Phillips - Menstrual Abnormalities + Miscellaneous Flashcards
(46 cards)
1
Q
What is menorrhagia?
A
- Heavy, but regular uterine bleeding
- NO intra-menstrual bleeding
- May be bleeding through pad, or onto her pants, or passing clots
2
Q
What is metrorrhagia?
A
- Bleeding between menses
- May be spotty or heavy
3
Q
What is menometrorrhagia?
A
- Heavy, irregular bleeding
- Very disconcerting, and may need to be treated
4
Q
What are the two categories of causes of menstrual abnormalities?
A
- Hormonal
- Structural (incl. neoplastic processes): something going on in the uterus, or cancer
5
Q
Who is likely to have ovulatory dysfunction? How might it present?
A
- Consider pt’s age -> peripubertal, perimenopausal pts more likely to have ovulatory dysfunction
- History: irregular, occasionally heavy bleeding
- Problem is anovulatory cycles -> if not ovulating, or not ovulating regularly, there will be no regular menses, and menstrual cycle will be irregular, and may be heavy
- Plenty of estrogen, but insufficient progesterone because she did not ovulate
6
Q
What if an adolescent presents with irregular bleeding?
A
- More of a nuisance; common in first couple years after menarche
- Very rare for it to be so heavy pt becomes anemic
- No need for an exam when adolescent presents with irregular bleeding -> reassurance that things will get better with time
- Treatment (if needed): OC’s or course of cyclic progesterone (attempt to reproduce normal cycle)
1. Sexually active: OCP’s or Depo-Provera IM! (usually no bleeding with Depo, which is fine)
2. Probably start with birth control pill or progesterone to simulate a normal cycle
7
Q
What 2 things should you be thinking about if a perimenopausal woman (>40-45) comes in with irregular bleeding?
A
- Likely anovulatory bleeding -> ovulatory dysfunc may result in infrequent bleeding, lighter menses or irregular bleeding
- BUT also older women at-risk for neoplasia which may present with menometrorrhagia -> must rule this out, incl. endometrial cancer or predisposing endometrial patterns
- This is different than the 15-y/o because the 45-y/o could have NEOPLASIA, so you have to rule that out before you proceed in treating anovulation
8
Q
If diagnosis of anovulatory bleeding is made in a perimenopausal woman, what next?
A
- Reassurance: nearing menopause
- Or replacement of progestins to establish normal cycle again -> Dr. P prefers progestin-only OCP’s to combo bc estrogen can predispose to VTE, stroke
1. Progesterone is what these pts do not have (can give either 2 wks out of the month, or once/day)
2. If you are not ovulating, you do NOT have progesterone (NO corpus luteum)
3. Oral medroxyprogesterone and Mirena IUD also options
9
Q
What should you be thinking about with anovulatory cycles in women of reproductive age?
A
- Polycystic ovarian syndrome (PCOS): common, and periods of amenorrhea and irregular bleeding
- Cause of infertility bc pt not ovulating
- May be associated with other health issues and metabolic problems -> not just a problem of reproduction
1. Insulin resistance
10
Q
Mom brings 15-y/o for recommendations. Menarche at age 12. She has irregular cycles that are often painful. What do you do?
A
- Several options for treatment, including reassurance
- Her growth would not be stunted by starting estrogen bc if she has started her period, she is mostly done growing
- OC or progesterone are also options for this pt
11
Q
What is the classic symptomatic triad of PCOS?
A
- 1) Anovulation: amenorrhea
1. Oftentimes, patient will tell you she’s never had regular periods -> HALLMARK - 2) Hyperandrogenic state: hirsutism, acne
- 3) Insulin resistance
- Of course, also have polycystic ovaries: attached US -> string of pearls of tiny cysts on cortex of ovary
- NOTE: INC risk of endometrial hyperplasia and cancer due to prolonged periods of amenorrhea; lots of estrogen, and no progestin
12
Q
What is the proposed pathway of PCOS?
A
- Starts with obesity, which is very hard to get under control
- No pulsatile, single release, but rather a low-level, continuous LH release from the pituitary
- Androstenedione: INC insulin resistance, making the patient more prone to obesity and T2D
- Not all patients with PCOS are obese
13
Q
What do you see here?
A
-
Acanthosis nigricans: hallmark of insulin resistance
1. Rough, velvety-appearing, darkened tissue
2. Lipid deposits
3. AA and Caucasians - NOTE: hyperandrogenic state contributes to insulin resistance
14
Q
How do you treat PCOS?
A
- Depends on what patient wants, but WEIGHT LOSS always recommended (for obese patients); as little as 10% change will help with symptomatology
- “Regular periods”: hormone therapy -> OCs DEC androgens (improves acne) by DEC LH
1. Provides regular, predictable menses, and prevents pregnancy - “Decrease unwanted hair”: OCs will help; some w/anti-androgen type progestins -> prevent hair from being produced, but won’t get rid of hair that is already there
1. Dipilatories or laser therapy for hair that is already there - “Pregnancy”: ovulatory agents, i.e., Clomid
1. Metformin: if she already has some insulin resistance, impending diabetes -> sometimes women’s periods will get regular just w/this
15
Q
What are 5 “other” causes of irregular bleeding?
A
- Pregnancy: all work-up in a reproductive aged woman should include a pregnancy test
-
Anorexia: more common in young women, but older women can present w/this too (or bulimia)
1. Gonadotropins (FSH, LH) will be very low (hypothalamic issue)
2. Can be life-threatening, and should be taken very seriously: risk of electrolyte imbalances, sudden death, osteoporosis, and heart disease -
Premature ovarian insufficiency (or failure): early menopause (premature if before age 40): FSH, LH high (>30), and estrogen low
1. Irregular bleeding or amenorrhea - Hypothyroidism: always test TSH -> would be elevated, causing irregular bleeding
- Hyperprolactinemia
- OTHERS: cervical cancer, endometrial cancer, cervicitis, endometrial polyp
16
Q
Appreciate this. Again.
A
Good job!
17
Q
What can you do when medical mgmt fails in tx of abnormal bleeding of hormonal etiology in perimenopausal women?
A
- Endometrial ablation: roller ball technology or laser to burn off endometrium
- Hysterectomy
18
Q
What are 4 causes of hirsutism/virilization?
A
- PCOS or similar process: adipose converts androstenedione to testosterone and estrogens
- Ovarian tumors: can produce abnormally high levels of testosterone (and androstenedione)
- CAH: abnormally high levels of DHEA in adrenal -> non-classical forms may be diagnosed in adulthood
- Constitutional hirsutism: no cause, familial
- NOTE: virilization may incl. deepened voice, hair growth, receding hairline, clitoral enlargement, etc.
19
Q
24-y/o presents with unwanted hair growth. This has been a chronic condition. On questioning, she has irregular menses and has not had a period in 3 months. What hormone will be elevated if she has PCOS?
A
- If she has PCOS, her androstenedione levels will likely be elevated
20
Q
How can a chronic anovulatory state lead to cancer?
A
- Excess estrogen and no progesterone can lead to endometrial hyperplasia
- This can lead to endometrial cancer
- This is unlikely in young patients, but in a pt over 30, who hasn’t had a cycle in 6 years, you would be concerned, and may biopsy her
- Birth control pills prevent endometrial cancer bc they stimulate ovulation
21
Q
What is a possible neoplastic cause of abnormal bleeding?
A
-
Uterine leiomyomata (aka, uterine fibroid): may cause menorrhagia, even to point of anemia and transfusion, esp. those that impede on uterine wall
1. Sometimes these pts present to ER due to so much bleeding and acute anemia - Risk factors: >35 y/o, AA, family history
-
Uterus enlarged and irregular in shape on US; can be in different places in uterus (attached image)
1. Can be so large the uterus is up to umbilicus or zyphoid, resulting in pressure or pain - Sub-mucosal: may see menorrhagia as a result of fibroids pushing in on surface of the endometrium
22
Q
How are uterine leiomyomatas managed?
A
-
If asymptomatic, no TX as long as patient is not having problematic vaginal bleeding (slow-growing)
1. Growth from small up to umbilicus quickly, have to think about leiomyosarcoma (RARE)
3. NEVER remove benign fibroid for concern about it turning into cancer; you can pick up on this growth via monitoring, or bleeding all of the time (i.e., menometrorrhagia) - Menorrhagia, anemia: NSAIDs will cut down on amount of bleeding or hormonal agents (Mirena IUD, progestin agents, or birth control pills)
- Pressure symptoms or infertility, but pt wants to preserve fertility -> myomectomy, or may take out just one large, dominant fibroid
- Hysterectomy: severe bleeding (need transfusion), pain, failed medical management, child-bearing complete for certain, or beyond reproductive age
23
Q
48-y/o. 7-month history of heavy, irregular bleeding. She has a 12-week size, irregularly shaped uterus, consistent with fibroids. What should you do?
A
- Do an endometrial biopsy
- Don’t give hormones unless you know she does not have cancer
24
Q
What 2 factors are important in assessing cancer risk in pt with abnormal bleeding? If (+) for these factors, what’s next to rule out neoplasia?
A
- HISTORY: menometrorrhagia or any bleeding postmenopausal, then evaluate to rule out cancer
- AGE: >45-y/o, unless has a history of anovulatory cycles, then sooner, i.e., PCOS (bc higher risk of endometrial cancer due to high, unopposed estrogen levels)
- Do these things:
1. Pap smear
2. Endometrial biopsy: simple procedure done in office -> small cannula inserted and small tissue aspirated; looked at by pathologist
a. Simple hyperplasia: tx with progestins bc can be reversed (OTC, for example)
b. Complex with atypia: hysterectomy bc pre-cancerous form
3. Ultrasound: if abnormal, requires pathologic diagnosis
25
How should you triage bleeding abnormalities?
- Triage by:
1. Type of bleeding
2. Age
3. Evaluate with “ruling out cancer” in mind
26
What is the epi of dysmenorrhea?
- _50% of menstruating women_: cramps, pains
- 10% require treatments, including bedrest
- Affects work and school productivity
- Peak age is _20-24 years of age_
- If a patient is going to have severe symptoms, dysmenorrhea appears in 90% of women _within 2 years after menarche_
27
What is the physiologic basis for dysmenorrhea?
- PROSTAGLANDINS: menstrual fluid from pts with dysmenorrhea have higher _PGF2-alpha_ and _PGE2_
1. Infusions of PG cause uterine contractions and pain
2. Anovulatory pts have no dysmenorrhea and low levels of PGs
- PROGESTERONE: predominant hormone in luteal phase -\> suppresses PG receptors, preventing the completion of the arachidonic acid (AA) cascade
1. Falls rapidly at end of the cycle, allowing the endometrium to shed; cascade put in motion, PGs produced -\> AA + receptor sensitization
28
What are the treatments for primary and secondary dysmenorrhea?
- PRIMARY: no known cause
1. _NSAID's_: PG synthetase INH -\> can prevent cascade from AA to PG production if given pre-menses
2. _Hormonal contraceptive_ agents prevent ovulation and progesterone interactions -\> if no progesterone, no INH, and release of INH
- SECONDARY: pain secondary to something like PID scarring, endometriosis, or ovarian cysts
1. _Treat the cause_
29
What is endometriosis?
- Endometrial tissue outside the endometrial cavity that _responds to estrogen and progesterone_ like endometrium
- _Benign_ condition, but causes symptoms due to the activity described above
- Affects 15% of all women; clinically apparent in the _30’s_
30
Where is endometriosis most common?
- _Peritoneal surface of the tube or ovary_ or other peritoneal surfaces
- Bluish-red dot in the attached image -\> know it’s endometriosis via biopsy
1. On the ovary here, with fallopian running right below pointer
31
What is this?
- _Endometriosis_ on bladder or colon
- Dark area is old blood or hemosiderin
- Might be some scarring present around these endometrial implants
32
What do you see here?
- _Chocolate cyst_ from endometriosis: full of old blood
1. Beginning to rupture as being removed: old blood, or blood clot
2. Right ovary and tube appear normal(ish)
- Ovary endometriosis in the image on the left
33
What are the 3 theories for how endometrial tissue gets outside the uterus?
- RETROGRADE FLOW of tissue through tubes -\> drips out, lodges on dependent peritoneal surfaces
1. Pts w/obstructions to outflow of menstrual fluid (imperforate hymen or o/birth defects) often have endometriosis
- TOTIPOTENTIAL CELLS differentiate into endometrial tissue -\> explains presence in lungs?
- HEMATOLOGIC SPREAD: lining escapes through vasculature and ends up in other parts of the body
34
What is the presenting symptom of endometriosis? Tx?
- _Dysmenorrhea_: painful periods
1. Pain begins days before menses, and is a little better on day 1 or 2 (distinct from 1o dysmenorrhea)
- Harder to tx than 1o dysmenorrhea, but _OCPs or Depo-provera_ usually work bc they stop ovulations, stop cascade of progesterone fall to prostaglandin synthetase
1. _NSAID's_ (INH conversion of precursors to PG) -\> schedule dose, beginning 2 days b4 expected menses
- If no relief, laparoscopy, but even if you see endometriotic implants, _biopsy required for dx_
35
What is this?
- Endometriosis histo: glandular structures on the right
- Ovarian stroma on the left
36
What two components must endometrial biopsy have?
- Biopsy of peritoneal surface
- Must have 2 components:
1. Glands
2. Stroma
- Plus hemosiderin
37
What are the "other" symptoms of endometriosis?
- Pelvic mass
- Pelvic pain
- Dyspareunia: pain with intercourse
- _Infertility_: 30-40% of infertile couples, the patient presents with signs of endometriosis
1. Hard to tell from severity/degree of endometriosis alone: some pts have little endometriosis, but are infertile, or have extensive endometriosis, but are NOT infertile
38
How do you dx endometriosis?
- May be suspected on exam
- Diagnosis via laparoscopy AND biopsy of implants to prove they are endometriotic
39
How do you treat endometriosis?
- -Depends on symptomatology and what patient is interested in
- LARGE: pelvic mass needs diagnosis (to rule out cancer) and treatment
1. Laparotomy and removal of mass
2. Hysterectomy and removal of ovaries in women with symptoms and done with childbearing -\> depends on patient’s needs
- PAIN OR INFERTILITY: laparoscopy
1. Fulgarate lesions with cautery or laser treatment: patients often respond well to this
2. Infertility with mild endometriosis: IVF bypassing the tube, and promoting healthy pregnancy, may be in order
- MEDICAL TX: OCPs, depo provera, or mirena IUD; scheduled NSAID's
40
34-y/o G1P0 lawyer trying to conceive. She and her husband have been trying for 15 months. Menses are regular, but having increasingly painful periods since she stopped taking her OC’s 2 years ago. What is your likely plan?
- Proceed with a workup of infertility, including a semen analysis
41
What is premenstrual syndrome (PMS)?
- Physical, psych, behavioral symptoms during same phase of menstrual cycle -\> _dysmenorrhea_, in some cases
- 5-10% of women have severe enough symptoms that they interfere with daily life, and require tx
- _Etiology unknown_; appears to worsen with age
1. Only women who are ovulatory, i.e., not on birth control pills, which relieve symptoms
42
What are the symptoms of PMS?
- Bloating
- Weight gain
- Irritability
- Difficulty concentrating
- Tiredness
- Moodiness
43
How is PMS diagnosed and treated?
- DIAGNOSIS: menstrual and symptom diary or calendar to see if really assoc w/menses, or more constitutional (getting worse at certain time)
1. Helps separate PMS diagnosis from other mood disorders
- TREATMENT: treat symptoms
1. NSAIDs if cramps or dysmenorrhea
2. Diuretics if bloating
3. Oral contraceptives
4. Diet -\> reduce salt (to reduce bloating), respond to cravings (this might be therapeutic); diet/exercise do seem to help
5. SSRIs can be prescribed continuously, or just around the time of menses, if moody
44
Ms. F has mood swings and irritability with every menses. She wonders what medication you can prescribe. What do you tell her?
- Since the cause is unclear, it is best to treat the predominant symptoms
45
What is premenstrual dysphoric disorder (PMDD)?
- Extreme form of PMS
- PMS symptoms of bloating, dysmenorrhea _+ at least 1 of these other symptoms_:
1. Sadness or hopelessness
2. Anxiety or tension
3. Extreme moodiness
4. Marked irritability or anger
- Extreme mood shifts that interfere with work and personal relationships
- Likely that underlying behavioral health issue is present
46
What is the treatment for PMDD?
- Similar to PMS, but much more like a psych illness
- _SSRIs_: all month or only in interval b/t ovulation and start of period -\> depends if underlying mental health disorder is diagnosed
- OCPs
- Regular exercise and proper diet
- _Nutritional supplements_: 1,200mg of Ca daily, Vit. B-6, Mg, and L-tryptophan
- Avoid stressors: avoid triggers, devo coping mech
