Menstruation

Risks of Estrogen & Progesterone Tx for Menopause

Venous Thromboembolism

Types of Dysmenorrhea

+ 1ry = not due to pelvic pathology & usually occurs 1yr after menarche. + 2ry = Due to pelvic pathology (Endometriosis, Uterine fibroids, PID)

DUB Intro

+ Abnormal frequency/intensity of menses due to NON-ORGANIC CAUSES! Diagnosis of Exclusion

Menopause Intro

+ Cessation of menses > 1 yr due to loss of ovarian function + Average age is 51

Diagnosis of Menopause

+ Clinical DX 1) FSH Assay MOST Sensitive Initial Test (↑serum FSH > 30 IU/mL) 2)↑serum FSH, LH, ↓estrogen (due to depletion of ovarian follicles)

Osteoporosis prevention in Women with Menopause

+ DEXA Scan @ 65y/o + Calcium (800mg qd or 1200mg w/food) + Vitamin D + weight bearing exercise + Bisphosphonates + Calcitonin + Estrogen (w or w/o progesterone) + SERM (Raloxifene, Tamoxifen)

Physical Exam of Menopause

+ Decrease in bone density + Skin-> Thin/dry, ↓'d elasticity + Vaginal: atrophy thin mucosa

Signs and Symptoms of Dysmenorrhea

+ Diffuse Pelvic Pain right before or w/onset of menses (+/- lower abdomen, suprapubic or pelvic pain may radiate to lower back & legs) + May be assoc. w/HA, N, & V. + Cramps usually last 1-3 days

State the Anti-Psychotic Drugs that can cause 2ry Amenorrhea

+ Dopamine-Antagonists disinhibit prolactin --> Prolactinemia + 1st and 2nd (less than 1st) Gen Antipsychotics

Phase in which this occurs and state effect: + Pulsatile GnRH from the Hypothalamus

+ Follicular (Proliferative) Phase + Effect is ↑FSH & LH from Pituitary gland to stimulate ovaries

Signs and Symptoms of Menopause

+ Hot flashes + vaginal atrophy + decreased libido + dyspareunia + mood changes.

Phase in which a pregnancy occurs & state what occurs

+ Luteal Phase + The Blastocyst (maturing zygote) keeps the corpus luteum functional (secreting Estrogen & Progest., which keeps the endometrium from sloughing)

Phase in which this occurs + Progesterone predominates

+ Luteal Phase (Secretory)

After Pregnancy is R/O, what is checked next for 2ndary Amenorrhea

+ Medications must be reviewed. + Dopamine will block prolactin. + Dopamine antagonists will increase prolactin, leading to amenorrhea.

Summary of the Menstrual Cycle

+ Menstruation: (1st days of Follicular) Withdrawal of progesterone & estrogen causes endometrial sloughing. + Follicular phase: (Days 1-12) --> FSH causes follicle maturation & estrogen secretion. --> Estrogen causes endometrial proliferation. + Ovulation (Days 12-14): LH surge causes oocyte to be released. +Luteal phase: (Days 14-28) Corpus luteum secretes progesterone, which causes: --> Endometrial maturation -->↓FSH, ↓LH

Dysmenorrhea Intro

+ Painful menstruation that affects normal activities + Pain either few days before or during menstruation.

Perimenopause defined as

+ Period right before menopause, characterized as having an irregular cycle due to falling levels of estrogen and progesterone. + Considered when before 40y/o

Types of Amenorrhea

+ Primary = no menses by 13 in patients w/o secondary sexual characteristics or no menses by 15 if secondary sexual characteristics are present + Secondary = absence of menses for 3 months in women w/a normal menstrual cycle & 6 months in women w/an irregular cycle.

Patient Presentation of PMS

+ Symptoms initiate during the luteal phase (1-2wks before menses), relieved w/in 2-3 days of onset of menses plus @ least 7 sxs free days during the follicular phase 1) Physical: Bloating, breast swelling/pain, HA, bowel habit changes, fatigue, muscle/joint pain 2) Emotional: depression, hostility, irritability, libido changes, aggressiveness 3) Behavioral: Food cravings, poor concentration, noise sensitivity, loss of motor senses

Normal Menstruation Physiology Intro

+ The menstrual cycle is the cyclical changes that occur in the female reproductive system. + The hypothalamus, pituitary, ovaries, & uterus interact, allow ovulation approx. 1qmonth (average 28d [+/-7 d])

Diagnosis of PMS

+ The patient should keep a symptom diary & symptoms should be noted to be cyclical for at least 2 cycles. + Symptoms initiate during luteal phase (1-2wks before menses), relieved w/in 2-3 days of onset of menses plus @ least 7 sxs free days during the follicular phase + If the patient doesn't demonstrate symptom free period during the follicular phase, then other causes should be sought.

Treatment for Acute Severe Bleeding in DUB

1) Acute SEVERE Bleeding-> IV Estrogen + Reduce dose as bleeding improves + D&C used if IV estrogen fails 2) Surgery -> TAH if the above fails (definitive management)

Types of DUB

1) Anovulation (90%) -> No ovulation = No progesterone = Unopposed Estrogen = proliferation (irregular, unpredictable bleeding) 2) Ovulatory (10%) ->Regular cyclical shedding* Ovulation w/prolonged progesterone secretion (due to ↓estrogen levels) -> ↑Blood loss from endometrial vessel dilation & Prostaglandins -> menorrhagia

Treatment for Anovulatory DUB

1) Anovulatory (90%) -> OCP's 1ST LINE! + Progesterone: if estrogen is contraindicated + GnRH Agonist: Leuprolide causes temp. amenorrhea 2) Surgery---> Done if not responsive to Tx + (TAH)Hysterectomy --> Definitive management + Endometrial Ablation--> if Pt doesn't want TAH

Diagnosis of DUB

1) Diagnosis of Exclusion. R/O everything else with....Pelvic Exam, Labs, and Scans Labs--> BHCG, CBC, TSH, Prolactin Scans --> U/S, MRI, Hysteroscopy 2) If W/U shows no evidence of organic cause & negative pelvic exam --> DUB is the DX

Management of PMS

1) Lifestyle modifications should be taken: + Stress reductions, exercise, caffeine & salt restriction. + NSAIDS, Vit B6 & Vit E 2) SSRI's (Fluoxetine, Sertraline, Paroxetine, Citalopram) 3) OCP's -> induces anovulation 4) Spironolactone -> for bloating 5) Refractory Breast Pain not responding to above Tx's -> +/- Danazol, Bromocriptine

Complications of Menopause

1) Loss of estrogen's protective factors --> ↑osteoporosis (↑fx's), ↑Cardiac risk & ↑lipids

Treatment for Primary Dysmenorrhea

1) NSAIDs -> inhibit prostaglandin mediated uterine activity 2) Ovulation Suppression: + OCPs/Depo-Provera/ Vaginal ring significantly reduces Symptoms 3) Laparoscopy -> if medications fail

Treatment for Ovulatory DUB

1) Ovulatory (10%) -> OCP's + Progesterone: PO or IUD (Mirena) + GnRH Agonist: Leuprolide 2) Surgery---> Done if not responsive to Tx + (TAH)Hysterectomy --> Definitive management + Endometrial Ablation--> if Pt doesn't want TAH

Etiology of Secondary Amenorrhea

1) Pregnancy (MCC of secondary) 2) Hypothalamus Dysfxn 3) Pituitary Dysfxn 4) Ovarian D/O's 5) Uterine D/O's 6) Medication Induced

Clues pointing to a secondary cause include:

1. Dysmenorrhea beginning in their 30s 2. Heavy/irregular bleeding 3. Dysmenorrhea occurring w/in 1st few cycles of menarche 4. Poor response to NSAIDs & contraception

Amenorrhea Intro

Absence of Menstrual period

Etiology of Primary Amenorrhea

Breast Absent --> 1) Gonadal dysgenesis (Turner syndrome, 45XO) - most common 2) Hypothalamic-Pituitary insufficiency (46XX) 3. Physiological delay (Ex. Athletes, illness, anorexia) Uterus Absent --> 1) Müllerian agenesis (46 XX) 2)Androgen Insensitivity (46XY)

PMDD Treatment

Drosperinone-Containing OCP's for PMDD

Pituitary Dysfunction, state the DX & TX

Dx-> ↓FSH, LH, ↑Prolactin --> MRI of Pituitary Sella (Prolactin inhibits GnRH) TX-> Dopamine agonists (pramipexole, ropinerole, bromocriptine).....if refractory then --> Transsphenoidal surgery (tumor removal)

Management of Menopause for women w/uterus

Estrogen & progesterone; the progesterone is used to protect against endometrial cancer. + Transdermal or Vaginal preferred VS PO

Management of Vaginal atrophy in menopause

Estrogen (transdermal, intravaginal)

Management of Menopause for women w/o uterus (s/p TAH-BSO)

Estrogen only

GnRH Pulses < 1 Hour Favor....

FSH Secretion

Goals in the Treatment of DUB

Goal-> Control acute bleeding, prevent future bleeding & minimize endometrial cancer risk 1) Acute SEVERE Bleeding-> IV Estrogen + Reduce dose as bleeding improves + D&C used if IV estrogen fails 2) Anovulatory (90%) -> OCP's 1ST LINE! + Progesterone: if estrogen is contraindicated + GnRH Agonist: Leuprolide causes temp. amenorrhea 3) Ovulatory (10%) -> OCP's + Progesterone: PO or IUD (Mirena) + GnRH Agonist: Leuprolide 4) Surgery---> Done if not responsive to Tx + (TAH)Hysterectomy --> Definitive management + Endometrial Ablation--> if Pt doesn't want TAH

GnRH Pulses > 1 Hour Favor....

LH Secretion

Treatment for Secondary Dysmenorrhea

Laparoscopy -> Done to R/O 2ry causes (Endometriosis or PID)

Müllerian agenesis (46 XX) PE, Labs, & Tx

PE --> + 2ndary Sex + Female External Genitalia but no Uterus, Tubes, Upper 1/3rd vagina Labs --> FSH/LH normal U/S = No uterus...Karotype shows XX TX --> Elevate vagina, Cannot get pregnant

Hypothalamic-pituitary insufficiency (46XX) PE, Labs, & Tx

PE -> No Breast Development Labs-> ↓FSH, ↓ LH...then --> Progesterone Challenge Test + If no withdrawal bleeding --cause is either (1) Hypothalamus-pituitary failure or (2) Uterine TX-> Clomiphene, Menotropin (Pergonal)

Gonadal Dysgenesis (Turner syndrome 45XO) PE, Labs, & Tx

PE -> Short webbed neck, no breast development Labs-> ↑ FSH, ↑LH U/S = Positive uterus, streak ovaries Tx-> Cyclic estrogen & progestins

Physiological delay (Ex. Athletes, illness, anorexia) PE, Labs, & Tx

PE--> Anorexia, Weight loss, Intense Exercise, Pregnancy before 1st period Labs--> Negative BHCG Normal or Low FSH/LH TX--> Reassurance U/S--> only if pregnant

Androgen Insensitivity (46, XY) PE, Labs, & Tx

PE--> Has Testes but looks female on the outside. + 2ndary Sex + Female External Genitalia but no uterus Labs --> FSH/LH Normal, Testosterone ↑, U/S = shows no uterus TX--> Elevate Vagina, Remove testicles after puberty, start estrogen

Asherman's Syndrome Path, Dx, Tx

Path -> Acquired endometrial scarring 2ry to postpartum hemorrhage, s/p D&C or endometrial infection DX-> Fails Progestin Challenge (can't bleed)

Amenorrhea Work Up

Pregnancy Test, Serum Prolactin, FSH, LH, TSH

Cause of Primary Dysmenorrhea

Prostaglandins & leukotrienes --> painful uterine muscle wall activity

PMDD Intro

Severe PMS w/functional impairment

Patient presentation of DUB

Bleeding that occurs without regular cycles OR Regular cyclical shedding w/menorrhagia

PMS Intro

Cluster of physical, behavioral, & mood changes with cyclical occurrence during the LUTEAL PHASE of the menstrual cycle.

Elevated prolactin levels

Indicative of Pituitary Adenoma

Risks of Estrogen Tx for Menopause

↑Risk of Endometrial CA, Thromboembolism (CVA, DVT, PE), Liver Dz