OBGYN - Menstruation
Which form of Estrogen? 1. Dominant in non-pregnant not in menopause 2. Dominant when patient has started menopause 3. Dominant in pregnancy
1. Estradiol 2. Estrone 3. Estriol / estertrol
Primary amenorrhea: failure of menarche onset by age _____ OR age ____ with lack of secondary sex characteristics
15 13
Secondary amenorrhea: the absence of menses for > ____ months in a patient with previously normal menstruation or ___ months in a woman with a history of irregular cycles
3 6
Premature menopause: menopause before ____ yo
40
Average age of menopause
51.5 years (44-55 years old)
2 Causes of dysfunctional (abnormal) uterine bleeding
Anovulatory (90%) Ovulatory (10%)
What dx? acquired endometrial scarring 2ry to postpartum hemorrhage, s/p D&C or endometrial infection
Asherman's syndrome (tx = estrogen)
What is always the first step in amenorrhea work up?
Beta-HCG
The HT arm of the Women's Health Initiative (WHI) trial was stopped prematurely, primarily because patients in the treatment group demonstrated an increased relative risk for
Breast cancer
Treatment for amenorrhea caused by hypothalamus dysfunction (low FSH/LH)
Clomiphene
What specific OCP can be given for PMDD
Drosperinone containing OCPs
What treatment for menopause? most effective symptomatic treatment Increased risk of endometrial cancer Often used in patients with no uterus
Estrogen
Which hormone? Thins cervical mucous Thickens the endometrium layer for implantation
Estrogen
What treatment for menopause? Protective effect against endometrial cancer Often used in patients with intact uterus
Estrogen + Progesterone
Menopause: most sensitive initial test
FSH (increased serum FSH > 30)
Roles of FSH and LH
FSH: causes follicle and egg maturation in the ovary LH: stimulates maturing follicle to produce estrogen
Estrogen + Progesterone effect on lipid panel
HDL and TG levels ↑, LDL levels ↓
What cause of 1ry amenorrhea? 46 XX, low FSH/LH
Hypothalamic-Pituitary insufficiency (athletes, anorexia, illness)
Sudden _____ surge causes ovulation (egg release)
LH
Which hormone? Forms the corpus luteum Breaks down the wall of the follicle to allow for the release of the ovum
LH
Hallmark of this disorder is marked disruption in functioning
PMDD
The transition between reproductive capability and menopause hallmark is irregular menstrual function, lasts 3-5 years
Perimenopause
Women frequently take large daily doses of vitamin B6 for PMS. They can be at risk for what?
Peripheral neuropathy (Associated with doses > 2000mg/day)
What cause of secondary amenorrhea? Low FSH/LH, high prolactin
Pituitary dysfunction (management = transsphenoidal surgery)
What happens to the corpus luteum if there is implantation?
Pregnancy → corpus luteum is functional → E&P secreted → endometrium does not slough off
What type of dysmenorrhea is more common in adolescents?
Primary
Primary dysmenorrhea vs secondary dysmenorrhea
Primary: Associated with release of prostaglandins Secondary: Associated with pelvic pathology
Sloughing of the endometrium in response to ___________ withdrawal
Progesterone
Which hormone? Stimulates estrogen production Initiates secretory phase of the endometrium Increases basal body temperature Inhibits LH and FSH
Progesterone
After ovulation, the ruptured follicle becomes the corpus luteum → secreting ________________?
Progesterone (some estrogen)
What test can be performed to distinguish ovarian abnormalities as cause for 2ry amenorrhea vs other causes?
Progesterone challenge test + withdrawal bleeding = ovarian amnormalities no withdrawal bleeding = hypothalamus-pituitary failure or uterine problem
What dx? Galactorrhea, amenorrhea, infertility, and decreased libido
Prolactinoma
Explain GnRH effect on LSH/FH
Pulsatile GnRH (hypothalamus) → increased FSH and LH (pituitary) → stimulation of ovaries
3 Treatment options for PMDD/PMS
SSRIs OCPs GnRH (refractory)
Alternative drugs for vasomotor symptoms with menopause
SSRIs (paroxetine) SNRIs clonidine gabapentin
Which type of dysmenorrhea? Pain with menstruation begins mid-cycle and increases in severity until end
Secondary
T/F: PMDD is a severe, sometimes disabling extension of premenstrual syndrome (PMS)
True
What cause of 1ry amenorrhea? XO karyotype, webbed neck, broad chest, high FSH/LH
Turner's syndrome
Gold standard for AUB diagnosis
Uterine Dilation and Curettage
Vitamins that can be taken for PMS
Vit B6 Vit D Calcium
Female athlete triad
disordered eating, amenorrhea, osteoporosis
Endometrium thickens ("builds up") because of __________
estrogen
Follicular phase: __________ predominates Luteal phase: ___________ predominates
estrogen progesterone
Chronic anovulation is seen with....
extremes of age
AUB in the absence of an anatomic lesion, is caused by a problem with the...
hypothalamic-pituitary-ovarian axis
PMS: Cluster of physical, behavioral, and mood changes with cyclical occurrence during the ________ phase of menstrual cycle
luteal
Estrogen causes _________ feedback in HPA system
negative
What cause of secondary amenorrhea? high FSH/LH, low estradiol
ovarian abnormalities
MC cause of secondary amenorrhea
pregnancy
Contraindications for estrogen + progesterone therapy
↑ triglycerides Undiagnosed vaginal bleeding Endometrial cancer History of breast CA or estrogen-sensitive cancers CVD History DVT or PE history
Menopause: Cessation of menses > ___ year d/t loss of ovarian function
1
More blood loss during menses and frequent and irregular bleeding between menses
Menometrorrhagia
Prolonged/heavy bleeding (>7 days or >80 mL); regular intervals
Menorrhagia
Uterine bleeding that occurs frequently and irregularly between menses
Metrorrhagia
Treatment for dysmenorrhea
NSAIDs, OCPs 2ry: treat underlying cause
What happens to the corpus luteum if there is no implantation?
No implantation → corpus luteum degenerates → steep drop in E&P → menstruation (first days of follicular phase)
Treatment for AUB
OCPs, NSAIDs, hysterectomy (definitive)
