Menstruation: AUB, PMS/PMDD, Dysmenorrhea

Polymenorrhea

Frequent menses, bleeding that occurs more often than every 21 days

Menorrhagia

Abnormally heavy and/or prolonged bleeding, typically considered blood loss > 80mL per cycle

-Frequently produces anemia

Metrorrhagia

Abnormal bleeding between periods 

Menometrorrhagia 

Abnormally heavy bleeding during and between periods 

polyp, malignancy, coagulopathy, iatrogenic

AUB: Etiology

-PALM → ______, Adenomyosis, Leiomyoma, __________ and hyperplasia

-COEIN → ____________, Ovulatory dysfunction, Endometrial, _________, Not yet classified 

pregnancy, bleeding, surgery, endocrine, thyroid, hyperandrogenism, uterus

AUB Workup: H & P

-History → _______ history, menstrual history and ________ pattern, sexual history, obstetric or gynecologic ________ history, contraceptive history, history of bleeding disorders, and history of _________ disorders

-Physical → enlarged _______, evidence of _____________ (hirsutism, acne, male pattern balding), galactorrhea, size and contour of the ______, and presence of an adnexal mass or tenderness

CBC, anemia, heavy, positive, coagulation, von Willebrand, ultrasound, biopsy, MRI

AUB Workup: Labs and Imaging

-Labs → ___, pregnancy test, and TSH

• All patients with heavy menstrual bleeding should be screened for ______

-For adolescents with _____ menstrual bleeding and adults with a _______ screening history → __________ studies should be considered to screen for ___ __________ Disease

-Transvaginal ________, hysteroscopy (for ______ or excision of lesion), and ___ only as a follow-up test when additional information could potentially impact clinical management

von Willebrand, anticoagulation, cirrhosis

AUB Etiology: Coagulopathy

-Accounts for 20% of acute uterine bleeding in adolescents, with ___ ________’s disease being the most common cause

• Followed by myeloproliferative disorders and immune thrombocytopenia 

-In adults, ____________ agents and acquired bleeding disorders like _______ are more common

platelets, aggregates, VIII, I, quantitative, qualitative, desmopressin

Von Willebrand Disease

-vonWillebrand Factor (vWF) → binds _________ to subendothelial surfaces, _________ platelets, and prolongs the half-life of factor ____

-Type I vWD

• Seen in 80% of patients with vWD

• A ___________ abnormality of the vWF molecule

-Type II vWD

• Seen in 15-20% of patients with vWD

• __________ defect in the vWF molecule is causative

-Treat with ______________ +/- oral contraceptives and TXA

anovulation, oligo

AUB Etiology: Ovulatory Dysfunction

-__________ → absence of ovulatory cycles

-_____-ovulation → shift between ovulatory cycles and anovulation

corpus luteum, progesterone, estrogen, irregular

Anovulatory Abnormal Uterine Bleeding

-_______ _______ does not form and cyclical secretion of ___________ does not occur 

-________ stimulates the endometrium continuously until it outgrows its blood supply 

-Sloughing then occurs incompletely

-Bleeding is ________ but can be profuse 

irregular, estrogen, primary, PCOS, regular, structural

Anovulatory vs Ovulatory Bleeding

-Anovulatory

• ______/infrequent bleeding that ranges from very light to very heavy

• Due to an _________-dominant / progesterone-deficient state

• ________ hypothalamic-pituitary dysfunction that is postmenarchal and in the menopausal transition

• ____ and other endocrine disorders

-Ovulatory

• ________ menstrual periods with heavy or prolonged flow

• Due to uterus ________ abnormalities and bleeding disorders

progesterone, 6

Ovulation Testing

-Serum ___________ level in the mid-luteal phase (18-24 days post menses)

-Normal mid-luteal phase levels are 6-25. If > _, ovulation occurred

endometrium, regular, exclusion, Prostaglandin, vasodilators, chlamydia 

AUB Etiology: Endometrial Causes

-Normal ovulation with a structurally abnormal _____________

• Normal ovulation is based on a history of _______ menstrual periods 

• Bleeding may be preceded by breast tenderness, bloating, and pelvic pain

-Diagnosis of _________

-Etiologies:

• Deficiency of local production of vasoconstrictors like Endothelin I and ____________ F2a

• Increased local production of ____________ like Prostaglandin E2 and Prostacyclin I2 

• Disorders of endometrial repair like inflammation from ____________

OCP

What is the most common cause of intermenstrual bleeding?

PID, bleeding, trauma

AUB Etiology: Not Yet Classified/Other

-___ or infections that cause endometritis

-Cervical erosions, polyps, and cervicitis may cause __________ from the cervix

-Vaginal infections, _______, and foreign bodies

Acute

Would you use conjugated equine estrogen, OCPs, progestins, and TXA to treat acute or chronic AUB?

IUD, combined

Chronic AUB should be treated with Levonorgestrel ___, Depo-Provera, oral progestin, __________ estrogen-progestin oral contraception, tranexamic acid, or NSAIDs

ablation, pregnancy, resection, hysterectomy

Surgical Management of AUB

-Endometrial _________ using heat directed at endometrium → minimally invasive treatment option in OR or in office

• _________ is contraindicated after, but this procedure does not prevent it

-Endometrial _________

-Uterine artery embolization

-_____________ is the definitive treatment for uterine bleeding

luteal, menses, neurotransmitter, serotonin, estrogen, abnormal

PMS and PMDD: Background and Pathogenesis

-Characterized by physical and/or behavioral symptoms during the ______ phase of the menstrual cycle and often into the first few days of _________

-PMS is very common, while PMDD affects approximately 2% of women

-Pathogenesis 

• Women with PMS/PMDD have an abnormal ______________ response (__________) to luteal phase hormonal changes

• Concentrations of _________ and progesterone are normal, but there is an __________ neurotransmitter response to luteal phase changes 

• PMDD is a much more severe form of PMS 

• Abnormal serotonin response 

mild, before, one, 5, menses, 3, bloating, anxiety, increased, stress

PMS

-Refers to a group of _____ to moderate physical, emotional, behavioral, or cognitive symptoms that last an average of 6 days per month

• ________ menses

-ACOG states “At least ____ symptom associated with economic or social dysfunction that occurs during the _ days before menses and is present in at least _ consecutive menstrual cycles”

-Physical Sx → abdominal ________, fatigue, breast tenderness, headaches, hot flashes, dizziness

-Behavioral Sx → irritability, _______, depression, confusion, _______ appetite, food cravings, diminished interest in activities

-Management → exercise, _____ reduction, chasteberry, OTC mends PRN

severe, reduced, distress, suicidal, SSRI, drosperinone, oophorectomy

PMDD

-Same symptoms as PMS but more _______, associated with _______ health-related quality of life

-Symptoms must be associated with significant ________ or interference with usual activities

-Associated with an elevated risk of _________ ideation and attempts

-Treatment → _____ are first line (Fluoxetine or Sertraline), could also try oral contraceptives (____________ as the progestin are best)

-Surgical treatment → bilateral ____________/salpingoophorectomy is considered only as a last resort

painful, younger, stress, recurrent, disease, endometriosis 

Dysmenorrhea: Background

-_______ menstruation

-RF → _______ age (particularly adolescents), smoking, ______

-Can be primary or secondary 

• Primary → ________, crampy, lower abdominal pain that occurs during menses in the absence of demonstratable ________ that could account for these symptoms (diagnosis of exclusion)

• Secondary → pain that occurs in females with a disorder that could account for their symptoms like ___________, adenomyosis, or fibroids 

prostaglandins, contractions, ischemia, dysmenorrhea

Primary Dysmenorrhea: Pathogenesis

-____________ released from endometrial sloughing at the beginning of menstruation → uterine ____________ that result in high intrauterine pressure → uterine pressure exceeds arterial pressure, causing _________ → anaerobic metabolites accumulate → Type C neurons are stimulated, resulting in _____________

lower, before, suprapubic, diarrhea

Primary Dysmenorrhea: Presentation

-_______ abdominal pain that is recurrent, crampy

-Typically starts 1-2 days _______ or with the onset of menses, gradually diminishing over 12-72 hours

-Usually confined to lower abdomen and ___________ area, but some patients also report severe back and/or thigh pain

-Severity of the pain ranges from mild to severe

-Nausea, __________, fatigue, headache, and a general sense of malaise often accompany the pain

exclusion, PID, imaging, NSAIDs, TENS

Primary Dysmenorrhea: Diagnosis and Treatment

-Diagnosis of ________, be sure to rule out ___, endometriosis, adenomyosis, and fibroids

• May need to order further testing and ________

• Dx made clinically 

-Mainstays of treatment are __________ and hormonal contraceptives

• Other options include _____ units, GnRH analogs, exercise, acupuncture, and heat therapy 

painful, later, pathology, bleeding, infertility

Secondary Dysmenorrhea

-________ periods typically with other symptoms of underlying pathology

-Onset typically _____ in life and correlates with the development of the underlying __________

-Pain worsens over time and improves with treatment or resolution of the underlying pathology

-Other possible sx → abnormal uterine _________, non-midline pelvic pain, absence of N/V/D, presence of dyspareunia or dyschezia, and _________