wh 1 menstruation, dysmenorrhea, abnormal uterine bleeding, & amenorrhea (part 2)

luteolysis

what is regression of the corpus luteum called?

3-4 days before menses, key to menstrual cycle

when does luteolysis start and what is its significance?

falls

what happens to estrogen and progesterone levels when luteolysis begins?

increases

what happens to secretion of FSH and LH when luteolysis begins?

proliferative

the follicular phase occurs at the same time as what uterine phase?

premenstrual syndrome (PMS)

what is the cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predicable relationship to menses?

luteal phase

symptoms occurring in what phase of the menstrual cycle is pathognomonic of PMS?

75%

up to ___ of women experience some recurrent PMS symptoms

20-40%

PMS causes what percentage of people to be mentally or physically incapacitated?

5%

PMS causes what percentage of people to be severe distress?

physiologic ovarian function (supported by efficacy of ovarian cyclic suppression either medically or surgically)

what is believed to be the trigger of premenstrual syndrome (PMS)?

breast tenderness (mastodynia)

what is the most common symptom of premenstrual syndrome (PMS)?

it is more severe and disabling

how is premenstrual dysphoric disorder (PMDD) different from premenstrual syndrome (PMS)?

true

true or false: there is no objective screening or diagnostic tool for PMS or PMDD available

charting symptoms

what is the best way to diagnose PMS or PMDD?

patient reports at least 1 affective and 1 somatic symptom during the 5 days before menses in each of the 3 prior menstrual cycles

according to the American College of Obstetricians and Gynecologists (ACOG) criteria, when can PMS be diagnosed?

4 days

PMS symptoms should be relieved within how many days of the onset of menses

13

PMS symptoms should not recur until at least cycle day ___

2

PMS symptoms should be reproducible during ___ cycles of prospective recording

depression

what is the most common associated psychiatric illness associated with PMS or PMDD?

-diet

-stress management

-cognitive behavioral therapy

-exercise

-medications

what is the treatment for PMS?

-calcium carbonate (bloating, food cravings, pain)

-magnesium (water retention)

-NSAIDs

-diuretics

-SSRIs (fluoxetine and sertraline)

-OC

-GnRH agonist

-surgical (b/l oophorectomy)

what medications can treat premenstrual syndrome (PMS)?

1000-1200mg/day

what is dosage of calcium carbonate used to treat PMS?

200-360mg/day

what is dosage of magnesium used to treat PMS?

start 14 days prior to menstruation and continue through the end of the cycle

how can SSRIs like fluoxetine and sertraline be used to treat PMS?

GnRH agonists

what treatment of premenstrual syndrome is considered "medical menopause"?

dysmenorrhea

what is one of the most common complaints from gynecologic patients?

prevents normal activity and requires medication (OTC or Rx)

dysmenorrhea is reserved for women whose pain...

-primary

-secondary

-membranous

what are the 3 types of dysmenorrhea?

no organic cause

what is primary dysmenorrhea?

pathogenic cause (endometriosis, uterine fibroids)

what is secondary dysmenorrhea?

cast of endometrial cavity shed as single entity, rare

what is membranous dysmenorrhea?

intense cramping pain due to passage of cast of endometrium through undilated cervix

what does membranous dysmenorrhea cause and why?

prostaglandin activity

primary dysmenorrhea: what has mechanism of pain been attributed to?

induces abnormal uterine contractions, contractions reduce uterine blood flow leading to uterine hypoxia

how does abnormal and increased prostanoid secretion cause primary dysmenorrhea?

day 1-2 of cycle

when is pain normally present during primary dysmenorrhea?

-pain on days 1-2 of cycle

-N/V

-diarrhea

-HA

what are the symptoms of primary dysmenorrhea?

late in adolescence

when does primary dysmenorrhea typically occur?

-no significant pelvic disease

-generalized pelvic tenderness (uterus>adnexa)

what would be seen on PE for pt with primary dysmenorrhea?

secondary dysmenorrhea due to endometriosis

what is the DDx for primary dysmenorrhea?

-NSAIDs

-codeine or stronger analgesics (severe pain)

-BR

-heat application

-antiprostaglandins (ibuprofen, naproxen)

-TENS (transcutaneous electrical nerve stimulator)

-exercise

-OC (when NSAIDs not beneficial)

-surgery (rare)

what is the tx of primary dysmenorrhea?

absence of ovulation and decreased prostaglandin production

what is the MOA of OC in treatment of primary dysmenorrhea?

abnormal menstrual bleeding, bleeding from other causes: pregnancy, systemic disease, cancer

what does abnormal uterine bleeding (AUB) include?

abnormal uterine bleeding (AUB)

what presents one of the most difficult problems in gynecology?

complication of pregnancy

with abnormal uterine bleeding (AUB) what must be considered in childbearing women?

heavy menstrual bleeding, >80mL of blood loss

what is menorrhagia?

-subcutaneous myomas (fibroid)

-pregnancy complications

-adenomyosis

-IUDs

-endometrial hyperplasia

-malignant tumors

-dysfunctional bleeding

what are causes of menorrhagia?

hypomenorrhea

what is cryptomenorrhea aka?

unusually light menstrual flow, may only be spotting

what is cryptomenorrhea?

hymenal or cervical stenosis

what are examples of obstructions that can cause cryptomenorrhea?

formation of scar tissue in uterine cavity

what is Asherman's syndrome?

-obstruction

-Asherman's syndrome

-OCP

what can cause cryptomenorrhea?

metrorrhagia

what is intermenstrual bleeding occurring at any time between menstrual periods?

-ovulatory (occurs midcycle as spotting)

-endometrial polyps

-cervical carcinoma

-exogenous estrogen administration

what are causes of metorrhagia?

periods that occur more often than every 21 days

what is polymenorrhea defined as?

anovulation

what is polymenorrhea usually associated with?

luteal

polymenorrhea is rarely due to a shortened ___ phase

bleeding that occurs at irregular intervals, amount and duration of bleeding varies

what is menometrorrhagia?

true

true or false: any condition that causes metrorrhagia can eventually lead to menometrorrhagia

malignant tumors or complications of pregnancy

with menometrorrhagia, what can sudden onset of irregular bleeding episodes be an indication of?

menstrual periods that occur more than 35 days apart

what is oligomenorrhea defined as?

no period for 6 months

what is amenorrhea?

decreased in amount and associated with anovulation

how is bleeding during oligomenorrhea?

-pregnancy

-pituitary-hypothalamus causes

-excessive weight loss

-estrogen secreting tumors

what causes oligomenorrhea?

cervical cancer

contact bleeding (post-coital bleeding) may be a sign of what?

-cervical eversion

-cervical polyps

-vaginal infection

-atrophic vaginitis

besides cervical cancer, what can cause contact bleeding (post-coital bleeding)?

polyp, adenomyosis, leiomyoma (uterine fibroid), malignancy & hyperplasia

in PALM-COEIN, what does PALM stand for?

coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified

in PALM-COEIN, what does COEIN stand for?

discrete structural

in PALM-COEIN, the PALM group are ____ entities

PALM-COEIN

what is the classification system used to describe AUB?

PALM group

in PALM-COEIN, what group is measured visually using imaging studies?

myoma

on PE for AUB, what does abdominal masses and enlarged, irregular uterus suggest?

adenomyosis or endometrial cancer

on PE for AUB, what does symmetrically enlarged uterus suggest?

cytologic exam

what is most useful to diagnose asymptomatic intraepithelial lesions of the cervix?

abnormal unless taking estrogen

cytologic exam: the presence of endometrial cells in a postmenopausal woman should be considered...

secretory

cytologic exam: endometrial cells should not be present during the ___ phase

pelvic ultrasound

what is an integral part of the gynecological pelvic exam for AUB?

transabdominally or transvaginally

how can a pelvic ultrasound be done?

empty

does a transvaginal pelvic US require a full or empty bladder?

full

does a transabdominal pelvic US require a full or empty bladder?

modification of pelvic US, performed following injection of saline by thin catheter into uterus

what is sonohysterography?

increases the sensitivity

what is the benefit of a sonohysterography?

endoscopic camera through cervix for direct visualization

what is a hysteroscopy?

hysteroscopy

what is the gold standard for evaluation of pathology in the uterine cavity?

dilation and curettage (D&C) (slowly being replaced w hysterscopy)

what is the gold standard to diagnose AUB?

-rectal or urological disorders

-thyroid disease

-liver disease

-coagulopathies

-meds

-extreme weight loss

what is the DDx for AUB due to non-gynecological disease and disorders?

dysfunctional uterine bleeding

what did anovulatory and not yet classified AUB used to be called?

dysfunction of hypothalamic-pituitary axis (results in continued estrogenic stimulation of endometrium)

what is anovulatory and not yet classified AUB likely due to?

extremes of reproductive ages (20% of cases in adolescents, 40% of cases in patients over 40 years old)

anovulatory bleeding occurs most commonly at the...

high dose estrogen IV

what do you treat ACUTE hemorrhage (AUB) with?

myomectomy

what is the treatment of myoma that allows pts to retain childbearing potential?

-high dose estrogen (acute hemorrhage)

-myomectomy

-endometrial ablation

-antifibrinolytic therapy

-depo-provera

-IUD

-hysterectomy

what is the treatment of AUB?

antifibrinolytic therapy

what is used to treat menorrhagia and decreases blood loss significantly during menses?

intramuscular progestin administration

what is Depo-Provera?

bleeding that occurs after 12 months of amenorrhea in a middle-aged woman

what is post menopausal bleeding?

FSH levels

what levels are helpful in distinguishing between menopause and hypothalamic amenorrhea?

> 30 mIU/mL

what FSH levels are highly suggestive of menopause?

post menopausal bleeding

what is more likely to be pathological than bleeding in younger women and always needs investigated?

exogenous hormones

what is the main etiology of post menopausal bleeding?

-exogenous hormones

-non-gynecological causes

-endometrial hyperplasia/cancer

-endometrial polyps

-cervical cancer

-ovarian cancer

-vaginal atrophy

what are the etiologies of post menopausal bleeding?