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)