The Menstrual Cycle
Premenstrual Syndrome
A 15-year-old female presents with generalized abdominopelvic pain which occurs every month after her regular, nonpainful menses. The pain, which is associated with headaches, bloating and depressed mood, begins 18 days after the last day of menstruation. She also complains of cyclic ankle swelling but denies a history of increased salt intake. Which of the following is the most likely diagnosis?
Premenstrual Syndrome
A 24-year-old woman presents for initial evaluation of cyclical symptoms of irritability, painful bloating and depression. These symptoms occur regularly 4-5 days prior to the beginning of menstruation. During these few days, this patient typically has to miss work due to the "awful pain and mental clouding." Which of the following is the most appropriate diagnosis?
Primary dysmenorrhea
A 28-year-old woman presents with difficult menses. She reports significant midline pelvic pain during the first two days of her regular menstrual cycles. The pain is so bad that she frequently misses work. Fortunately, her pain is self-limited, as the rest of her cycle is relatively comfortable. Assuming she has no organic cause for her symptoms, which of the following is the most likely diagnosis?
Endometriosis
A 29-year-old woman presents with cyclic pelvic pain that has been increasing over the last 7 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis?
Vaginal foreign body
A 3-year-old girl presents to the ED with her mom and grandmother for evaluation of vaginal spotting. The child has no other complaints and specifically denies sexual abuse or trauma when questioned alone. The child is acting appropriately and there are no external lesions or signs of trauma. Internal pelvic exam is difficult due to the patient's age. If we rule out the most common gynecological condition in prepubertal children, what is the next most likely etiology of her symptoms?
Primary dysmenorrhea
A 30-year-old woman misses work and presents to the Emergency Department with severe pelvic pain rated at 6/10. She states it began yesterday with the onset of menstruation. She has regular cycles with normal blood flow amount, but has not had this pain before. She denies spine, urologic and rectal symptoms. Vital signs are normal, and physical examination as well as pelvic ultrasound is unremarkable. Serum beta-hCG is negative. Other than referral to a gynecologist for further evaluation, which of the following is the most appropriate diagnosis?
Uterine leiomyoma
A 32-year-old African American woman presents to the outpatient office complaining of constant pelvic pressure with low back pain for several years. Her menstrual cycles are described as heavy and prolonged. Last menstrual period was ten days ago. Obstetrical history is significant for one full term pregnancy and two subsequent miscarriages. Gynecological history is significant for first menarche at the age of nine years. Family history is negative for gynecological malignancy. Physical exam reveals a firm, mobile, enlarged, nodular uterus. What is the most likely diagnosis?
Endometriosis
A 32-year-old G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last six months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but denies any vaginal discharge. On examination, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are appreciated. Her pregnancy test is negative. What is the most likely diagnosis? Note: The correct answer will provide the most specific diagnosis.
Endometrial hyperplasia
A G2P2 46-year-old woman presents to her gynecologist's office with a six month history of irregular, heavy menses. She states her cramps are no worse than usual and she does not have dyspareunia or postcoital bleeding. On physical exam, she has a body mass index of 32 kg/m2. A bimanual examination reveals a normal-appearing cervix and a smooth, regularly-shaped uterus that is not enlarged. Which of the following is the most likely diagnosis? Note: The correct answer will provide the most specific diagnosis.
Endometriosis
A benign, estrogen-dependent condition thought to be caused by retrograde menstruation that results in endometrial tissue developing in extrauterine sites. It occurs most commonly in the pelvis, with the ovaries, posterior cul-de-sac, and anterior cul-de-sac affected most frequently.
Mullerian dysgenesis
A condition characterized by the congenital absence of the uterus and vaginal upper two-thirds in the setting of a normal complement of sex chromosomes (46,XX).
Asherman's syndrome
A condition in which past uterine procedures, like cesarean section or dilation and curettage, causes formation of uterine synechiae.
Abnormal (dysfunctional) uterine bleeding
A diagnosis of exclusion; refers to excessive, noncyclic bleeding which is mainly due to anovulation. Anovulatory bleeding is caused by the failure of the corpus luteal cyst to form, leading to absence of progesterone and unopposed estrogen stimulation on the endometrium. This ultimately results in endometrial hyperplasia and unpredictable bleeding.
Endometriosis
A disease of women of reproductive age that is rare in postmenopausal women unless they are on estrogen replacement therapy. Dysmenorrhea, pelvic pain, and dyspareunia are the most frequent presenting complaints, but patients may have bowel or bladder symptoms as well. Infertility is found in a quarter of patients.
Premenstrual Syndrome
A myriad of symptoms including sleep disturbances, decreased focus, emotional lability, breast tenderness, or HA that resolve after menstruation begins and do not hinder one's personal or professional life.
Polymenorrhea
A thin 19-year old woman presents with abnormal vaginal bleeding stating that her menstrual cycle interval has shortened to 18 days. She reports normal flow and that her cycle lasts for 3-4 days. She has been under a lot of stress. What is this pattern of bleeding called?
Secondary dysmenorrhea
Abnormal uterine bleeding associated with non-midline pelvic pain, which can be due to endometriosis, uterine fibroids or pelvic inflammatory disease
Premenstrual Syndrome
Alterations in the renin-angiotensin-aldosterone axis and altered antidiuretic hormone function describes the underlying pathophysiology of cyclic edema, a symptom that is associated with which of the following?
Postmenopausal bleeding
Any bleeding that occurs greater than 6 months after cessation of menses.
Primary dysmenorrhea
Applying local heat and taking oral vitamin E or thiamine have been shown to give some improvement in the symptomatic management for which of the following?
Polycystic ovarian syndrome (PCOS)
As little as 5% total weight reduction has been shown to improve the metabolic and reproductive abnormalities associated with this disorder and is the first line treatment for women who desire to conceive. Clomiphene citrate is the next line treatment if weight loss does not lead to return of ovulation, followed by low-dose gonadotropin therapy.
Primary amenorrhea
Causes include obstruction of the outflow tract, androgen insensitivity, gonadal dysgenesis, hyperprolactinemia, and dysfunction of the hypothalamus, pituitary, or thyroid.
Perimenopause
Characterized by irregular menstrual cycles and is often accompanied by hot flashes, sleep disturbances, mood symptoms, and vaginal dryness.
Premenstrual Dysphoric Disorder
Defined by the American Psychiatric Association DSM-5 as a constellation of symptoms prior to menstruation that hinder one's personal or professional life; include mood swings, anger, irritability, sense of hopelessness or tension, and anxiety or feeling on edge. Anger and irritability are what differentiate this condition from its milder counterpart.
Polycystic ovarian syndrome (PCOS)
Demonstration of hyperandrogenism in a patient with an abnormal degree of menstrual irregularity fulfills the diagnostic criteria.
Endometriosis
Diagnosis of this condition can be confirmed in most cases by direct laparoscopic visualization. The classic pelvic finding is a fixed retroverted uterus, with scarring and tenderness posterior to the uterus. Biopsy of selected implants confirms the diagnosis.
Menorrhagia
During the menstruation section of a gynecologic history, you determine that your 36-year-old patient's menstrual periods are increasing in length from four days to eight days, even though she still cycles every 28 days. She also reports more blood flow than typical during the first three days of these new eight day periods. Which of the following terms correctly defines this abnormal uterine bleeding?
Menorrhagia
Excessive bleeding (>80 mL per cycle) or menstruation >7 days that is mainly due to an anatomic or hemostatic abnormality, such as inherited or acquired clotting disorders (ITP, von Willebrand disease), anticoagulant use, ovarian endocrine disorders, and disorders of the endometrium (adenomyosis, leiomyoma, polyps and carcinoma).
Primary amenorrhea
Failure of menarche by age 13 in a woman with no secondary sex characteristics (i.e. breast development, pubic, and axillary hair).
Primary amenorrhea
Failure of menarche by age 15 in a woman with apparently normal sexual development.
Menometrorrhagia
Heavy uterine bleeding at irregular intervals.
Premenstrual Syndrome
In women whose daily function is altered due to the cyclical, luteal phase symptoms of this disorder, SSRIs are recommend as first-line therapy. Options include sertraline or fluoxetine, administered on a daily basis or only during the second half (luteal phase) of the patient's menstrual cycle. OCPs are recommended as second line therapy in those women who cannot tolerate the side effects of, or do not respond to, SSRIs. Third-line treatment of continued severe symptoms in women who do not tolerate or respond to SSRIs or OCPs is with gonadotropin-releasing hormone agonists (leuprolide or nafarelin).
Menopause
Increased follicle-stimulating hormone, decreased estrogens and decreased progesterone.
Oligomenorrhea
Infrequent menstruation with cycles of greater than 35 days, which can be associated with prolactinomas, thyrotoxicosis, perimenopause, Prader-Willi syndrome, Graves disease, athletes, excessive exercise, breastfeeding, polycystic ovarian syndrome, and eating disorders.
Metrorrhagia
Light uterine bleeding at irregular intervals.
Polymenorrhea
Menstrual cycles occurring at intervals less than 21 days often caused by stress, excessive exercise, hormonal imbalance, endometriosis, perimenopause, fibroids, and sexually transmitted infections.
Atrophic vaginitis
Physical examination of the vaginal canal reveals pale, dry and shiny epithelium without frank discharge or superficial lesions. Diagnosis is mainly clinical.
Secondary amenorrhea
Pregnancy is the most common cause.
Hypomenorrhea
Scanty menstruation that is most commonly associated with emotional stress, excessive exercise and dieting, Asherman's syndrome, and post-myomectomy.
Primary dysmenorrhea
Significant pain associated with the first few days of menses which alters normal activity or requires pain medication to control in a patient who is otherwise stable. Risk factors include smoking, obesity, early age of menarche, nulliparity and heavy menstrual flow. First line treatment is with NSAIDs followed by acetaminophen (2nd line).
Menopause
Symptoms of this condition can be summarized using the mnemonic HAVOCS: Hot flashes, Atrophy of Vagina, Osteoporosis, CAD, Sleep abnormalities.
Secondary amenorrhea
The absence of menses for more than 3 cycles or 6 months in women who have previously menstruated.
Primary amenorrhea
The most common cause is gonadal dysgenesis due to a chromosome abnormality.
Menopause
The permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea.
Adenomyosis
This condition most commonly presents as abnormal uterine bleeding and painful menses and physical exam reveals an enlarged uterus that is typically boggy and smooth.
Primary dysmenorrhea
This condition occurs only during menstrual cycles and has no organic cause. Elevated levels of PGF2α lead to and increase in uterine contractions. Treatment is with NSAIDs and acetaminophen. Abdominopelvic heat is also beneficial.
Adenomyosis
This is a condition in which endometrial glands invade the musculature of the uterus, producing a diffusely large and tender uterus on examination, along with a high likelihood of chronic pelvic pain.
Atrophic vaginitis
This is a major cause of vaginal dryness in postmenopausal women and is further characterized by burning, pruritus, discharge, bleeding and possibly dyspareunia. Commonly associated urinary symptoms include frequency, dysuria, and recurrent infections.
Endometrial hyperplasia
This is the most common cause of abnormal uterine bleeding in older, obese women and is the result of unopposed estrogen over a period of time. Risk factors include older age, obesity, diabetes, polycystic ovarian syndrome, and certain genetic mutations.
Abnormal (dysfunctional) uterine bleeding
This is the most common cause of abnormal vaginal bleeding in reproductive women. Initial lab tests include a complete blood count, serum prolactin level, serum β-hCG and serum thyroid stimulating hormone level.
Polycystic ovarian syndrome (PCOS)
This is the most common cause of infertility in women.
Atrophic vaginitis
This is the most common cause of postmenopausal bleeding.
Vulvovaginitis
This is the most common gynecological condition in prepubertal children owing to a lack of estrogen, developing toilet hygiene, and frequent use of baths, perfumed soaps, and bubbles.
Mittelschmerz
Unilateral midcycle pelvic pain related to ovulation.
Postcoital bleeding
Vaginal bleeding after intercourse suggesting cervical pathology (cervical cancer must be ruled out).
Polycystic ovarian syndrome (PCOS)
You are seeing a 16-year-old girl in clinic because of menstrual irregularity. She had menarche at 12 years of age and since then has had irregular menses that occur every 80 to 90 days. Her periods last for five to seven days with moderate amount of bleeding. She denies sexual activity. She does not report pain with menses and does not take any medication. She admits to shaving excess hair on her upper lip and chest. On examination, you note BMI of 30, severe acne on face, and Tanner 5 breasts and pubic hair. Her vital signs are normal. Which of the following is the most likely diagnosis? Note: The correct answer will provide the most specific diagnosis.
