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menstruation Flashcards

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1
Q

what is the average blood loss is during menstruation?

A

30mL

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2
Q

what are the 3 sites of hormonal control?

A

hypothalamus
anterior pituitary
ovary

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3
Q

What happens during the follicular phase?

A

variable in length from cycle to cycle
ovarian follicles mature w/in the ovary and get ready an egg
follicles secrete estradiol as they mature
overlaps w/ uterine proliferative phase
Rise in FSH during the first few days of the cycle results in stimulation of ovarian follicles
Only one dominant follicle will grow to maturity

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4
Q

what happens during the ovulation phase?

A

mature egg is released from the follicle
estradiol stimulates a large amount LH (LH surge) which starts around day 12
Release of LH matures the egg and weakens the wall of the follicle to rupture and release its secondary oocyte
Follicle that ruptures fills with blood and there may be some bleeding into the abdominal cavity which can cause peritoneal irritation and lower abdominal pain called Mittelschmerz

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5
Q

What happens during the ovulation phase

A

if both ovaries release an egg and both eggs are fertilized-fraternal twins
which of the 2 ovaries ovulates every month occurs at random
after the egg is released-fallopian tube. After 1 day, if the egg is not fertilized it will disintegrate/dissolve in the fallopian tube
If fertilized by sperm w/in the fallopian tube, the embryo will take 3 days to implant into the endometrium

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6
Q

what happens during the Luteal phase?

A

consistent in length from cycle to cycle
FSH and LH cause the remaining parts of the follicle that released the egg to transform into the corpus luteum (requires FSH/LH to maintain itself)
the corpus luteum secretes progesterone which induces the production of estrogen
progesterone and estrogen suppresses FSH/LH
Over time the corpus luteum atrophies if it is not fertilized which results in decreased progesterone production which triggers menstruation

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7
Q

What happens during the luteal phase if pregnancy occurs?

A

corpus luteum persists b/c the embryo produces hCG which is very similar to LH and preserves the corpus luteum

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8
Q

What happens during the luteal phase if pregnancy does not occur

A

corpus lutem degenerates 4 days before the next menses because of the low levels of FSH/LH

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9
Q

what is the first sign that the woman is not pregnant

A

menstruation

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10
Q

how long is the menstruation cycle

A

avg duration is 3-5

1-8 days is normal

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11
Q

what affects menstruation?

A

thickness of endometrium, medications, underlying disease

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12
Q

what is the proliferative phase

A

restoration of the endometrium from preceding menstruation

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13
Q

Second phase during the uterine cycle?

A

lining of the uterus proliferates/grows

Ovarian follicles secrete estradiol (estrogen) as they mature

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14
Q

What effect does estrogen have during the uterine cycle?

A

initiates the formation of a new layer of endometrium in the uterus
stimulates the cervix to produce fertile cervical mucus

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15
Q

what happens during the secretory phase

A

preparation of the uterus for implantation of fertilized egg

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16
Q

What is the function of the corpus luteum during the secretory phase?

A

produces progesteron (pro gestation) which helps increase blood flow to the uterus and increase uterine secretions. It also reduces the contractility of the smooth muscle in the uterus and raises the woman’s basal body temperature

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17
Q

What happens if fertilization does not occur during the secretory phase?

A

the corpus luteum regresses (decreased progesterone and estrogen which supports the endometrium) so endometrium cannot maintain itself resulting in vascular spasms-endometrial ischemia-menstruation
(length of phase is constant 14days)

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18
Q

A patient has a cycle of 21days when does she ovulate?

A

day 7

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19
Q

A patient has a cycle of 36days when does she ovulate?

A

day 22

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20
Q

regular spontaneous menstruation requires the following?

A

functional hypothalamic-pituitary-ovarian endocrine axis
competent endometrium
Intact outflow tract from internal to external genitalia (uterus, cervix and vagina)

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21
Q

How does estrogen affect cervical mucus changes?

A

makes the mucus thinner and more alkaline (promotes transport and survival of sperm )

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22
Q

how does progesterone affect the mucus?

A

makes the mucus thicker

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23
Q

what effect does estrogen have on the breasts?

A

causes proliferation of mammary ducts

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24
Q

what effect for progesterone have on the breasts?

A

causes growth of lobules and alveoli

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25
what is menorrhagia
heavy or prolonged menstrual flow
26
what is hypomenorrhea
light menstrual flow
27
what is polymenorrhea?
bleeding at <21 day intervals
28
what is Oligomenorrhea?
bleeding at > 35 day intervals
29
what is metrorrhagia
bleeding that occurs at irregular intervals
30
what is dysmenorrhea
painful menstruation
31
what is the most common cause of secondary cause of amenorrhea
pregnancy
32
what are uterine causes for amenorrhea?
pregnancy | asherman's syndrome
33
what are cervical causes for amenorrhea?
stenosis/scarring
34
what are vaginal reasons for amenorrhea?
vaginal agenesis transverse vaginal septum Imperforate hymen
35
what are Ovarian reasons for amenorrhea?
menopause
36
what is asherman's syndrome?
uterine scarring | MC occurs after surgery d/t dilation and curettage
37
what are symptoms of ashermans
spotting | infertility
38
what is the Tx for ashermans
remove scar tissue
39
what is the etiology of cervical stenosis?
may be present at birth or develop secondary to cervical Surgery (cone biopsy, loop excision, or cryotherapy, trauma)
40
what are the Signs of cervical stenosis
amenorrhea, pelvic pain, and endometriosis, infertility
41
how is the dx of cervical stenosis made?
made clinically inability to pass small cervical dilator
42
what is the Tx for cervical stenosis?
opening/widening the cervical canal
43
what is mullerian aplasia?
congenital absence of the uterus and upper 2/3rds of the vagina. may have normal external genitalia or reveal only a small dimple at the vaginal introitus 46,XX karyotype
44
what is the Tx for mullerian aplasia
multidisciplinary approach
45
what will an imperforate hymen look like in an infant on exam?
infants may present as mucocolpos (accumulation of vaginal secretions behind the hymen and it appears shiny
46
what does imperforate hymen look like on adolescents?
presents as primary ammenorrhea and cyclic pelvic pain, difficulty w/ defication or urination secondary to mass effect. Inspection will reveal a purplish-red hymen membrane
47
what is the Tx for imperforate hymen?
surgery
48
How is a transverse vaginal septum present
in incomplete septum asymptomatic but may appear at the beginning sexual intercourse resulting in dyspareunia
49
how is a transverse vaginal septum dx?
US or MRI
50
what is the tx for transverse vaginal septum
surgery
51
What is sheehan's syndrome?
postpartum amenorrhea resulting from post-partum pituitary necrosis secondary to severe hemorrhage and hypotension
52
how is sheehan's syndrome tx
surgical ablation and irradiation
53
How does thalassemia major cause amenorrhea?
iron deposits in the pituitary resulting in destruction of the cells that produce LH and FSH
54
how does a prolactinoma present in amenorrhea?
galactorrhea
55
what is the Tx on prolactinoma
bromocroptine
56
what meds can cause hyperprolactinemia?
anti-psychotics, anti-depressants, anti-HTN, morphine, H2 antagonists
57
what cause defects in GnRH transport
trauma, compression, radiation, tumors and infiltrative disorders
58
Menorrhagia is defined as?
>80mL per cycle and interferes with
59
what are some causes of menorrhagia?
``` Pregnancy IUD Uterine Fibroids Cancer DUB Endometiral hyperplasia hyperthyroidism ```
60
How to tx menorrhagia d/t IUD
remove the IUD also remember the presence of an IUD does not mean that other pathology is not present need to rule out pregnancy, hyperplasia and cancer
61
What is the first thing you want to do in the management of menorrhagia?
``` 1st exclude pregnancy moderate hemorrhage Oral contraceptives at 2-4x usual dose Conjugated estrogen 2.5mg q4-6Hrs Methoxyprogesterone acetate ```
62
How to manage severe hemorrhage
D&C Emergency Hysterectomy In malignancy radiation to control bleeding Endometrial ablation- cauterizing the endometrium results in amenorrhea or reduces menses need to ensure no further children are desired
63
what is the definition of metrorrhagia?
intermenstrual bleeding/spotting
64
what causes metrorrhagia?
midcycle or ovulatory endometrial polyps which would be found on bx or w/hysteroscopy OCP Endometritis-occurs after pregnancy or w/use of IUD Cancer-dx w/ pap smear
65
what are causes of postcoital bleeding
cervical polyps cervicitis cervical cancer atrophhy on menopausal female d/t low estrogen
66
what is oligomenorrhea?
>35 days between menses
67
what are causes for oligomenorrhea?
pregnancy hypogonadotropic hypogonadism: stress, weight loss, excessive exercise anovulation hypothyroidism
68
what is polymenorrhea
<21days between menses
69
causes for polymenorrhea
``` anovulation incorrect use of OCP pregnancy fibroids polyps ```
70
what is hypomenorrhea
unusually light menstrual flow/ spotting
71
what are causes of hypomenorrhea
cervical stenosis following cervical surgery | OCP's very normal w/low dose pill and does not indicated an increased risk of pill failure
72
what is painful menstruation that prevents normal activity and requires medication
dysmenorrhea
73
what are the 2 types of dysmenorrhea
primary no organic causes | secondary pathologic cause
74
what is the physiology of dysmenorrhea?
associated with ovulatory cycles, does not occur at menarche but later in adolescence secondary to abnormal and increased prostaglandins induces abnormal uterine contractions
75
what are the sings and symptoms of dysmenorrhea primary dz?
starts on the first day of menses or the second day | nausea, vomiting, diarrhea, H/A
76
what are the signs/symptoms of secondary dz of dysmenorrhea
starts 1-2 weeks before menses, peaks 1-2 days before day 1 and the pain stops on day 1 of menses
77
what is the Tx of dysmenorrhea?
NSAIDs or acetaminophen -best if taken at earliest onset of symptoms and even starting 1-2 days Heating pad in addition to NSAID/Tylenol can give added benefit Codeine or a stronger analgesic may be required in severe pain OCP's lowest dosage however pills w/ increased estrogen can prevent pain
78
what is dysfunctional uterine bleeding?
bleeding that is not associated with ovulation after all other pathology
79
DUB makes up what percent of abnormal bleeding?
60%
80
how will DUB present in adolescents?
first few cycles are frequently anovulatory and therefore are irregular, though heavy bleeding may occur
81
what type of work up would you want to do for DUB?
physical exam w/ pelvic and rectal exam, pelvic U/S and basic blood work to exclude pregnancy or pathologic cause
82
what is the Tx for DUB
acute hemorrhage: High dose estrogen IV | Hemodynamically stable: oral estrogen followed by medroxyprogesterone
83
what is the cause of DUB in post menopausal women?
more likely to secondary to pathologic causes therefore requires further work up
84
what are possible causes of DUB in postmenopausal women?
exogenous hormone vaginal atrophy vulvar lesions tumors of the reproductive tract
85
what type of work up should you do for a postmenopausal
Pelvic US to evaluate ovaries Hysteroscopy endocervical curettage w/endometrial sampling/biopsy If dx unknow D&C
86
what us premenstrual syndrome
cyclic occurrence of symptoms that are sufficient severity to interfere w/some aspects of life and that appear w/ consistent and predictable relationship to the menses
87
when is premenstrual dysphoric disorder given?
when PMS symptoms disrupt daily functioning
88
what percent of women experience some PMS symptoms
75%
89
when is the highest incidence of PMS in women
late 20's to early 30's rare adolescence resolves after menopause
90
what are the symptoms of PMS
HA, breast tenderness, pelvic pain, bloating, tension, irritability, dysphoria, mood, lability, lack of energy, sleep changes, altered ADLs, social w/d, change in appetite
91
How is the Dx of PMS made
1 somatic and 1 affective sx occurring during the 5 days before menses in each of the 3 prior menstrual cycles relieved w/in 4 days of the onset of menses w/o recurrence until at least cycle day 13
92
what is the Tx of PMS
``` avoid caffeine, alcohol, tobacco,salt stress reduction, exercise, sports bra calcium carbonate-bloating Vit B6 and Vit E Magnesium NSAID SSRI Anxiolytics ```
93
what is Adenomyosis
extension of endometrial glands into uterine musculature
94
what are the signs and symptoms of adenomyosis?
severe secondary dysmenorrhea and menorrhagia or may be asymptomatic
95
how is the dx of adenomyosis?
r/o other major causes of pain/bleeding | endometrial bx, D&C or hysteroscopy will rule out ednometrial cancer
96
what is the Tx for adenomyosis?
D&C HnRH agonist hysterectomy
97
what is endometriosis
condition in which endometrial tissue grows outside the endometrial cavity found almost exclusively in pre-menopausal women starts in 20-30s
98
where is the most common site for endometriosis?
ovary
99
where are other common sites of implantation for endometriosis?
``` fallopian tubes Uterine cul de sac uterosacral ligaments uterus colon lung brain scar tissue ```
100
what are complications of endometriosis/
``` adhesions infertility chronic pain endometriomas obstruction and impairment of vital organs catamenial pneumothoraces caramenial seizures ```
101
what are the positive risk factors for endometriosis?
``` Fm Hx Early menarche long duration of menstrual flow heavy bleeding during menses shorter cycles ```
102
what are negative risk factors for endometriosis
regular exercise higher parity longer duration of lactation
103
what were the signs/symptoms of endometriosis
the extent of the dz does not correlate with the severity of the symptoms maybe completely asymptomatic secondary dysnmenorrhea infertility chronic pelvic pain bloody stools, hematuria, pain w defecation or urination
104
what will the physical exam look like for Endometriosis?
may have no evidence on PE tender nodules in the posterior vaginal fornix pain upon uterine motion uterus may be fixed and retroverted d/t adhesions tender adnexal mass implants in healed wounds
105
how is endometriosis diagnosed?
direct visualization of lesions/implants is required -lapraoscopy diagnostic imaging studies do not help in the diagnosis w/ the exception of ruling out other disorders
106
how is endometriosis treated
based on severity of symptoms, location and severity of dz medical surgical
107
what is the medical tx for endometriosis?
``` 1st line NSAIDs hormonal tx (goal is to interrupt the cycles of stimulation and bleeding of endometrial tissue) (OCP's progestins) 2nd line: high dose progestin (medroxyprogesterone acetate)-induces pseudomenopause GnRH agonists ```
108
what is the surgical tx for endometriosis
used in severe dz consevative to preserve fertility attempt to destroy endometriotic tissue laparotomy
109
what is the definitive tx for endometriosis
TAH

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