Menstruation - OB/GYN EOR

Minus normal physiology and amenorrhea!! Listen to the violent nature album by I Prevail for the vibes

Dysfunctional uterine bleeding (AKA abnormal uterine bleeding (AUB))

Uterine bleeding of abnormal quantity, duration, or schedule

3-80 mL

Average blood loss during menses

Menorrhagia

AUB defined as bleeding for 7+ days or more than 80 mLs

Cryptomenorrhea

AUB defined as light flow

metrorrhagia

AUB defined as bleeding between periods (spotting)

Polymenorrhea

AUB defined as less than 21 days between cycles (hella periods)

Oligiomenorrhea

AUB defined as more than 35 days between cycles

Menmetrorragia

AUB defined as excessive or prolonged bleeding at irregular intervals

Anovulation (ovaries produces estrogen but don’t ovulate, so there’s unopposed estrogen)

What causes 90% of AUB?

Luteal phase defect (results in difficulty achieving pregnancy)

An etiology of AUB in which ovulation occurs BUT the corpus luteum does not fully form to make sufficient progesterone (we never get to the secretory phase)

a sudden drop in estrogen that occurs mid-cycle at the time of ovulation

Mid Cycle spotting is related to

Polyp, adenomyosis, leiomyoma, malignancy/hyperplasia, coagulation, ovulatory disorder, endometrial, iatrogenic, not yet classified

What does PALM-COEIN stand for?

Preg (1st step DUH) → CBC, TSH, Iron studies, PT/PTT, progesterone, prolactin, FSH → TVUS (1st line imaging) → endometrial biopsy

Work up for AUB

Unopposed estrogen therapy, tamoxifen usage, menopause after 55, PCOS, 35+ with obesity/HTN/DM, if 45+, post menopausal bleeding

When is an endometrial biopsy indicated for AUB?

IV high dose estrogen, high dose OCs

Treatment for acute hemorrhage associated with AUB

OCPs, TXA (adjunctive), IUD, NSAIDs, hysterectomy (definitive), endometrial ablation

Chronic management of AUB

Leiomyoma (Fibroids)

A benign uterine smooth muscle tumors that derive from the muscle cells of the myometrium (most common benign gynecological tumor and most common cause of AUB)

Intramural (most common), submucosal, subserosal, parasitic

Types of Fibroids

Increasing age, AA (5X more common), nulliparity, obesity, fam hx, HTN

Risk factors for Fibroids

Growth is estrogen dependent and may increase in size with relation to the menstrual cycle, anovulatory states, during pregnancy, and after menopause

Patho for fibroids

Menorrhagia and irregular bleeding (submucosal - watch for iron deficiency anemia), dysmenorrhea, pelvic pressure, pain, hydroureter/nephrosis (IF A MEGA FIBROID)

Clinical manifestation of leiomyomas (most asymptomatic)

palpable, firm, nontender asymmetric mobile mass in the abdomen or pelvis; enlarged mobile uterus with an irregular contour

PE findings for Leiomyomas

TVUS (focal heterogeneous hypoechoic, well circumscribed mass with shadowing), Hysteroscopy (submucosal), laparoscopy (r/o carcinoma)

Diagnostics for Leiomyomas

Observation, Leuprolide (most effective medical management), Levonorgestrel-releasing IUDs (dysmenorrhea), progestin, GnRH analogs, Hysterectomy (definitive), Myomectomy (fertility preservation)

Management plan for leiomyomas

Adenomyosis

Condition in which endometrial glandular tissue and stroma are present within the myometrium

Heavy menstrual bleeding, dysmenorrhea

Clinical manifestations of adenomyosis

Mobile, enlarged (glandular), boggy (soft) uterus that may be fixed if concurrent endometriosis

PE findings for adenomyosis

Hcg, H/H, STI testing (if pelvic pain), TVUS

Workup for Adenomyosis

asymmetric thickening of myometrium, myometrial cysts, linear striation, loss of endomyometrial border, increased heterogeneity

TVUS findings in adenomyosis

Levonorgestrel-releasing IUD, Total hysterectomy (definitive)

Management of adenomyosis

Polyp

A localized hyperplastic overgrowth of endometrial glandular/stromal tissue around a vascular core that forms a sessile or pedunculated projection from the endometrial surface

tamoxifen, obesity, HRT, lynch and cowden syndrome

Risk factors for endometrial polyps

OCPs, levonorgestrel containing IUD

Protective factors for endometrial polyps

intermenstrual bleeding

Clinical presentation of endometrial polyps

TVUS (1st line), sonohysterography/diagnostic hysterography, histology post polypectomy (diagnostics)

Diagnostics for endometrial polyps

Polypectomy

Treatment for endometrial polyps

Increased prostaglandins

Etiology for primary dysmenorrhea

menarche before 12, nulliparity, smoking, fam hx, obesity

Risk factors for primary dysmenorrhea

Pelvis/uterine pathology

Etiology of secondary dysmenorrhea

endometriosis, PID, adenomyosis, leiomyomas

Risk factors for secondary dysmenorrhea

Recurrent, crampy, midline lower abdominal/pelvic pain 1-2 days before menses that diminish over 12-72 hours, associated with HA, N/V/D

Clinical presentation for dysmenorrhea

Supportive care (heat, vitamin B/E, exercise), NSAIDs with OCPs (first line)

Management plan for dysmenorrhea

unresponsive to 3 cycles of initial therapy to r/o secondary causes

When is laparoscopy indicated for dysmenorrhea

Menopause

Cessation of menses for 1 year due to loss of ovarian function leading to a drop in estrogen and progesterone (average age is 51)

Perimenopause

Transition between reproductive capability and menopause that is characterized by irregular menses and lasts 3-5 years

Increased FSH, LH, estrone (predominates after menopause)

Decreases: Estradiol (hella), Progesterone

No Change: Testosterone

Hormonal changes in Menopause

hot flashes, night sweats, sleep disturbances, mood changes, skin/hair/nail changes, increased risk of CVD events, hyperlipidemia, osteoporosis, dyspareunia, vaginal atrophy

Signs of estrogen deficiency

HRT, SSRIs, Bisphosphonates (osteoporosis), Topical vaginal estrogens (vaginal atrophy)

Management of Menopause

H/o breast cancer, CHD, previous VTE/Stroke/TIA, active liver disease, unexplained vaginal bleeding, high risk endometrial cancer

Contraindications for HRT

Premenstrual Syndrome (PMS)

A cluster of physical, behavioral, and mood changes with cyclical occurrence during the luteal phase of the menstrual cycle

Premenstrual Dysphoric Disorder (PMDD)

Severe PMS with functional impairment that must be present for 1 YEAR

A: at least 5 symptoms in the final week before menses

B: 1+ of theses → affective lability (mood swings), irritability, depressed, anxiety

C: 1+ of these → decreased interests, difficulty concentrating, lethargy, change in appetite, hypersomnia/insomnia, sense of being overwhelmed, breast tenderness or swelling, joint/muscle pain, bloating, weight gain

D: 2+ cycles

Diagnostics criteria for PMDD - DSM-V (if less than 5 its PMS)

Sxs occurring 1-2wks BEFORE menses (luteal phase), RELIEVED within 2-3days of the onset of menses + 7 sxs-free days during the follicular phase

Cycle timeline for PMDD

Lifestyle Modification (stress reduction + exercise, NSAIDs, vitamins B6/E limit caffeine/EtOH/cigarettes/salt), Spironolactone (bloating and tender breast), SSRIs (1st line - fluoxetine, sertraline, citalopram), OCPs (must contain drospirenone)

Management of PMDD