadal dysgenesis) (low-norm= hypogonadotropic hypogonadism) 
Karyotype 
Prolactin, TSH 
Testosterone
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23
Q

Imaging for primary amenorrhea include

A

base these on H&P findings!
Pelvic sonogram if you suspect pelvic anomalies
CT/MRI if you suspect pituitary pathology

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24
Q

What are goals in primary amenorrhea treatment

A

Establish a firm diagnosis (and treat it)
Restore ovulatory cycles and achieve fertility if desired
Prevent complications (hypoestrogenism, hyperandrogenism)

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25
Increasing estrogen in primary amenorrhea may induce
thelarche!
26
Refer primary amenorrhea patient to
counseling endocrine or Gyno surgery if necessary
27
What are the possible causes of secondary amenorrhea
``` PREGNANCY!!!!!!!! Ovarian dysfunction Hypothalamic dysfunction pituitary dysfunction uterine dysfunction ```
28
Functional or hypothalamic disorders causing secondary amenorrhea include
``` weight loss exercise nutrition deficiency stress celiac disease ```
29
Pituitary diseases causing secondary amenorrhea include
``` prolactin secreting tumor hyperprolactinemia Sheehan syndrome hypothyroidism head trauma ```
30
What is Sheehan syndrome
post-partum amenorrhea 2/2 pituitary necrosis from severe hemorrhage and hypotension after giving birth
31
What are ovarian causes of secondary amenorrhea
``` PCOS Primary ovarian insufficiency (premie ovarian failure, no oocytes before 40) Autonomous hyperandrogenism (androgen secreting tumors) ```
32
What are causes of primary ovarian insufficiencu
turner syndrome fragile x permutation AI ovarian destruction chemo/radiation
33
What is Asherman's syndrome
Scarring of the endometrial lining 2/2 postpartum hemorrhage or endometrial infection w/ D&C
34
PE that should be performed in secondary amenorrhea include
vitalls general skil (oily? acne? hirsutism?) HEENT (parotid swelling, dental erosion= bulemia) Carciac, pulm (everyone) Breast Pelvic (clitorimegaly, estrogen deficiency)
35
Lab studies you should get for secondary amenorrhea include
``` PREGNANCY!!! HCG (urine or serum) TSH Prolactin FSH/LH total testosterone ```
36
What si the progestin challenge test
Administer 10mg Medroxyprogesterone for 10 days to assess ESTROGEN status If patient has enough estrogen, they should have a withdrawal bleed w/in 2 weeks If no withdrawal bleed, patient may be pregnant, severe hypoestrogenism, or uterine defect
37
Imaging for secondary amenorrhea should include
Pelvic sonogram CT adrenals (virilization, elevated testosterone) CT/MRI (suspect pit problem)
38
Goals of secondary amenorrhea treatment include
establish firm Dx (and Tx it) restore ovulatory cycles and treat infertility Tx hypoestrogen and hyperandrogen
39
What is the MCC of abnormal uterine bleeding
anovulatory cycles
40
What is polymenorrhea
abnormally frequently menses at intervals <24 days
41
What is menorrhagis
Excess/prolonged menses (>80ml or >7 days) at normal intervals
42
What is metorrhagia
Irregular episodes of uterine bleeding
43
FIGO says these acronyms are causes of abnormal uterine bleeding
``` PALM-COEIN Polyp Adenomyosis Leiomyoma Malignancy/hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified ```
44
Other DDx for abnormal uterine bleeding are
``` systemic disorders (hepatic dz, renal dz, thyroid dz) Trauma (lac, abrasion, FB) Organic conditions (pregnancy, endometriotis, cervicitis) ```
45
What is dysfunctional uterine bleeding
when all identifiable causes of AUB are ruled out! | DUB is a Dx of EXCLUSION
46
Initial eval for abnormal uterine bleeding should include
confirm that the uterus is actually the source of bleeding setermine if pt is pre menarchal or postmenopausal Exclude PREGNANCY
47
On further evaluation of abnormal uterine bleeding, determine
``` bleeding pattern If endometrial sampling is needed (if post-menopausal or obese) Coag evaluation If it started 2/2 contraceptiove method consider concurrent factors ```
48
If a woman comes in with AUB, PE should include
check for pallor, tachycardia, hypotension, and excessive bruising Pelvic (verify uterine source, check for IUD strings, uterine size)
49
Labs for AUB should include
HCG, CBC, iron | +/- coags, bleeding time, TSH, LFT, FSH
50
Diagnostics for AUB should include
pelvic sonogram Pap and cervical cultures endometrial biopsy
51
How can you manage AUB
If less significant, obs hormonal treatments endometrial ablation hysterectomy (extreme cases)
52
What are the types of dysmenorrhea
Primary: no readily identifiable cause (MC in 17-22) Secondary: 2/2 organic pelvic dz (MC as women age)
53
Why does dysmenorrhea occur
Corpus luteum regresses PGE2 and PGF2 are released from the endometrium 2/2 cell lysis during menstruation Uterus contracts, causing ischemia
54
Primary dysmenorrhea may present like this
Few hours before, or just after onset of menstruation; lasts 12-72 hours Cramp like, intermittent Most intense in lower abdomen, radiates to low back and upper thighs Associated n/v/d, HA, LBP, fatigue Pelvic is normal
55
Lab tests for primary dysmenorrhea should include
HCG +/- PAP with cultures But, if H&P is consistent with other lab studies then no other labs or imaging is necessary
56
Conservative treatment for primary dysmenorrhea includes
``` Decrease caffeine intake apply heat gently massage lower abdomen get sleep! exercise yoga, acupuncture Calcium, Mg, B-complex Stop smoking ```
57
Pharm Tx for primary dysmenorrhea is
1 line: NSAIDS! (Ibu 300mg q6hr x 3-4 d) If not desiring pregnancy, OCP to reduce menstrual flow and inhibit ovulation If resistant: CCB (nifedipine) for vasodilation
58
When is follow up or referral required for primary dysmenorrhea
``` Pain worsens with each menses Pain lasts > first 2 days Meds pt used to take no longer work Menstrual bleeding increasingly heavy Pain accompanied by fever Abnormal discharge Pain occurs unrelated to menses ```
59
How does secondary dysmenorrhea usually present
depends on underlying cause; not limited to menses but can worsen w/ menstruation Associated with dyspareunia, infertility, and AUB Develops in 30-40 y/o NOT as related to first day of menses
60
Potential causes of secondary dysmenorrhea include
``` PID Uterine fibroids Ovarian cysts pelvic congestion endometriosis ```
61
How do you treat secondary dysmenorrhea
COC work great! can try POP or NSAIDS if can't take estrogen Complicated cases +/- surgery (laparoscopy for Dx, hysterectomy, oopherectomy, myomectomy)
62
What is PMS
physical, mood related and behavioral changes tat occur in a regular, cyclic relationship to LUTEAL phase usually RESOLVE with onset of menses
63
What is PMDD
premenstrual dysphoric disorder; basically PMS with more severe emotional symptoms
64
Etiology of PMS is
unclear; may be genetic, or 2/2 abnormal SEROTONIN response to hormone fluctuations
65
Physical manifestations of PMS include
Bloating Fatigue Breast tenderness Headaches
66
Behavioral manifestations of PMS include
Labile mood, irritability Increased appetite Forgetfulness Difficulty concentrating
67
What are PMDD self rating questions that help distinguish from PMS (Affective Sx)
Depressed, sad, down, or feeling hopeless? feel worthless or guilty? Anxious, keyed up, or on edge? Mood swings, sensitive to rejection or feelings easily hurt? Angry or irritable?
68
What is PMS diagnostic criteria
1-4 Sx of physical, behavioral, or affective
69
What are PMDD diagnostic criteria
5+ symptoms of physical, behavioral, or affective
70
DSM 5 criteria for PMDD is
5+ Sx present the week prior to menses and resolves a few days after menses: Need 1+: mood swings, sudden sadness, sensitive to rejection, anger, irritable, feel hopeless, depressed, tense, anxious, feel on edge Need 1+: Hard to concentrate, appetite change, diminished interest in usual activities, fatigue, feel overwhelmed, breast tenderness, bloating, weight gain, joint aches, sleep too much or not enough
71
In order to diagnose PMS or PMDD, you must R/O
Underlying psych d/o menopausal transition thyroid disorder mood disorder
72
How do you manage PMS/PMDD
Non-pharm: aerobic exercise, stress reduction technique Pharm: SSRI (fluoxetine, sertraline, citalopram, paroxetine, escitalopram) during luteal phase only +/- ovulation suppression (GnRH agonist, ECOC)

Summer FDTN Exam 3 (25 decks)

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