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Women's Health Exam 1 > Menstruation > Flashcards

Menstruation Flashcards

(93 cards)

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1
Q

Average menarche age

A

12-13 YO

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2
Q

Average age of menopause

A

51

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3
Q

normal cycle

A

24-38 days
<8 dyas long
5-80 mL blood (30 mL = average)

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4
Q

Primary amenorrhea is considered

A

absence of menstruation by 15 YO w/ secondary characteristics
OR
absence by age 13 w/o secondary characteristics

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5
Q

secondary amenorrhea is considered

A

no period for 3 cycles
OR
6 consecutive months in women who were previously menstruating

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6
Q

Causes of primary amenorrhea

A

gonadal dysgenesis/ POI (most common)
Hypothalamic or pituitary
Outflow tract disorders
receptor abnormality or enzyme deficiency

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7
Q

Dysgensis results in

A

hypergonadotropic hypogonadism

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8
Q

Turner syndrome

A

45 XO
ovaries don’t respond to gonadtropins (one of most common causes of premature ovarian failure)

Results in premature depletion of oocytes and follicles

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9
Q

Presentation of turners

A

short, webbed neck, wide nippl

“streak ovaries” and sexual infantilism

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10
Q

Swyer syndrome

A

46, XY
Mutation in SRY gene - gonads fail to differentiate into testes; lack of AMH, T, and DHT = female external & internal genitalia

NO SECONDARY SEX CHARACTERISTICS (in contrast to AIS)

male appears like female

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11
Q

POI

A

46, XX w/ menopause before age 40

usually presents as secondary amenorrhea but can present as primary

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12
Q

Causes of POI

A

chemo
radiation
FX (FMR1 gene mutation)
autoimmune oophoritis

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13
Q

PCOS

A

rarely causes primary amenorrhea
ovulatory dysfunciton
hyperandrogenism w/ amenorrhea in absence of other causes

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14
Q

Hypogonadotropic hypogonadism

A

low FSH due to:

  • abnormal hypothalamic GnRH secretion (leaing to decreased gonadotropin pulse d/c)
  • congenital absence of GnRH
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15
Q

Hypothalamic amenorrhea

A

abnormal GnRH secretion in absence of patho process; decreased FSH/LH pulsations, low or normal FSH & LH, absent LH surge (absent follicular development & ovulation; low estradiol secretion)

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16
Q

Causes of hypothalamic amenorrhea

A

stressors (eating disorders, physical or psychological stress, weight loss, excessive exercise – female athletes triad)

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17
Q

Kallmann’s syndrome

A

idiopathic hypogonadotropic hypogonadism (congenital GnRH deficiency) + anosmia

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18
Q

Pituitary causes of primary amenorrhea

A
  • micro/macroadenomas (cushings, prolactinomas, thyrotropinomas)
  • Isolated hyperprolactinemia (mainly secondary amennorhea): causes galactorrhea, hypothyroidism & some meds increase prolactin levels
  • infiltrative disease/cranial tumors that cause pituitary stalk compression (sarcoid, hemochromatosis)
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19
Q

Outflow tract disorders

A

Uterine- Mullerian Agenesis (vaginal agenesis)

Vagina- Imperforate hymen & transferse vaginal septum

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20
Q

Mullerian agenesis

A

46, XX w/ congenital absence of oviducts, uterus and upper vagina (normal gonad function: estrogen - breasts)

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21
Q

Imperforate hymen & transferse vaginal septum presentation

A

cyclic pelvic pain & perirectal mass from sequestration of blood in vagina

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22
Q

Androgen insensitivity syndrome (receptor/enzyme abnormality)

A

46, XY w/ female phenotype
Abnormality of androgen receptor (complete or partial)
- testes make T and AMH but body is not responsive
- high T concentrations!!!

Have breast development, absence of acne, & voice changes at puberty & absent axillary/pubic hair

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23
Q

Dx for AIS

A

Pelvic US- absent upper vagina, uterus & fallopian tube; tests remain in intra-abdominal or partially descended (mistaken for hernia)

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24
Q

Tx for AIS

A

remove testes (risk of testicular CA)

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25
5-alpha reductase deficiency
46, XY can't convert T to DHT (no differentiation of male genitaliea) AMBIGUOUS GENITALIA @ BIRTH Undergo virilization @ puberty but no enlargement of external genitalia or prostate
26
Ambiguous genitalis
5-alpha reductase deficiency
27
17-alpha hydroxylase deficiency
46, XX or XY | lack enzyme to produe cortisol or sex steroids; overproduction of mineralcorticoids (high ACTH)
28
Presentation of 17-alpha deficiency
female w/ HTN and lack of pubertal development OR 46, XY w/ incompletely developed external genitalia
29
HTN
17-alpha hydroxylase deficiency
30
When to initiate eval for amenorrhea
15 w/ no bleeding 13 w/ no menses or thelarche No menarche w/i 3 years of thelarch
31
Order of sexual development
thelarche > pubarche > growth spurt > menarche | "boobs, pubes, grow, flow"
32
Anosmia
Kallman Syndrome
33
Virilization/hirsutism
PCOS
34
Labs for primary amenorrhea
``` Urine/serum HCG serum FSH prolactin TSH Pelvic u/s (uterus?) ``` no uterus: karyotype & total T (mullerian agenesis (XX) or AIS (XY)) elevated FSH: Karyoptype (XO = turner, XY = swyer) FSH low/normal: + breast: outflow tract or endocrine (PCOS, hyperprolactinemia, thyroid disease) - breast: recheck FSH, LH, consider pituitary MRI (congenital GnRH deficiency or constitutional delay of puberty)
35
Tx for primary amenorrhea
based on underlying etiology Goals: - treat cause - restore ovulatory cycle/preserve fetility - prevent complications (hypoestrognemia - osteoporosis) Psych counseling Refer to endocrinologist/gyne Surgical referral for outlet obstruction or gonadectomy
36
Causes of secondary amenorrhea
PREGNANCY Ovarian dysfunction Hypothalamic dysfunction Pituitary dysfunction Uterine dysfunction
37
PCOS
2/3 to diagnose: - androgen excess (acne, hirsutisim, elevated T) - ovulatory dysfunction (amenorrhea or oligomenorrhea - polycystic ovaries
38
Causes of ovarian dysfunction
PCOS POI Hyperandrogenism (tumors secreting androgens- lead to pronounced virilization)
39
Etiologies of POI
turner FX autoimmune ovarian destruction radiation/chemo
40
Hypothalamic & pituitary causes of secondary amenorrhea
Functional hypothalamic amennorhea (weight loss, exercise, nutritional deficiencys, stress, inflammation, lesions, celiac, head trauma) ``` Pituitary disease - hyperprolactinemia - prolactinoma or med induced (antipsychotics) Sheehan syndrome (postpartum pituitary necrosis due to hemorrhage and hypotension) Iron deposition (hemosiderosis) Primary hypothyroidism (thyrotroph/lactotroph) ```
41
Meds causing prolactinemia
antipsychotics
42
Sheehan syndrome
Postpartum amenorrhea resulting from postpartum pituitary necrosis secondary to severe hemorrhage and hypotension
43
Asherman's Syndrome (uterine dysfunction)
scarring of endometrial lining, usually secondary to postpartum hemorrhage or endometrial infection followed by instrumentation such as dilation and currettage
44
Acanthosis nigricans
PCOS
45
Exopthalmos, goiter, abnormal DTRs
Hypothyroidism
46
Galactorrhea
Pituitary tumor
47
Labs for secondary amenorrhea
``` urine/serum HCG FSH Prolactin TSH Total Testosterone (if evidence of hyperandrogenism) ```
48
Imaging for secondary amenorrhea
Pevlic US Pituitary MRI Adrenal CT (if significant virilization & elevated T)
49
Progesterone challenge
no withdrawal bleed = no estrogen (low FSH) - functional hypothalamic amenorrhea withdrawal: PCOS
50
Abnormal uterine bleeding (AUB)
<24 or >38 days bleed > 8 days >80 mL blood loss intermenstrual bleeding
51
Types of AUM
AUM/HMB (heavy menstrual bleeding) | AUM/IMB (intermenstrual bleeding)
52
Etiologies of AUM (PALM-COEIN)
Polyp adenomyosis (endometrium into myometrium) Leiomyoma (fibroids) Malignancy & endometrial hyperplasia ``` Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic (anticoags, hormonal contraceptives) Not otherwise classified ```
53
13-18 YO AUM
``` anovulation OCP Pelvic infection coagulopathy tumor MOST COMMON: immature HPO axis ```
54
19-39 YO AUM
``` pregnancy lesions (leiomyoma, polyp) Anovulatory cycles (PCOS) OCP endometrial hyperplasia endometrial CA ```
55
40-menopause AUM
anovulatory bleeding endometrial hyperplasia/carcinoma Endometrial atrophy Leiomyoma
56
Anovulation
immature HPO axis
57
Menorrhagia
anovulation or bleeding disorder
58
Amenorrhea
``` pregnancy chromosomal abnormality hypothalamic hypogonadism congenital absence of uterus cervix/vagina structural abnormalities ```
59
Most common presentation of anovulatory AUB
UNPREDICTABLE, varying bleeding amounts & intervals related to hypothalamic abnormalities or PCOS
60
Ovulatory AUB presentation
regular cycle length; Mittelschmerz, PMS sx, changes in cervical mucus Menorrhagia, polymenorrhea, oligomenorrhea, intermenstrual bleeding
61
menorrhagia
lesions coag disorder liver failure renal failure
62
Polymenorrhea
luteal-phase disorder | short follicular phase
63
Oligomenorrhea
prolonged follicular phase
64
Intermenstrual bleeding
due to cervical pathology (dysplasia, infection) or an IUD
65
Perimenopause age
47 years
66
What is perimenopause
5-10 years before menopause (51); anovulation due to decliniing # of follicles lengthened intermenstrual intervals, skipped cycles, episodes of amenorrhea
67
When to get bx for intermenstrual bleeding
frequent, heavy or prolonged bleeding (hyperplasia or cancer)
68
Postmenopausal bleeding
ABNORMAL! endometrial carcinoma assess w/ pelvic US or EMB
69
Mittelschmerz
one sided pain in abdomen due to ovulation
70
Molimina symptoms
breast tenderness ovulatory pain bloating
71
Dx for anovulatory bleeding suspected
CBC, TSH, prolactin, fasting glucose w/ fasting insulin | Screen for eating disorders, stress, female athlete triad
72
Suspect ovulatory bleeding dx
Menorrhage: CBC: consider LFT, Bun/Creat, coag Order pelvic US (exclude fibroids) EMB to exclude endometrial hyperplasia intermenstrual bleed: pap and cervical culture
73
Who should get EMB?
postmenopause w/ any bleeding 45 YO - menopause w/ AUB: if ovulatory OR if bleeding is frequent, heavy or prolonged (>5 days) Age <45 w/ AUB and: - risk factors of unopposed estrogen exposure (obesity, chronic anovulation, PCOS) - persistent bleeding - failed management for AUB
74
Management for unstable bleeding
admit | IV estrogen or possible D&C
75
Management of acute AUB in stable patients
outpatient Hormonal: - COC (monophasic w/ 35 mcg ethinyl estradiol- 3 pills qd x 7 days) - medroxyprogesterone (provera) orally - High dose estrogen w/ antiemetic Tranxemic acid (lysteda) IV or oral ( those who don't wanna take hormones)
76
Medical tx for chronic AUB
hormones: - levonorgesterel (mirena) IUD - depot medroxyprogesteron (depo-provera) - estrogen/progestin OCP Tranexamic acid (lysteda) - 3x/day for up to 5 days during menstruation NSAIDs - 1st day of bleeding til cease
77
Surgery for chronic AUB
endometrial ablation Hysterectomy (extreme cases) Endometrial artery embolization/myomectomy (leiomyomas)
78
Primary dysmenorrhea
painful mesntraution w/ no patho cause occurs during ovulatory cycle age 17-22 is typical age
79
Secondary dysmenorrhea
painful menstruation due to underlying disease (endometriosis, adenomyosis, uterine fibroids) More common as woman ages
80
Cause of pain
uterine contractions and ischemia due to prostaglandin release
81
Primary dysmenorrhea presentation
``` few hours before or just after onset of menstruation Lasts 12-72 hours cramp-like/intermittent lower abdomen radiate to back/thighs N/V/D, h/a, LBP, fatigue Pelvic exam normal ```
82
Tx for primary dysmenorrhea
heat/massage/exercise/yoga nutritional supplements (increase dairy consumption, B complex) Smoking cessation NSAIDS (first line: ibuprofen 400 mg PO q 4-6 hours x 3-4 days) Hormonal contraceptives (COC, mini pill, depo, mirena IUD)
83
Resistant cases of primary dysmenorrhea
laparoscopy and/or possible GnRH analogue
84
F/u and referral needed if
``` pain worse w/ each menses last longer than 2 days of menses meds don't help pain menstrual bleeding becomes heavier pain accompanied by fever abnormal d/c or bleeding pain occurs at time unrelated to menses ```
85
Common causes of secondary dysmenorrhea
``` endometriosis adenomyosis adhesion PID Leiomyomas ```
86
Tx for secondary dysmenorrhea
treat underlying cause | Hormone (COCs) -- progestin or NSAIDS if contraindicated for estrogen
87
Complicated secondary dysmenorrhea tx
diagnostic laparoscopy hysterectomy oophorectomy myomectomy
88
PMS
A group of physical and behavioral changes that occur in a regular, cyclic relationship to the LUTEAL PHASE that interfere with some aspect of the patient’s life
89
PMDD
PMS w/ more severe emotional sx
90
Cause of PMS
unknown; due to hormone fluctuations triggering an abnormal serotonin response Progesterone increases MAO --> MAO reduces serotonin availability --> serotonin is decreased in the progesterone-dominant luteal phase
91
Dx criteria for PMA
1-4 sx that are physical/behavioral or affective/psych in nature OR >5 sx that are physical or behavioral - presence of at least one sx occuring in luteal phase - leads to impairment in functioning - sx remit @ menses
92
Non-pharm tx for PMS
``` decrease salt/caffeine/alcohol aerobic exercise supplement Mg, Ca (swelling/pain) acupuncture, yoga Cognitive therapy ```
93
Pharm tx for PMS
``` SSRI (1st line for PMDD) - continuous or luteal phase Oral contraceptives (Yaz) NSAIDs Spironolactone (bloating) GnRH agonist (refractory) ```

Women's Health Exam 1 (5 decks)

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