Women's Health EOR: Menstruation (Smarty PANCE)

What is primary vs secondary amenorrhea?

Primary: no menarche by age 15 with secondary sex characteristics OR age 13 without secondary sex characteristics; Secondary: absence of menses for 3 months (regular cycles) or 6 months (irregular cycles)

What is the most common cause of secondary amenorrhea (excluding pregnancy)?

Polycystic ovary syndrome (PCOS) - accounts for 30% of secondary amenorrhea cases

What is the initial workup for secondary amenorrhea? Use mnemonic PHAT

Pregnancy test (always first), Hyperprolactinemia (prolactin), Androgen excess (testosterone, DHEAS), Thyroid function (TSH)

What is the progestin challenge test used for in amenorrhea?

Tests for estrogen production and patent outflow tract - withdrawal bleeding after progesterone indicates adequate estrogen and normal anatomy

What are the most common causes of primary amenorrhea?

Constitutional delay (most common), gonadal dysgenesis (Turner syndrome), Müllerian agenesis, androgen insensitivity syndrome, imperforate hymen

What defines dysfunctional uterine bleeding (DUB)?

Abnormal uterine bleeding due to anovulation without structural/systemic pathology - diagnosis of exclusion

What is abnormal uterine bleeding (AUB) classified by? Use PALM-COEIN

Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy; Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified

What is the most common cause of abnormal uterine bleeding in reproductive age women?

Anovulation due to polycystic ovary syndrome (PCOS)

What is the first-line medical treatment for anovulatory bleeding?

Combined oral contraceptives (suppress endometrium and regulate cycles) or progestins (stabilize endometrium)

When should endometrial biopsy be performed for abnormal uterine bleeding?

Women >45 years, women <45 with risk factors (obesity, PCOS, unopposed estrogen), failed medical management

What is primary vs secondary dysmenorrhea?

Primary: painful menses without pelvic pathology (excess prostaglandins); Secondary: painful menses due to underlying pathology (endometriosis, adenomyosis, fibroids)

What is the pathophysiology of primary dysmenorrhea?

Excess prostaglandin F2α production causing uterine hypercontractility, vasoconstriction, and ischemia

What is the first-line treatment for primary dysmenorrhea?

NSAIDs (ibuprofen, naproxen) - inhibit prostaglandin synthesis, start 1-2 days before menses

What is the most common cause of secondary dysmenorrhea?

Endometriosis - ectopic endometrial tissue causing inflammation and pain

When should secondary dysmenorrhea be suspected?

Pain starting after age 25, progressively worsening pain, dyspareunia, pelvic exam abnormalities, failed NSAID therapy

What is the definition of menopause?

Permanent cessation of menstruation for 12 consecutive months due to loss of ovarian follicular activity (average age 51)

What are the classic vasomotor symptoms of menopause?

Hot flashes and night sweats - occur in 75-80% of menopausal women

What is the first-line treatment for moderate to severe menopausal vasomotor symptoms?

Systemic hormone therapy (estrogen ± progestin) - most effective treatment

What are the contraindications to hormone therapy in menopause?

Breast cancer history, coronary artery disease, prior VTE, active liver disease, unexplained vaginal bleeding, stroke history

What is the treatment for genitourinary syndrome of menopause?

Vaginal estrogen therapy (preferred for isolated urogenital symptoms) - low systemic absorption

What is the normal menstrual cycle length and duration?

Cycle length: 21-35 days (average 28 days); Flow duration: 2-7 days; Blood loss: 25-80 mL per cycle

What are the four phases of the menstrual cycle?

Menstrual phase (days 1-5), Follicular/proliferative phase (days 1-14), Ovulation (day 14), Luteal/secretory phase (days 15-28)

What hormones drive the follicular vs luteal phase?

Follicular phase: FSH and estrogen (estradiol); Luteal phase: progesterone from corpus luteum

What triggers ovulation in the menstrual cycle?

LH surge (triggered by high estradiol levels) - occurs approximately 24-36 hours before ovulation

What happens if fertilization does not occur?

Corpus luteum degenerates, progesterone and estrogen levels fall, endometrium sheds (menstruation begins)

What is premenstrual dysphoric disorder (PMDD)?

Severe form of PMS with significant mood symptoms causing functional impairment - occurs in 3-8% of women

What are the core symptoms of PMDD? Use mnemonic DAMFI

Depressed mood, Anxiety/tension, Mood lability, Feelings of hopelessness/anger, Impaired function

When do PMDD symptoms occur in relation to menses?

Symptoms present in luteal phase (week before menses), resolve within days after menses onset, symptom-free in follicular phase

What is the first-line treatment for PMDD?

SSRIs (fluoxetine, sertraline) - can be used continuously or luteal phase only (more effective than for depression)

What are alternative treatments for PMDD if SSRIs fail?

Combined oral contraceptives (continuous or extended cycle), GnRH agonists, spironolactone (for bloating)

What is premenstrual syndrome (PMS)?

Recurrent physical and emotional symptoms in luteal phase that resolve with menses - affects 20-40% of women

What are the most common physical symptoms of PMS?

Bloating, breast tenderness, headaches, fatigue, appetite changes, sleep disturbances

What are the most common emotional symptoms of PMS?

Irritability, mood swings, anxiety, depression, difficulty concentrating

How is PMS diagnosed?

Clinical diagnosis - prospective symptom diary for 2 consecutive cycles showing luteal phase symptoms that resolve with menses

What lifestyle modifications help PMS symptoms?

Regular exercise, stress reduction, adequate sleep, limit caffeine/alcohol/salt, complex carbohydrates, calcium supplementation (1200mg daily)

What is the difference between PMS and PMDD?

PMDD has more severe mood symptoms with significant functional impairment; PMS symptoms are milder without major life disruption

What medical treatments are used for moderate to severe PMS?

SSRIs (first-line for mood symptoms), combined oral contraceptives, NSAIDs (for pain), spironolactone (for bloating)