Menstruation: Normal and Amenorrhea

Menarche

Onset of menstruation

-Median age is 12.4 years old

bleeding, least, low, thins, decreased, prostaglandin, myometrium

Menstrual Cycle: Early Follicular Phase

-Starts with the onset of ___________

-Early follicular phase

• Menstruation

• Ovarian cycle → ovary is _____ active, hormones are ___

• Endometrial cycle → menstruation occurs, endometrium _____

-Degeneration and sloughing of endometrial lining due to ____________ estrogen and progesterone

-Causes release of uterine ________________, which stimulates rhythmic contractions of uterine ______________

end, FSH, follicles, proliferation, thickens, mucus, lubricates

Mid-Follicular Phase

-___ of menstruation

-___ stimulates folliculogenesis and estradiol production

-Ovarian cycle → several _________ start to develop

-Endometrial cycle → __________ of endometrial glands

• Endometrium _________ and regenerates

• Endocervical glands produce thin, clear _______

• __________ vagina and facilitates sperm transport

dominant, developing, thickens, egg white, mucin, sperm, LH, 36

Late Follicular Phase

-Ovarian cycle → one follicle is selected as the __________ follicle, while the rest of the growing follicles stop ____________ (atresia)

-Endometrial cycle → endometrium ___________ more and the cervical mucus becomes more “stringy” (also known as “____ _______ cervical mucus”)

-_____ protein in this cervical mucus is important for _____ transit to the uterus 

-__ surges, also known as the midcycle surge → ovulation occurs ~__ hours later

-Monitoring for a LH surge is often used to help detect ovulation

released, fallopian, uterine, 14

Ovulation

-The oocyte is _________ from the follicle at the surface of the ovary, where it then travels down the ___________ tube to the uterine cavity

-Typically occurs around day __ in the average menstrual cycle

ovulation, not, corpus luteum, progesterone, pregnancy, suppresses, increase, 6

Luteal Phase: Early

-Begins with __________ and ends with new cycle if the oocyte is ___ fertilized

-Usually lasts 14 days

-Ovarian Cycle:

• Follicle changes to form ________ ________, which produces large amounts of ___________ to prepare the body for __________

• Progesterone _________ growth of new follicles 

• Causes ________ in basal body temperature 

• Progesterone _ or more ng/mL confirms ovulation

hCG, corpus albicans, fertilized, progesterone

Luteal Phase: Late Luteal Phase & Ovarian Cycle

-If ___ is not produced by an embryo, the corpus luteum declines and becomes the _______ ________ before resolving completely

-If the oocyte becomes __________, the early embryo begins to make hCG, which maintains the corpus luteum and ___________ production

implants, decline, meses, 14

Late Luteal Phase: Endometrial Cycle

-If the oocyte becomes fertilized, it _______ in the endometrium several days after ovulation

-If there is no implantation, the uterus throws a hissy fit

-_______ in estradiol and progesterone results in the loss of endometrial blood supply → endometrial sloughing and onset of ______ approximately __ days after LH surge, therefore restarting the cycle

irregular, 24-38, 2-8, interfere, spotting, between, scheduled, common

Normal Menstrual Cycle in Young Females

-Frequency → during the first 2 years after menarche, cycles may be _________

• Normal is every __-__ days (after first 2 years)

-Duration → flow length is approximately _-_ days 

-Regularity → cycle variation depends on the age range, however, anything greater than 9 days is considered abnormal 

-Volume → subjective, but normal menstrual blood loss should not ______ with a patient’s physical, social, emotional, and/or material quality of life 

• 3-6 pads/tampons per day (on average)

-Intermenstrual bleeding → _______ at the beginning of the cycle is normal, but bleeding _______ regular cycles is not considered normal 

-Unscheduled bleeding → should be no bleeding on hormonal contraceptives except for ________ withdrawal bleeding (placebo pills), however, irregular bleeding is a _________ side effect of hormonal contraceptives 

38, 8, heavy, irregular, primary, breast

When to Evaluate for a Menstrual Problem?

-Cycles are persistently less than 24 days or greater than __ days

-Flow lasts more than _ days

-Flow is subjectively too _____ or light

-Intermenstrual bleeding

-Cycles are initially regular then become _________

-Evaluate ______ amenorrhea when menses have not started within 3 years of _____ development

Primary

What type of amenorrhea is being described?

-Absence of menarche by age 15 years in the presence of normal growth and secondary sex characteristics

Secondary

What type of amenorrhea is being described?

-Absence of menses for more than 3 months in females who previously had regular menstrual cycles

-Absence of menses for more than 6 months in females who had irregular cycles

Pregnancy

What is the most common cause of amenorrhea?

15, absence, breast, 13, secondary, pain, before

Primary Amenorrhea

-Even though the definition is no menses by age __, there are other scenarios that would merit evaluation:

• If no menses have occurred and there is a complete _________ of secondary sex characteristics (such as _____ development) by age __

• If secondary sex characteristics have developed and there is cyclic pelvic ____ with amenorrhea, even if _______ age 15

pregnancy, TSH, Turner, ultrasound

Primary Amenorrhea: Evaluation

-History and physical

-Labs → hCG (rule out ________), FSH, LH, ___, prolactin

-Karyotype → ________ Syndrome, FMR I premutation

-Pelvic ________

High

In the evaluation of primary amenorrhea in someone with a uterus present, _____ FSH would lead you to ordering a karyotype to test for Turner Syndrome or other genetic disorders

FSH, 2, outflow, endocrine, MRI

-In the evaluation of primary amenorrhea in someone with a uterus present, a low or normal ___ with breast development more than Tanner stage _ warrants an ultrasound.

• If there is a uterine anatomic abnormality identified on US, there is likely an ______ tract disorder like an imperforate hymen

• If there is no abnormality detected, the amenorrhea is likely due to underlying __________ disorder like PCOS

-In the evaluation of primary amenorrhea in someone with a uterus present, a low or normal FSH with breast development less than Tanner stage 2 warrants a repeat FSH + LH.

• Regardless of the lab values, a pituitary ___ to rule out sellar mass in some patients may be indicated

Karyotype, testosterone

In the evaluation of primary amenorrhea in a patient without a uterus, the next steps should be to order a __________ and serum total __________

3, 6, 9, 35, same

Secondary Amenorrhea

-Many women occasionally miss a single period. Further evaluation is indicated when:

• _ months of secondary amenorrhea

• _ months in women with previously irregular cycles

-Oligomenorrhea

• <_ menstrual cycles per year or cycle length greater than __ days

• The etiologic and diagnostic considerations for oligomenorrhea are the ____ as for secondary amenorrhea

negative, TSH, MRI, testosterone 

Secondary Amenorrhea: Evaluation

-History and physical 

-Labs (after checking that hCG is _________) → FSH, prolactin, ___, estradiol

-Pituitary ___ and serum total ____________ may be indicated 

fertility, osteoporosis

Secondary Amenorrhea: Management

-Goals of management are:

• Correct underlying pathology if present

• Help the woman achieve ______ if desired

• Prevent complications like ____________

40, estrogen, high, idiopathic, surgery, menopause, 25, low, HRT, donor

Premature Ovarian Insufficiency

-Loss of ovarian function before __ years old, infertility, low ________, ____ FSH and LH

-Causes:

• _________ is MC

• Genetic = Turner Syndrome, FMRI premutation

• Autoimmune = thyroid disease, Addison’s Disease

• Iatrogenic = _______ related

-Patients have __________ symptoms

-Labs:

• FSH > __ on 2 occasions, > 4 weeks apart

• ___ estradiol

-Management:

• ___ until natural menopause age and _____ oocyte if desires pregnancy