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Women’s Health EOR > Menstruation > Flashcards

Menstruation Flashcards

1
Q

Define amenorrhea. Initial work-up components

A 
Absence of menses 
Workup:
Pregnancy test
Serum prolactin
FSH, LH
TSH
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2
Q

Define primary amenorrhea

A

Failure of menarche onset:

  • By age 15 in the presence of secondary sex characteristics
  • By age 13 in the absence of secondary sex characteristics
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3
Q

Etiologies?
>15y/o with amenorrhea
Breast present, uterus present

A

Outflow obstruction
Transverse vaginal septum
Imperforate hymen

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4
Q

Etiologies?
>15y/o with amenorrhea
Breast present, uterus absent

A 
Mullerian agenesis (46 XX)
Androgen insensitivity (46 XY)
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5
Q

Etiologies?
13y/o with amenorrhea
Breast absent, uterus present

A 
Elevated FSH/LH -> Ovarian causes
Premature ovarian failure (46 XX)
Gonadal dysgenesis (ex. Turner’s 45 XO)
Normal-low FSH/LH:
hypothalamus-pituitary failure 
Puberty delay 
Athletes
Illness
Anorexia
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6
Q

Etiologies?
13y/o with amenorrhea
Breast absent, uterus absent

A

Breast absent, uterus absent-> Rare. Usually caused by a defect in testosterone synthesize. Presents like a phenotypic immature girl w/ primary amenorrhea (will often have intra-abdominal testes)

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7
Q

Etiologies?

Secondary amenorrhea

A

Pregnancy -> MC

Hypothalamus dysfunction (35%)
Path: disruption of normal pulsatile hypothalamic secretion of GnRH that directly leads to subsequent dec FSH and/or dec LH secretion by the pituitary gland

Pituitary Dysfunction (prolactin-secreting pituitary adenoma; 19%)

Ovarian Disorders
Path:
Polycystic Ovarian Syndrome
Premature Ovarian Failure 
Follicular failure or follicular resistance to LH or FSH
Turner’s syndrome

Uterine Disorders
Path:
Scarring of the uterine cavity
Asherman’s syndrome = acquired endometrial scarring secondary to postpartum hemorrhage, s/p D&C or endometrial infection

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8
Q

Secondary amenorrhea due to hypothalamus dysfunction
Path
Dx
Tx

A

Path: disruption of normal pulsatile hypothalamic secretion of GnRH that directly leads to subsequent dec FSH and/or dec LH secretion by the pituitary gland

  • Hypothalamic disorders
  • Anorexia/weight loss 10% below ideal body weight)
  • Exercise
  • Stress
  • Nutritional deficiencies
  • Systemic disease (Celiac)

Dx:
Normal-low FSH & LH
Low estradiol, normal prolactin

Tx: stimulate gonadotropin section
Clomiphene
Menotropin

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9
Q

Secondary amenorrhea due to pituitary dysfunction
Path
Dx
Tx

A

Path: prolactin-secreting pituitary adenoma

Dx:
Dec FSH, LH
Inc prolactin (galactorrhea)
MRI of pituitary sella; prolactin inhibits GnRH

Tx: transsphenoidal surgery (tumor removal)

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10
Q

Secondary amenorrhea due to ovarian disorders
Path
Pt
Dx

A 
Path:
Polycystic Ovarian Syndrome
Premature Ovarian Failure 
Follicular failure or follicular resistance to LH or FSH
Turner’s syndrome

Pt: sx of estrogen deficiency (similar to menopause)-> Hot flashes, Sleep and mood disturbances, Dyspareunia, dry/thin skin, Vaginal dryness/atrophy

Dx:
Inc FSH, LH and dec estradiol -> ovarian abnormalities (primary disorder)
Normal-dec FSH, LH -> pituitary or hypothalamus abnormalities (secondary or tertiary)
Progesterone Challenge Test: 10mg medroxyprogesterone x10 days
+withdrawal bleeding -> ovarian (pt is anovulatory or oligoovulatory) and there is enough estrogen present (which built up endometrial lining)
No withdrawal bleeding:
Hypoestrogenic: ex-> Hypothalamus-pituitary failure
Uterine: ex-> Asherman’s or uterine outflow tract (imperforate hymen)

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11
Q

Secondary amenorrhea due to uterine disorders
Path
Dx
Tx

A

Path:
Scarring of the uterine cavity
Asherman’s syndrome = acquired endometrial scarring secondary to postpartum hemorrhage, s/p D&C or endometrial infection

Dx:
Pelvic U/S: absence of normal uterine stripe
Hysteroscopy: to dx and tx

Tx:
Estrogen tx to stimulate endometrial regeneration and the denuded area

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12
Q

Cryptomenorrhea

A

light flow or spotting

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13
Q

Menorrhagia

A

heavy or prolonged bleeding @ normal menstrual intervals

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14
Q

Metrorrhagia

A

irregular bleeding between expected menstrual cycles

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15
Q

Menometrorrhagia

A

irregular, excessive bleeding between expected menstrual cycles

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16
Q

Oligomenorrhea

A

infrequent menstruation (prolonged cycle length >35 days but <6m)

17
Q

Polymenorrhagia

A

frequent cycle interval (<21 days)

18
Q

Define dysfunctional uterine bleeding

A

abnormal frequency/intensity of menses due to non-organic causes. Normal cycle: 24-38 days w/ menstruation lasting 4.5-8 days

19
Q

Dysmenorrhea
Path
Pt
Tx

A

Painful menstruation that affects normal activities
Path:
-Primary: not due to pelvic pathology
Inc prostaglandins -> painful uterine muscle wall activity.
Pain usually starts 1-2 yrs after onset of menarche in teens
-Secondary: due to pelvic pathology
endometriosis, adenomyosis, leiomyomas, adhesions, PID
Inc incidence as women age (>25 yrs)

Pt:
Diffuse pelvic pain right before or with the onset of menses (+/- lower abdomen, suprapubic or pelvic pain that may radiate to lower back and legs)
May be associated with HAs, N/V
Cramps usually last 1-3 days
PE: normal

Tx:
NSAIDs
Ovulation suppression
Laparoscopy

20
Q

Menopause
Path
Pt
Tx

A

Path:Cessation of menses >1yr due to loss of ovarian dysfunction
~50-52 year old
Pt
Estrogen deficiency changes: menstrual cycle alterations, vasomotor instability (hot flashes), mood changes, skin/nail/hair changes, inc CV events, HLD, osteoporosis, dyspareunia (due to vaginal atrophy), urinary incontinence
Atrophic vaginitis: thin, yellow discharge, vaginal pH >5.5, pruritus
Irregular menstrual cycles but no premenstrual symptoms
Dx
PE: dec bone density, skin-> thin, dry, decreased elasticity, vaginal-> atrophy thin mucosa
FSH assay most sensitive initial test (inc serum FSH >30 IU/mL)
Inc serum FSH, Inc LH, Dec estrogen
-Due to depletion of ovarian follicles
-Androstenedione levels don’t change
-Estrone is the predominant estrogen after menopause
Tx
Vasomotor insufficiency/hot flashes: estrogen, progesterone, clonidine, SSRIs, gabapentin
Vaginal atrophy: estrogen (transdermal, intravaginal)
Osteoporosis prevention:
-Calcium + Vitamin D
-Weight bearing exercise
-Bisphosphonates
-Calcitonin
-Estrogen (+/- progesterone)
-SERM-> raloxifene, tamoxifen
Hormone Replacement therapy (RCT):
Estrogen only, estrogen + progesterone

21
Q

Define premature menopause and associated factors

A 
Premature menopause: menopause before the age of 40. May occur sooner in pts w/:
DM
Smokers
Vegetarians 
Malnourished pts
22
Q

Complications for menopause

A

Inc osteoporosis (inc fractures)
Inc CV risks
Inc lipids

23
Q

HRT risk and benefits of

Estrogen only

A

Benefits:
most effective sx tx (mood, hot flashes, vaginal atrophy)
Transdermal or vaginal preferred vs PO
No increased risk of breast cancer

Risks:
Inc risk of endometrial cancer (unopposed estrogen) so often used in pts w/ no uterus (s/p hysterectomy)
Thromboembolism (CVA, DVT, PE)
Liver disease

24
Q

HRT risk and benefits of

Estrogen + Progesterone

A

Continue dose daily doesn’t cause menstrual-like bleeding
Sequential (cycling): dose changes- can cause menstrual like bleeding but less often than normal cyclical bleeding

Benefits: 
Sx relief 
Dec heart and stroke risk
Dec osteoporosis 
Dec dementia 
Protective against endometrial cancer-> often used if pt still have intact uterus (progestin protect against unopposed estrogen that may lead to endometrial cancer)

Risks:
Venous thromboembolism
+/- slightly inc risk of breast cancer (controversial)

25
Q

Etiologies for abnormal uterine bleeding

A 
PALM-COEIN
Structural causes for abnormal uterine bleeding:
-Polyp
-Adenomyosis
-Leiomyoma
-Malignancy and hyperplasia 
Non-structural causes for abnormal uterine bleeding: 
-Coagulopathy 
-Ovulatory
-Endometrial
-Iatrogenic
-Not yet classified
26
Q

Polyps
path
dx

A

Path:
-Epithelial proliferations composed of endometrial glands and fibrotic stroma
-Common; 10-30% women with AUB have polyps
-Usually benign
Dx:
TVS (transvaginal U/S)
SIS (saline infused sonography) “saline hyst”
Hysteroscopy
Color flow doppler-> visualization of a single feeding vessel

27
Q

Adenomyosis
Path
Pt
Dx

A

Path:
-Direct extension of endometrial glands and stroma beyond the basalis
-Incidence may >60% of women 30-35, most are parous
-Diffuse type MC, focal involvement is termed adenomyoma
Pt:
-Secondary dysmenorrhea
-enlarged, globular uterus
Dx:
-U/S: Globular uterine enlargement not explained by leiomyomata, Uterine wall thickening w/ anteroposterior asymmetry, Obscure endometrial/myometrial border
-MRI
-Histopathologic (up to 1/3 of hysterectomy specimens)

28
Q

Leiomyoma
Path:
Types:
Tx:

A 
Path:
-Benign fibromuscular tumors of the myometrium 
-When symptomatic, AUB MC sx
-Proposed etiology: venous congestion within uterus 
Types:
-Pedunculated 
-Intracavitary 
-Submucosal 
-Intramural 
-Subserosal 
Tx: 
-Observation
-Medical therapy
-Myomectomy
-Hysterectomy 
-Alternatives: uterine artery embolization, high intensity focused U/S
29
Q

Abnormal uterine bleeding
malignancy and hyperplasia
Path:
Endometrial cancer risk factors:

A 
Path:
-Most endometrial cancers arise from progression of endometrial hyperplasia-endometrial thickening with proliferation of irregularly sized and shaped glands with increased gland to stroma ratio 
-Hyperplasias are designated atypical if they demonstrate nuclear atypia 
Endometrial cancer risk factors: 
-Unopposed estrogen (#1 risk factor) 
-Obesity
-Early menarche, late menopause
-Nulliparity
-Tamoxifen use (in postmenopausal women)
-Hereditary nonpolyposis colorectal cancer, breast and ovarian cancer
-DM, HTN
-Age (post-menopausal women)
-Prior pelvic irradiation
30
Q

Abnormal uterine bleeding
Coagulopathy
Path:

A

Path:

  • Coagulation defect-> Von willebrand disease MC
  • Meds:Coumadin, heparin, ASA, NSAIDs
31
Q

Abnormal uterine bleeding
Ovulatory
Path:

A 
Absence of cyclic progesterone production from the corpus luteum every 22-35 days produces abnormal uterine bleeding 
Common endocrinopathies: 
-PCOS
-Hypothyroidism
-Hyperprolactinemia 
-Obesity
-Mental stress
-anorexia, weight loss, extreme exercise
32
Q

Abnormal uterine bleeding
Endometrial
Path:

A

When heavy menstrual bleeding occurs in the context of predictable and cyclic bleeding typical of ovulatory cycles and no other identifiable cause is identified, the mechanism is probably a primary disorder of the endometrium
Examples:
-disorders of endometrial hemostasis
-deficiencies in local production of vasoconstrictors or vasodilators
-accelerated lysis of endometrial clot from overproduction of plasminogen activator
-disorders of endometrial repair
-inflammation
-infection

33
Q

Abnormal uterine bleeding
Iatrogenic
Path:

A 
Medical interventions or devices
OCPs
Patches
DMPA?
Mirena
TCAs, phenothiazines, drugs that impact serotonin uptake may cause ovulatory dysfunction and result in AUB
34
Q

Abnormal uterine bleeding
Not yet classified
Path:

A

Chronic endometritis
Arteriovenous malformations
Myometrial hypertrophy

Women’s Health EOR (17 decks)

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