Menstruation

What is the definition of secondary amenorrhea?

1. Absence of menses for 3 months when previous menses were NORMAL 2. Absence of menses for 6 months in women whose previous menses were IRREGULAR

How do you treat primary dysmenorrhea?

1. Begin w/ NSAIDs- take 1 to 2 days prior to menses (or whenever pain usually starts) and continue for 2-3 days 2. OCP help to reduce pain and length on menstruation 3. Other: regular exercise, applying heat may help,

Name some possible causes of metrorrhagia

1. Endocervical polyps 2. cervical CA 3. Uterine cancer 4. IUD

Name the 3 phases of the ovarian cycle

1. Follicular phase 2. Ovulation phase 3. Luteal phase

How can you relieve vasomotor symptoms of menopause?

1. Lifestyle modifications 2. Oral contraceptives prescribed per individual risk factors (hormone replacement therapy)

Name the 3 phases of the uterine cycle

1. Menstruation phase 2. Proliferative phase 3. Secretory phase

What is the definition of primary amenorrhea?

1. The absence of menses by age 13 in the absence of secondary sex characteristics 2. The absence of menses by age 16 in the presence of secondary sex characteristics

How do you treat secondary dysmenorrhea?

1. Treat any underlying pathology/remove IUD

Name 4 of the MC genetic causes of primary amenorrhea

1. Turners syndrome (45,XO) -webbed neck and no breast development 2. Hypothalamus- pituitary insufficiency (46,XX) -no breast development 3. Imperforate hymen (46,XX) -normal breast development -surgical treatment 4. Androgen sensitivity (46,XY) -high testosterone -normal breast development

How long do you need to have amenorrhea before menopause can be dx?

12 months

How much calcium does a postmenopausal women need?

1200mg daily

What is the average length of an entire cycle?

28 days is the average length of a cycle

How long should HRT be continued?

3 to 5 years -patient may be allowed to continue HRT if a thorough risk examination has been done, and patient understands these risks

On average, how much blood is lost during menstruation?

30mL on average

What is the mean age of menopause?

51 years old

How much vitamin D?

800 units daily

What is the definition of polymenorrhea?

<21 days between menses

What is the definition of oligomenorrhea?

>35 days between menses

At what age should a DEXA scan be performed?

At age 60 -or earlier depending on family hx and risk factors

What should be the first diagnostic test to do in a pt who is presenting with amenorrhea?

B-hCG TSH Prolactin level

What form of estrogen is dominant in post-menopause?

Estrone

What is the diagnostic lab which confirms menopause?

FSH>30mIU/mL with a low estradiol level

What is usually the etiology (etiologies) behind primary amenorrhea?

Genetic or anatomical (congenital) abnormality

Name an endocrine etiology that could cause amenorrhea

Hyperprolactinemia -pituitary adenoma -look for concurrent galactorrhea

How does the effect of estradiol on LH differ between the follicular phase and the ovulation phase?

In the follicular phase, estrogen levels are lower and inhibit release of LH. But in the ovulation phase, estrogen levels are higher and peak, which result in a surge of LH hormones being released

Exactly how does LH cause ovulation to occur?

It weakens the wall of the follicle, causing it to rupture and release its secondary oocyte

What happens to the ovary if it is not fertilized?

It will disintegrate after 1 day in the fallopian tube

What is the preferred treatment for someone with mild PMS?

Lifestyle changes -reduce cafeine -get rest -NSAIDs -reduce alcohol consumption

What are some symptoms of Premenstrual Syndrome?

Long range of symptoms including: -cramps -bloating -aggressiveness -irritability -lethargy -food cravings

What is the definition of metrorrhagia?

Mid-cycle bleeding

What is a complication of follicular rupture that results in bleeding into the abdomen and lower abdominal pain?

Mittelschmerz

What is first line treatment for DUB?

Oral contraceptives help to restore predictable menstruation cycles as well as decrease bleeding

What are the 2 cycles of the menstruation cycle?

Ovarian cycle & Uterine cycle

How would you distinguish PMDD from major depressive disorder?

PMDD is cyclical and relates to the menses

How can you treat mild/moderate menorrhagia?

Perform a pregnancy test first 2-3x's the normal estrogen dose for 14-21 days, followed by progesterone for 10 days

When is the most common cause of secondary amenorrhea?

Pregnancy

When emotional symptoms predominate along with other physical symptoms which are cyclic and relate to menses, this can be called what?

Premenstrual dysphoric disorder (PMDD)

What are the differences in the peak ages between primary and secondary dysmenorrhea?

Primary -peak age is early 20's Secondary -incidence increases with age

How does the onset of pain differ between primary and secondary dysmenorrhea?

Primary -onset is usually right around the first day of menses and lasts for a about2-3 days Secondary -onset is less related to the beginning of menses

What is primary dysmenorrhea?

Primary dysmenorrhea is painful menstruation d/t an excess of prostaglandins and leukotriene levels - NO PATHOLOGIC ETIOLOGY

What is a progesterone challenge test? What would results indicate?

Progesterone challenge is used to determine in inadequate estrogen is the cause of amenorrhea -medroxyprogesterone acetate administered -if bleeding occurs, then normal estrogen and amenorrhea is d/t anovulation -if no bleeding occurs, then low estrogen levels present

When is DUB most likely to occur? (age)

Right after menarche as well as perimenopausal women

What is the first line treatment for a patient with PMDD

SSRI's -fluoxetine -citalopram -escitalopram -sertraline -venlafaxine

What is secondary dysmenorrhea?

Secondary dysmenorrhea is painful menstruation d/t a clinical condition -PATHOLOGIC ETIOLOGY -ex: endometriosis, fibroids, IUD, etc.

When is the definition of menstruation?

Shedding of the uterine lining

What is premature menopause? What is another name for it?

Spontaneous premature ovarian failure -cessation of menses before age 40

How long does it take for a fertilized ovary to reach the uterus?

Takes 3 days to reach the uterus, and 3 more days to implant into the endometrium

What is Mullerian aplasia? Secondary or Primary amenorrhea?

The absence of a uterus & the upper 2/3rds of the vagina -normal ovary development -normal breast development -primary amenorrhea

If fertilization does occur, in which part of the fallopian tube is it most likely to happen?

The ampulla, which is the widest part of the fallopian tube

Explain what happens during the ovulation phase? When does this phase occur?

-Occurs about 12 days into menstruation cycle (last 48 hrs) -a peak in estradiol levels causes a surge of LH -this surge of LH causes mature follicle to rupture and release an ovary

Explain what happens in the follicular phase. Is it variable or consistent with regard to time?

-Rise in FSH in the first few days of this phase -Stimulates follicles to mature, with one follicle dominating -Estradiol (estrogen) is produced by these follicles -length of this phase is variable

What other treatments might you consider for a patient who is post-menopausal?

-bisphosphonates -calcitonin -calcium and vit. D SERMs

What are the risks of HRT?

-breast cancer -uterine cancer -cardiovascular dz (MI) -cognitive changes

What is Sheehan's syndrome?

-complication of labor/pregnancy -hemorrhage that leads to hypotension and necrosis of pituitary gland 2ndary to lack of blood flow

What are the contraindications for HRT?

-family hx of breast or uterine CA -vascular dz -liver dz

How does the corpus luteum (progesterone) prepare the endometrium for implantation?

-increases basal body temp -increases blood flow to the endometrium -reduces contractility of smooth muscles of the uterus

Explain what happens during the luteal phase? Is it consistent or variable in regard to time?

-it is consistent from cycle to cycle (14 days) -ruptured follicle becomes the corpus luteum -corpus luteum secretes progesterone, which also causes the release of more estrogen (helps prepare the endometrium for implantation) -if fertilization does not occur, corpus luteum will atrophy-> triggers menstruation -if it does occur, embryo will secrete hCG which preserves the corpus luteum

Explain what happens in the menstruation phase

-loss of the corpus luteum and progesterone triggers menstruation -lasts about 3-5 days and 30mL of blood loss -painful cramping can occur

What happens during the proliferative phase? What phase of the ovarian cycle does it overlap with?

-overlaps with the follicular phase -estradiol secreted from maturing follicles stimulates growth of a new layer of endometrium -length of this phase is variable

What happens during the secretary phase? What phase of the ovarian cycle does it overlap with?

-overlaps with the luteal phase -consistent in regard to time (14 days) -progesterone and estrogen from corpus luteum prepared endometrium for implantation

What are some common s/s of menopause?

-sleep cycle changes -hot flashes (which can affect sleep) -irritability -vaginal atrophy, dryness, dyspareunia -accelerated bone loss -loss of cardiovascular protection -skin thins and becomes less elastic

What are some contraindications for prescribing OCP to a postmenopausal women?

-smoker -HTN -vascular disease -hx or fam hx of breast cancer or endometrial CA -focal headaches

What are some treatment options for vaginal atrophy d/t menopause?

-vaginal ring contains estradiol is preferred over esterase (topical cream).

How does the ovary get into the fallopian tube?

The fimbria at the end of each tube sweep the mature ovary into the tube

What is the technical definition of menopause?

The last menses

What is Asherman syndrome? Primary or secondary amenorrhea? How do you treat?

Uterine scarring, adhesions most commonly caused by surgery (D&C) -secondary amenorrhea -treat with removal of adhesions

What other tests should be performed when unexpected uterine bleeding has occurred?

Want to r/o pathology: -ultrasound to evaluate ovaries, uterus, and endometrial thickness -evaluate cervix and do a pap smear -endometrial biopsy/D&C -ECC

When using HRT, how do we attempt to diminish the risk of uterine cancer?

We use estrogen as well as a progestin to help control the proliferation of the endometrium

What is the definition of Dysfunctional Uterine Bleeding (DUB)?

abnormal uterine bleeding that is not related to pathology: diagnosis of exclusion

What should be done if post-menopausal bleeding occurs?

any post menopausal bleeding should be evaluated by endometrial biopsy/curettage to r/o cancer

What is the definition of menorrhagia?

excessive menstrual bleeding >80mL and interferes w/ patient's life

What is another option for tx if OCP do not work?

hysterectomy

What is the definition of dysmenorrhea?

painful menstruation that prevents normal activity

What is the most important diagnostic test to do when a women comes in with DUB (or even metrorrhagia)?

r/o pregnancy with a pregnancy test