Menstruation

Question 1

Define amenorrhea. Initial work-up components

Answer 1

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

Question 2

Define primary amenorrhea

Answer 2

Failure of menarche onset:

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

Question 3

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

Answer 3

Outflow obstruction
Transverse vaginal septum
Imperforate hymen

Question 4

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

Answer 4

Mullerian agenesis (46 XX)
Androgen insensitivity (46 XY)

Question 5

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

Answer 5

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

Question 6

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

Answer 6

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)

Question 7

Etiologies?

Secondary amenorrhea

Answer 7

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

Question 8

Secondary amenorrhea due to hypothalamus dysfunction
Path
Dx
Tx

Answer 8

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

Question 9

Secondary amenorrhea due to pituitary dysfunction
Path
Dx
Tx

Answer 9

Path: prolactin-secreting pituitary adenoma

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

Tx: transsphenoidal surgery (tumor removal)

Question 10

Secondary amenorrhea due to ovarian disorders
Path
Pt
Dx

Answer 10

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)

Question 11

Secondary amenorrhea due to uterine disorders
Path
Dx
Tx

Answer 11

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

Question 12

Cryptomenorrhea

Answer 12

light flow or spotting

Question 13

Menorrhagia

Answer 13

heavy or prolonged bleeding @ normal menstrual intervals

Question 14

Metrorrhagia

Answer 14

irregular bleeding between expected menstrual cycles

Question 15

Menometrorrhagia

Answer 15

irregular, excessive bleeding between expected menstrual cycles

Question 16

Oligomenorrhea

Answer 16

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

Question 17

Polymenorrhagia

Answer 17

frequent cycle interval (<21 days)

Question 18

Define dysfunctional uterine bleeding

Answer 18

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

Question 19

Dysmenorrhea
Path
Pt
Tx

Answer 19

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

Question 20

Menopause
Path
Pt
Tx

Answer 20

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

Question 21

Define premature menopause and associated factors

Answer 21

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

Question 22

Complications for menopause

Answer 22

Inc osteoporosis (inc fractures)
Inc CV risks
Inc lipids

Question 23

HRT risk and benefits of

Estrogen only

Answer 23

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

Question 24

HRT risk and benefits of

Estrogen + Progesterone

Answer 24

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)

Question 25

Etiologies for abnormal uterine bleeding

Answer 25

``` 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 ```

Question 26

Polyps path dx

Answer 26

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

Question 27

Adenomyosis Path Pt Dx

Answer 27

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)

Question 28

Leiomyoma Path: Types: Tx:

Answer 28

``` 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 ```

Question 29

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

Answer 29

``` 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 ```

Question 30

Abnormal uterine bleeding Coagulopathy Path:

Answer 30

Path: - Coagulation defect-> Von willebrand disease MC - Meds:Coumadin, heparin, ASA, NSAIDs

Question 31

Abnormal uterine bleeding Ovulatory Path:

Answer 31

``` 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 ```

Question 32

Abnormal uterine bleeding Endometrial Path:

Answer 32

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

Question 33

Abnormal uterine bleeding Iatrogenic Path:

Answer 33

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

Question 34

Abnormal uterine bleeding Not yet classified Path:

Answer 34

Chronic endometritis Arteriovenous malformations Myometrial hypertrophy