Menstrual Disorders - Taylor

What is the difference between primary and secondary amenorrhea?

Primary amenorrhea is absence of menstruation by age 15; secondary amenorrhea is absence of menstruation for 3 cycles or 6 months in someone who previously menstruated.

What should be ruled out first when evaluating a patient presenting with amenorrhea?

Pregnancy; obtain a pregnancy test before investigating other causes.

What are the four critical reproductive system components involved in evaluating amenorrhea?

Hypothalamus, pituitary, ovaries, and uterus/outflow tract.

What causes amenorrhea in patients with excessive exercise or inadequate caloric intake?

Hypothalamic suppression reduces reproductive hormone signaling, resulting in decreased ovarian estrogen production and absent menstruation.

What is the initial treatment for amenorrhea associated with anorexia or excessive exercise?

Increase caloric intake, restore weight when indicated, and reduce excessive exercise quantity or intensity.

Which medications can cause hyperprolactinemia-associated amenorrhea?

Antipsychotics such as risperidone, paliperidone, and haloperidol; metoclopramide, clomipramine, verapamil, and opioids are additional potential contributors.

What are the mechanism and treatment options for hyperprolactinemia-associated amenorrhea?

Remove the offending medication if possible; dopamine agonists such as cabergoline (Dostinex) and bromocriptine (Parlodel) decrease prolactin, allowing FSH and LH secretion to normalize and menstruation to resume.

Which medication can induce withdrawal bleeding in amenorrhea of unknown etiology, and how long is it administered?

Oral medroxyprogesterone acetate (Provera) for 5-10 days after appropriate evaluation.

What is the difference between primary and secondary dysmenorrhea?

Primary dysmenorrhea is painful menstruation with normal pelvic anatomy; secondary dysmenorrhea is painful menstruation associated with underlying pathology such as endometriosis.

What is the pathophysiology of primary dysmenorrhea?

Prostaglandins and leukotrienes stimulate uterine smooth muscle contractions, reducing oxygen delivery to surrounding tissues and producing menstrual cramps.

What is the first-line pharmacologic treatment for primary dysmenorrhea, and why does it work?

NSAIDs such as ibuprofen (Advil/Motrin) inhibit prostaglandin synthesis, reducing uterine contractions and menstrual pain.

What nonpharmacologic treatments are identified for dysmenorrhea?

Heat therapy, acupuncture, decreasing strenuous exercise, and a low-fat vegetarian diet.

What is Taylor's treatment sequence when primary dysmenorrhea does not respond adequately to NSAIDs?

Consider combined hormonal contraception for approximately 2-3 cycles; if ineffective, consider depot medroxyprogesterone acetate or a levonorgestrel intrauterine system.

How is heavy menstrual bleeding defined, and what findings may accompany it?

Menstrual blood loss greater than 80 mL or bleeding lasting more than 7 days; possible findings include fatigue, lightheadedness, orthostasis, tachycardia, low hemoglobin/hematocrit, and low iron.

What underlying conditions should be considered in a patient with heavy menstrual bleeding?

Pregnancy-related complications, endometrial polyps, endometriosis, uterine fibroids, and bleeding disorders.

What are the initial treatment options for heavy menstrual bleeding based on whether contraception is desired?

If contraception is desired, consider combined hormonal contraception or a levonorgestrel IUD; if contraception is not desired, consider NSAIDs during menstruation, with tranexamic acid or progestin-based treatment if needed.

What are the generic name, brand name, and mechanism of Lysteda?

Tranexamic acid (Lysteda) is an antifibrinolytic that reversibly blocks lysine-binding sites on plasminogen, reducing fibrin degradation and menstrual blood loss; it does not provide contraception.

How do NSAIDs and tranexamic acid differ in treating heavy menstrual bleeding?

NSAIDs decrease prostaglandin synthesis and can reduce menstrual pain and blood loss; tranexamic acid inhibits fibrin degradation to reduce menstrual blood loss.

What is endometriosis, and how can it contribute to infertility?

Endometriosis involves endometrial-like tissue outside the uterine cavity; repeated hormonal stimulation causes growth, bleeding, inflammation, and adhesions that can distort pelvic anatomy and interfere with ovarian and fallopian tube function.

What is first-line pharmacologic treatment for endometriosis when contraception is desired versus when it is not desired?

When contraception is desired, consider combined hormonal contraceptives, levonorgestrel IUDs, progestin-only pills, or progestin injections; when contraception is not desired, NSAIDs can provide pain relief.

What is Taylor's treatment sequence for endometriosis when first-line therapy is ineffective?

First-line options include hormonal contraceptives, progestins, and NSAIDs; second-line options are GnRH agonists or antagonists; last-line options include danazol and aromatase inhibitors.

How does hormonal contraception improve endometriosis symptoms compared with NSAIDs?

Hormonal contraception decreases dysmenorrhea and suppresses stimulation of endometriotic lesions; NSAIDs provide symptomatic pain relief by decreasing prostaglandin production.

How can PMS be recognized based on symptom timing and presentation?

Affective, cognitive, and physical symptoms such as irritability, anxiety, cravings, bloating, and insomnia typically occur 5-7 days before menstruation during the luteal phase and dissipate around menstrual onset.

What distinguishes PMDD from PMS in a clinical case?

PMDD involves severe cyclic premenstrual symptoms that significantly interfere with work, relationships, or daily functioning; Taylor describes at least 5 symptoms occurring across 2 menstrual cycles.

What are the recommended treatments for PMDD, and which brand/generic oral contraceptive should be recognized?

Lifestyle changes PLUS at least one of the following: an SSRI, cognitive behavioral therapy (CBT), or a drospirenone-containing combined oral contraceptive such as Yaz (drospirenone/ethinyl estradiol).