Abnormalities in the menstrual cycle
Treatment
Low dose combined oral contraceptives are especially useful in those patients with PCOS medroxyprogesterone can be used to prevent endometrial hyperplasia in anovulatory clients who do not need contraception.
Uterine Cycle Endometrium responds to Ovaries Proliferative Phase is first: Goes with Follicular phase Estrogen stimulates endometrium to thicken
The endometrium responds to cyclic changes in ovarian steroids. The first phase of uterine cycle is the proliferative phase. This phase corresponds to the follicular phase of the ovarian cycle. Estrogen stimulates the endometrium to thicken and form progesterone receptors to increase blood flow to the endometrium. The second phase of the uterine cycle is called the secretory phase and correlates with the luteal phase of the ovarian cycle.
Questions continued Post menopause and estrogen therapy IUD
Your assessment should include the pap test history, gynecologic surgeries, sexually-transmitted infections or other infections of the genital tract or organs, contraception history. Ask about hormone therapy in postmenopausal women to rule out a history of taking unopposed estrogen that can lead to endometrial hyperplasia. Abnormal bleeding may be caused by an IUD or related to the use of hormonal contraception. Ask about eating disorders, weight changes, increased exercise and stress.
Amenorrhea Primary or Secondary Primary: no menses by 14 and no sexual characteristics or no menses by 16 and has sexual characteristics Secondary: Absence of menses for 3 months when previously had it
absence of menses classified as primary or secondary amenorrhea. Primary amenorrhea is absence of menses by age 14 with delay in maturation of secondary sexual characteristics or absence of menses by age 16 with evidence of sexual characteristics. Secondary amenorrhea is absence of periods for a length of time equivalent to a total of at least three of the previous cycle intervals or six months of amenorrhea.
Assessment of additional symptoms other than amenorrhea
Ask the patient about headaches, acne, hirsutism, emotional stress, depression, nutritional patterns, and athletic activity.
Cause of Secondary Amenorrhea
Causes of secondary amenorrhea include: pregnancy, hormonal contraception, PCOS, thyroid, pituitary, menopause, outflow tract obstruction, ovarian function abnormalities.
Management for Sexually active Female Dysmenorrhea Combination Oral Contraceptives 3 consecutive cycles without breakthrough bleeding First day start system
Combine oral contraceptives may be considered for the first line therapy in a sexually active female. Take active contraceptive pill for three cycles without allowing withdrawal bleeding is especially beneficial. Use first day start system. Also consider depo or the mirena. Other treatment options are vitamin B1 100 mg PO daily, magnesium. Consult or refer, you will refer to gynecologist if poor response to NSAID therapy or need evaluation and management of secondary dysmenorrhea.
Hypothyroidism and abnormal uterine bleeding Graves disease: hyperthyroid and Hypothyroid
Abnormal uterine bleeding can be a sign of significant systemic disease, especially if findings from the pelvic examination are normal. Thyroid dysfunction -Graves' disease is one of the most common causes of hyperthyroidism. Hyperthyroidsm can result in oligomenorrhea or amenorrhea. Hypothyroidism can cause either amenorrhea or menorrhagia
Abnormal uterine bleeding
Abnormal uterine bleeding is one of the most common reasons why women seek health care. It can be a normal physiologic event such as irregular bleeding that often accompanies menarche or perimenopause. However, it can also signal pathologic life-threatening conditions such as an ectopic pregnancy or endometrial cancer.
Diagnostic for Dysmennorhea
Diagnostic studies for dysmenorrhea include: KOH and wet prep, increased WBCs can indicate sexual transmitted infections or pelvic inflammatory disease. Also perform chlamydia and gonorrhea testing, a pregnancy test, an ultrasound. Pap smear may be deferred if obvious vaginal or cervical infection exists.
Assessment Pelvic Exam: sexually active Screen for STI Fever Masses
For the sexually active female, a thorough pelvic exam is mandatory to establish diagnosis. Screening for sexually transmitted infections is indicated by the patient's history or symptoms. With primary dysmenorrhea, pelvic findings will be completely normal except a mildly tender uterus. secondary dysmenorrhea may reveal pelvic pathologies. Assess for fever, abdominal masses, abdominal tenderness, guarding or rebounding. Focal abdominal pain can identify the source. For example, left lower quadrant pain suggest bowel, ureter, Fallopian tube, or ovary involvement. Assess for vaginal discharge, cervical erythema, purulent mucus, friability, cervical motion tenderness, uterine enlargement, or tenderness, masses, immobility, and firmness.
Amenorrhea
Amenorrhea is a symptom not a diagnosis. It is characterized as primary or secondary. Primary amenorrhea is classically defined as the absence of menses by age 16. However recent guidelines suggest a diagnosis of primary amenorrhea should be considered if a patient has not reach menarche by 14 to 15 years of age or has not done so within three years of the larche.
Assessment questions
Ask the patient what has changed? How is the menstrual cycle different than it usually is? Ask the patient about the dates of her last three menstrual periods and the date of her last normal menses. Ask about the color and character of her flow and related signs and symptoms. Ask about previous treatment for abnormal bleeding.
Metrorhagia: excessive flow, duration or both Menometrorrhagia irregular and heavy Intermenstrual: anytime other than normal menses
Metrorrhagia is uterine bleeding that is excessive in flow or duration or both. Menometrorrhagia is irregular, heavy bleeding. Intermenstrual bleeding is bleeding at any time between otherwise normal menses.
Ibuprofen 400mg PO TID Prostaglandin inhibitor Increase up to 800mg or switch Need 2-3 cycles before switching
Patient may take ibuprofen 400 to 800 mg PO TID PRN. Ibuprofen is a potent prostaglandin inhibitor and lessons flow and controls cramping. Mefenamic acid is 500 mg PO loading dose then 250 to 500 mg PO Q6 hours PRN. If inadequate response, increase the dosage or switch to other product allow minimum of 2 to 3 cycles to evaluate before switching the medicine.
Primary Dysmenorrhea Secondary Dysmennorhea: an underlying pathology causes pain.
Women with primary dysmenorrhea are generally ovulatory and produce progesterone in the luteal phase. Women with primary dysmenorrhea produce excessive amounts of prostaglandin. This increases the force of uterine contractions. Uterine contractions reduce uterine blood flow causing ischemia. Secondary dysmenorrhea involves the underlying pathology. These pathologies may include endometriosis, adenomyosis, uterine leiomyomas, or pelvic inflammatory disease. The pathology may act directly or indirectly on the pelvic anatomy to cause pain symptoms during menstrual flow. Secondary dysmenorrhea may be associated with dyspareunia, dysuria, abnormal uterine bleeding, or infertility.
Secondary Amenorrhea
Secondary amenorrhea is absence of menses for more than three cycles or six months in women who previously had menses.
Surgical guidelines D&C Ablation: causes infertility Ultrasound: endometrial stripe greater than 10, D&C
Surgical treatment involves a D&C. Endometrial ablation should not be performed on a woman who desires to maintain her fertility. Uterine artery embolization will retain fertility. Hysterectomy should be the last option. When ultrasound is available and the endometrial stripe is greater than 10 mm in the presence of acute excessive uterine bleeding, D&C should be considered.
Symptoms associated with Primary Dysmenorrhea
Symptoms associated with primary dysmenorrhea include: fatigue, nervousness, and irritability, dizziness, syncope, bloating, headache, mood changes, nausea, vomiting, constipation, and diarrhea.
Assessment
The assessment of abnormal uterine bleeding should include a detailed menstrual history. Pregnancy will need to be ruled out. include her current age as well as the age of menarche and menopause. Include information about her cycle length. Please ask how the patient is calculating her cycle length. Is she including the first day of spotting? Is she including the days when the flow is light when she determine her menstrual cycle length. Ask about the duration of her menstrual cycle. Ask about the estimated amount of flow and when the menstrual pattern changed.
Assessment General outline
The assessment should include the history. History should include the gynecologic history, pubertal development history, menstrual history, obstetrical history, contraceptive history, and endocrine history.
Cause of Abnormal Uterine bleeding
The cause of abnormal uterine bleeding can be physiologic, pathologic, or pharmacologic. Endocrine reasons for abnormal uterine bleeding include: diabetes, PCOS, thyroid disease, pituitary and Cushing's. Medications that may cause abnormal uterine bleeding include: amphetamines, anticoagulant, antipsychotics, benzodiazepines, hormone therapy, SSRIs, glucocorticoids. Soy has been associated with alterations in estrogen levels.
Ovarian Cycle Follicular phase: Estrogen peaks, Ovulation 24 hours later Luteal Phase: Ovulation indicates transition into Luteal. Progesterone dominant, changes endometrium
The menstrual cycle involves both changes in the ovary and the uterus. These are hormonally mediated. The ovarian cycle is divided into a follicular phase and luteal phase. During the follicular phase a single follicle becomes dominant and thereby available to undergo ovulation. Becoming the selected follicle is based on its ability to produce the most estradiol. The rest of the follicles undergo atresia. As estradiol increases, FSH decreases. During the follicular phase estrogen levels peak about 24 hours before ovulation. LH surge occurs and ovulation occurs 24 to 36 hours later. Ovulation indicates the transition to the luteal phase. There's a shift from estrogen dominance to progesterone dominance. Once the follicle ruptures the corpus luteum develops and produces large amounts of progesterone. Progesterone suppresses further follicular growth and produces changes in the endometrium. The luteal phase is approximately 14 days.
Cause of Dysmenorrhea Production of Prostaglandins in endometrium
The most common explanation of dysmenorrhea is an overproduction of prostaglandins within the endometrium. Dysmenorrhea is diagnosed by history and ruling out other causes, especially pregnancy and pelvic inflammatory disease.
Management Low dose combined oral contraceptives Progesterone: chronic heavy bleed Menorrhagia: cyclic MPA
low dose combined oral contraceptives, NSAIDs. Progestogen therapy can be used to treat chronic heavy bleeding that is due to anovulation. Women with chronic menorrhagia can be offer cyclic MPA which is Provera at doses of 10 mg a day for 10 to 14 days, with therapy being repeated every 30 to 40 days.
Management general Goals
management of abnormal uterine bleeding includes: normalizing the bleeding, correct any anemia, prevent cancer. Acute life-threatening hemorrhage necessitates physician referral and medical management in a hospital setting.
Physical exam in Amenorrhea
note any weight changes. Note secondary sexual characteristics and Tanner staging. Note their eyes, skin, thyroid enlargement. On the pelvic examination, note the presence or absence of normal structures.
Causes of Amenorrhea
pregnancy, Mullerian agenesis, testicular feminization Turner syndrome, gonoadal dysgenesis, imperforate hymen, transverse vaginal septae. An obstructed bimanual examination needs referral and follow-up.
Physical exam
The physical examination should include height, weight, BMI, vital signs, hair, body fat distribution. Hirsutism, acne, and alopecia to indicate androgen excess. Observe for signs of anemia such as pale skin and delayed capillary refill. Palpate the thyroid do a breast examination and check for galactorrhea as well as do a pelvic examination Other tests to do during the physical examination include the pap test, cervical culture, and your bimanual examination.
Dysmenorrhea Management NSAIDS: treatment of choice Take before pain starts with 2 days or up to 1 week Regular intervals With food
Treat the causes of secondary dysmenorrhea as indicated. supportive treatment of primary dysmenorrhea. This includes having the patient to eat regularly, use dry or moist heat to the abdomen, consume a high fiber diet, and do aerobic exercise.Pharmacological interventions include the use of NSAIDs. NSAIDs are the treatment of choice for primary dysmenorrhea. They work most effectively when taken before pain becomes severe. They should take it with food. Take NSAIDs two days or more or up to one week before the onset of menses at regular intervals around the clock.
Additional concerns and considerations when someone comes in with abnormal uterine bleeding Always rule out cancer as cause
problems with the hypothalamic pituitary axis may cause systemic illness, post menarche, perimenopause, stress, eating disorders ,severe dieting and or weight loss, excessive exercise, In genital tract, atrophy, cancer, endometriosis, infections, fibroids, polyps, and trauma may cause abnormal uterine bleeding. Signs of gynecologic malignancies such as endometrial and cervical cancer may present as abnormal uterine bleeding often in the form of metrorrhagia. Gynecologic cancers should be ruled out whenever a woman presents with abnormal uterine bleeding. Uterine bleeding that occurs in women who are postmenopausal is always considered abnormal and endometrial cancer needs to be ruled out. Infections like gonorrhea, Chlamydia, and endometritis may cause irregular spotting due to irritation and inflammation.
Menstrual Cycle Feedback cycle between hypothalamus, pituitary gland and Ovaries 21-35 days 20ml - 60 ML
uring the menstrual cycle a series of events occur that we talked relation and the preparation of the endometrium for pregnancy. It involves feedback between the hypothalamus, pituitary gland, and the ovaries. Cyclic changes induce development of the dominant follicle that results in ovulation and corpus luteum formation. If pregnancy does not occur at the endometrium sloughs, resulting in menstruation. Most women have cycles lasting from 21 to 35 days, with 2 to 6 days of flow and an average blood loss of 20 to 60 mL.
Oligomenorrhea: Intervals greater than 35 days. Polymenorrhea: intervals 21 days or fewer Hypomenorrhea: regular but less than normal amount Menorrhagia: regular but bleeding greater than 80 ml or lasts longer than 7 days
Oligomenorrhea is infrequently occurring menses at intervals greater than 35 days. Polymenorrhea is menses at intervals of 21 to 24 days or fewer. Hypomenorrhea is regular bleeding and less than normal amount. Menorrhagia is regularly occurring bleeding excessive in duration and flow is greater than 80 mL per cycle or lasting longer than seven days.