Disorders of Menstruation and the Uterus Flashcards Preview

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Flashcards in Disorders of Menstruation and the Uterus Deck (102)
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1

1. What is amenorrhea?
Describe what would consitute amenorrhea in the following ages:
2. By age 15 in presence of what? 4
3. At age 13 in the absence of what?
4. At age 12-13 evaluate what?

1. DEFINITION: No history of any menses

2. normal growth and secondary sexual characteristics
3. secondary sexual characteristics
4. evaluate cyclic menstrual pain
(inperforate hymen)

2

Amenorrhea: Primary
Etiologues?
5

1. Chromosomal abnormality (gonadal dysgenesis, Turner’s syndrome) 50%

2. Hypothalamic hypogonadism 20%

3. Mullerian agenesis (absence of uterus, cervix and vagina 15%

4. Transverse vaginal septum or imperforate hymen 15%

5. Other:
-CAH,
-PCOS,
-androgen insensitivity

3

Amenorrhea: Primary
Hx findings?
9

1, cyclic pelvic pain,
2. other stages of puberty,
3. headaches,
4. virilization,
5. galactorrhea,
6. medications,
7. stressors, weight change
8. illness
9. FH of delayed puberty

4

Amenorrhea: Primary
Possible Exam findings?
3

1. Tanner Staging (Breast development is a marker for Estrogen = Ovary)

2. Pelvic exam to confirm patent hymen and presence of vagina

3. Signs of Turner’s (low hairline, web neck, widely spaced nipples with shield chest)

5

Amenorrhea: Primary
1. Initial Lab?

2. Further lab based upon what? 2

3. What could these furthers labs be? 5

4. Initial imaging? 1

1. FSH

2.
-FSH and
-presence or absence of breast development and uterus

3. could include
-karyotype,
-testosterone,
-TSH,
-prolactin and
-pregnancy test

4. Initial imaging: ultrasound to confirm uterus

6

Amenorrhea: Secondary
1. RULE OUT WHAT?
2. Ovarian causes? 2
3. Hypothalamic causes? 3
(What is decreased in hypothalamic causes?)

1. PREGNANCY
2. OVARIAN 40%
-PCOS 20%
-Primary Ovarian Insufficiency (PCO) less than 40 yo

3. HYPOTHALAMIC
-Weight loss and exercise
-Nutritional deficiencies: low body fat; celiac
-Emotional stress or illness
(FUNCTIONAL (decreased GnRH))

7

Amenorrhea: Secondary
1. Nonfunctional hypothalamic causes? 1
2. Pituitary causes? 4
3. Uterine causes? 2

1. Hypothalamic
Infiltrative tumors (rare)

2. Pituitary
-Hyperprolactinoma
-Other causes of elevated prolactin
-Injury to pituitary
-Hypothyroidism

3.
-Asherman’s syndrome (acquired scarring of cavity)
-Tuberculosis

8

What are some injuries to the pituitary that would cause secondary amenorrhea?
3

1. Sheehan’s syndrome,
2. radiation,
3. infiltrative disease like hemochromatosis

9

Amenorrhea: Secondary
Hx questions?
9

1. Menstrual hx
2. Exercise and eating patterns,
3. Medications that may increase prolactin
4. Stress
5. Post partum hemorrhage
6. Radiation to head
7. Headaches
8. Hot flashes
9. Uterine surgeries

10

Amenorrhea: Secondary
exam? 4

Initial labs? 6

1. BMI,
2. hirsutism
3. galactorrhea
4. UTERINE SIZE

1. pregnancy test,
2. FSH,
3. TSH,
4. prolactin,
5. possibly testosterone and
6. DHEA-S

11

What is dysmenorrhea?

Painful periods

12

1. Describe what primary dysmenorrhea is?
2. How does it typically present? 3
3. Describe what secondary dysmenorrhea is? Associated with which dz processes? 3

1. Primary: No obvious cause, typically

2. begins in adolescence as -
-crampy,
-midline lower abdominal pain
-associated with onset of menses

3. Secondary: Symptoms attributed to specific problem like
-endometriosis,
-adenomyosis or
-fibroids or PID

13

Dysmenorrhea: Primary
Risk factors?
8

1. Age less than 30
2. BMI less than 20
3. Smoking
4. Menarche less than 12
5. Irregular/prolonged/heavy menses
6. Hx of sexual assault
7. Family hx
8. Younger age of first child and higher parity lower risk

14

1. Dysmenorrhea: Primary
PP?

2. Uterine ischemia results in what?

1. Prostaglandins released with endometrial sloughing induce contractions

2. anaerobic metabolites which stimulates type C pain neurons

15

Dysmenorrhea: Primary
Presentation?
4

1. Pain begins after ovulatory cycles established

2. May start 1-2 days before menses; gradually diminishes over 12-72 hours

3. Unilateral pain or non-cyclic pain suggests other dx

4. Nausea, diarrhea, headache may be present

16

Dysmenorrhea: Primary
Dx?
4

1. No physical exam findings
2. No lab abnormalities
3. No imaging study findings
4. Dx by history and normal exam

17

Dysmenorrhea: Primary
1. General evaluation?
2. What things suggest secondary causes? 5

1. EVALUATION: Focus on exclusion of secondary dysmenorrhea:

2.
- Onset of symptoms >25
- Nonmidline pain
- Dyspareunia
- Progression of symptoms
- Abnormal uterine bleeding suggest secondary causes

18

Dysmenorrhea: Primary
Firstline Rx?
4

1. Self-care: heating pad, exercise and relaxation techniques

2. NSAIDs

3. Suppression of menses with contraceptive hormones

4. Limited data and small studies report reduced cramps with diet and supplements: low fat-vegetarian diet;3-4 dairy servings/day; vit E 2 days before thru 1st 3days of menses; 1-2 gm fish oil/d; Vit B1 100 mg/d; vit B6 200 mg/d

19

Dysmenorrhea: Secondary
Causes?
10

1. Endometriosis 2. Adenomyosis
3. Fibroids 4. Ovarian cysts
5. Intrauterine/pelvic adhesions
6. Obstructive endometrial polyps
7. Obstructive mullerian anomalies
8. Cervical stenosis 9. IUD
10. Pelvic congestion syndrome

20

Abnormal Uterine Bleeding (AUB)
Basic labs? 5

1. CBC
2. Prolactin
3. TSH
4. Pregnancy test
5. Chlamydia testing when indicated

21

Abnormal Uterine Bleeding: Diff Dx
9

1. Polyp
2. Adenomyosis
3. Leiomyoma
4. Malignancy

5. Coagulation
6. Ovulatory dysfunction
7. Endometrial
8. Iatrogenic
9. Not yet classified

22

Abnormal Uterine Bleeding: Terms
1. Polymenorrhea?
2. Menorrhagia?
3. Metrorrhagia?
4. Oligomenorrhea?

1. cycles less than 24 days
2. heavy menstrual bleeding
3. bleeding between periods
4. cycles> 35 days

23

Abnormal Uterine Bleeding:Coagulation
20 % of women presenting with heavy menstrual bleeding have an underlying bleeding disorder

SUCH AS?

VonWillebrand’s

24

Abnormal Uterine Bleeding: Coagulation
IN ADDITION TO HEAVY MENSTRUAL PERIODS, REFER FOR HEMATOLOGIC EVALUATION :

1. If also have one of the following?
3

2. Refer with two of the following? 3

1.
-Hx of postpartum hemorrhage
-Hx of unexplained bleeding with surgery
-Hx of bleeding with dental work

2.
-Frequent gum bleeding
-Epistaxis or unexplained bruising 2X a month
-Family Hx of bleeding

25

Abnormal Uterine Bleeding: Ovulatory
1. Caused by what as a result of anovulation or oligo-ovulation?

2. What may cause this?

1. chronic unopposed estrogen influence

2.
-Hyperandrogenic (PCOS)
-Hypothalamic dysfunction (anorexia)
-Thyroid disease
-Elevated prolactin
-Medications
-Iatrogenic
-Premature ovarian insufficiency

26

What is PMS and PMDD?

1. PMS = Premenstrual Syndrome

2. PMDD = Premenstrual Dysphoric Disorder


-Severity of symptoms are disruptive at home/social situations/at work

-Cyclic physical and/or behavioral symptoms that recur in the luteal phase and first few days of menses. (Present for at least 3 months)

27

PMS and PMDD: Risk Factors
4

1. Genetics: variation of estrogen receptor alpha gene
2. History of traumatic events/anxiety disorder/higher daily hassle scores
3. Lower education
4. Smoking

28

PMS and PMDD: Pathophysiology
Theories?
2

1. Abnormal response to normal concentrations of estrogen and progesterone

2. Cyclic changes in circulating estrogen and progesterone trigger an abnormal serotonin (neurotransmitter) response

29

PMS and PMDD
1. Usually starts when?

2. Must cause significant what?

1. Usually start in 20’s

2. Must cause significant distress or interference with normal activities

30

PMS and PMDD: Symptoms
Physical symtpoms? 6

PHYSICAL
1. Abdominal bloating
2. Extreme fatigue
3. Breast pain
4. Headache
5. Hot flashes
6. Dizziness