L6 Menstruation Disorders

Endocrine process that involves the physical, emotional, and sexual maturation

puberty

what is the 6 step Sexual maturation sequence

1. Accelerated growth & ovarian enlargement

2. Thelarche – breast development; most common earliest detectable secondary sex characteristic on PE

3. Pubarche – pubic hair development

4. Maximum growth aka Growth spurt

5. Menarche – start of menses

6. Ovulation – rarely occurs with menarche

There is an association with _________ and the onset of puberty

fat tissue

ex. BMI, socioeconomic conditions, nutrition, and access to preventive healthcare may influence timing and progression of puberty

what is the sexual maturity rating that is a descriptions of development of secondary sex characteristics (breast development & pubic hair changes)

Tanner stages

absence of menses

Amenorrhea

primary amenorrhea is defined as the absence of menses at age _________ in the presence of ___________

15 years

normal growth and secondary sexual characteristics

secondary amenorrhea is the absence of menses for more than ________ in persons with regular cycles or ____________

3 cycles

6 months with irregular cycles

Primary amenorrhea is often due to what 4 main causes?

-Gonadal dysgenesis, e.g. Turner Syndrome; 43% (ovaries don't develop properly)

-Mullerian agenesis - absence of vagina and/or uterus; 15% (congenital)

-Physiologic delay of puberty (often genetic); 14%

-Polycystic Ovarian Syndrome; 7%

what are a few other causes of primary amenorrhea?

GnRH secretion deficiency, weight loss, transverse vaginal septum, hypopituitarism, imperforate hymen, prolactinoma

Secondary amenorrhea mc eti

pregnancy – most common cause

What is a cause of secondary amenorrhea related to hypothalamic dysfunction?

Decrease in GnRH secretion due to functional hypothalamic dysfunction.

What factors can lead to functional hypothalamic dysfunction?

Weight loss, excessive exercise, nutritional deficiencies, and obesity.

What effect do hypothalamic tumors have on menstruation?

They can lead to decreased GnRH secretion, causing secondary amenorrhea.

Which chronic diseases can cause secondary amenorrhea?

Type 1 Diabetes Mellitus and Celiac disease.

What is a common condition associated with hyperprolactinemia?

Prolactinomas, which can also present with galactorrhea.

How can thyroid disease affect menstruation?

It can lead to secondary amenorrhea.

What ovarian disorder is associated with secondary amenorrhea?

Polycystic Ovarian Syndrome (PCOS).

What is primary ovarian insufficiency (POI)?

Depletion of ovarian reserve before age 40, characterized by rising FSH/LH levels and dropping estradiol levels.

What type of tumors can cause secondary amenorrhea?

Ovarian tumors, pituitary tumors, hypothalamic tumors

What condition is characterized by uterine adhesions and can lead to secondary amenorrhea?

Asherman Syndrome.

dx? Secondary amenorrhea + stress, weight, diet, exercise habit changes, eating disorder

functional hypothalamic amenorrhea

what drugs can cause 2nd ameno

-OCP

-high-dose progestin

-danazol

-metoclopramide -antipsychotic drugs

-opiate

-marijuana

dx? Secondary amenorrhea + hirsutism, acne, irregular periods

polycystic ovaries

dx? Secondary amenorrhea + Galactorrhea

hyperprolactinemia

dx? Secondary amenorrhea + HA, visual field defects, fatigue, polydipsia, polyuria

sellar masses

dx? Secondary amenorrhea + hot flashes, vaginal dryness, poor sleep, decreased libido

primary ovarian insufficiency (POI)

dx? Secondary amenorrhea + history of dilation & curettage, endometriosis, infection leading to scarring

Asherman syndrome

If neuro exam = visual field defects and secondary ameno, what is the likely cause?

pituitary mass/prolactinoma (sellar mass)

In primary amenorrhea, be sure to evaluate

-Tanner stages

-Genital tract anatomy

Secondary amenorrhea, what 3 Imagings do you order

Pelvic ultrasound, MRI or CT depending on history

Secondary amenorrhea, what Laboratory tests do you order

-Pregnancy test - serum HCG

-TSH to r/o thyroid disease

-Serum prolactin (PRL) to r/o hyperprolactinemia

-FSH to evaluate hypothalamic-pituitary axis

-E2 (estradiol) to evaluate the pituitary - ovarian axis

-If signs of hyperandrogenism, then order testosterone

what day of menses should you draw labs IF menses occurs?

Day 3

What does an abnormal TSH indicate?

Thyroid disease

What does elevated prolactin suggest?

Hyperprolactinemia, rule out prolactinoma

What does elevated FSH with low E2 indicate?

Primary Ovarian Insufficiency (POI), repeat FSH to confirm

What does low to normal FSH and normal E2 suggest?

Polycystic Ovary Syndrome (PCOS) or intrauterine adhesions

What does low to normal FSH with low E2 indicate?

Hypothalamic-Pituitary Axis (HPA) disorder or Secondary hypogonadotropic hypogonadism

What is the result of insufficient hormone production by the hypothalamus or pituitary?

Low estrogen and progesterone

What imaging should be considered if there are hormone production issues?

Pituitary MRI

What does elevated testosterone likely indicate?

Polycystic Ovary Syndrome (PCOS)

What does the Progesterone Challenge Test evaluate?

The integrity of the endometrial lining.

What does the Progesterone Challenge Test determine about a patient?

Whether a patient has adequate estrogen, a competent endometrium, and a patent outflow tract.

When should the Progesterone Challenge Test be considered?

In patients with normal labs and a history of uterine instrumentation.

What is the purpose of the Progesterone Challenge Test?

To evaluate the presence of withdrawal bleeding after administering progesterone.

What is the dosage and duration for Medroxyprogesterone in the Progesterone Challenge Test?

Medroxyprogesterone 10 mg PO for 10-14 days.

What is expected to happen after completing the Progesterone Challenge Test?

Induction of withdrawal bleeding.

What should be done if there is no withdrawal bleeding after the Progesterone Challenge Test?

Refer to GYN for further evaluation.

What test may be considered if there is no withdrawal bleeding?

Estrogen-progesterone withdrawal test.

What does the Estrogen-progesterone withdrawal test determine?

If the patient is in a hypoestrogenic state.

What condition should be ruled out if there is no withdrawal bleeding?

Uterine adhesions.

Secondary amenorrhea- Treatment Goals

-Treat underlying pathology, if possible

-Achieve fertility, if possible

-Prevent complications of disease

What is the treatment for functional hypothalamic dysfunction causing secondary amenorrhea?

Lifestyle changes and cognitive behavioral therapy (CBT)

What is the first line treatment for hyperprolactinemia?

Cabergoline, a dopamine-agonist that suppresses prolactin and shrinks tumors

What is the treatment for primary ovarian insufficiency?

Hormone replacement therapy (HRT) to reduce the risk of osteoporosis and cardiovascular disease (CVD)

What is the treatment for hypogonadotropic hypogonadism?

Pulsatile GnRH or human menopausal gonadotropins

What is the treatment for intrauterine adhesions?

Hysteroscopic lysis of adhesions followed by a course of estrogen to stimulate regrowth of endometrial tissue

What is the treatment approach for polycystic ovarian syndrome (PCOS)?

-Lifestyle changes

-OCP

-spironolactone -metformin

What 2 meds can induce ovulation when treating for PCOS?

letrozole or clomiphene citrate

Uterine bleeding of abnormal quantity, duration, or schedule

abnormal uterine bleeding (AUB)

2 major Eti of AUB

PALM (polyp, adenomyosis, leiomyoma/fibroid, malignancy/hyperplasia)

COEIN (coagulopathy, ovulatory dysfxn, endometrial, iatrogenic, not classified)

what is the purpose of a pelvic exam for AUB ?

confirm bleeding site; size & contour of uterus; adnexal mass and/or tenderness

labs from AUB will show what?

urine HCG with possible serum HCG

what is the imaging of choice to evaluate AUB and why?

- pelvic ultrasound

- r/o masses, assess endometrial thickness

what diagnostic procedure is used for AUB? what is it ruling out?

- endometrial biopsy

- to rule out endometrial cancer

what 2 types of pt need an endometrial biopsy?

> 45 y/o - menopause with frequent, heavy, prolonged, intermenstrual bleeding

< 45 y/o with persistent bleeding for 6 months or more

how to manage AUB?

Treat underlying disease

Fibroids tx

medical or surgical therapy

Endometrial polyps tx

hysteroscopic polypectomy

Adenomyosis tx

medical or surgical therapy, including hysterectomy

Coagulopathy tx

treat underlying disorder (vWB disease, hemophilia)

When no clear etiology for AUB found on evaluation, treat the pt with _______

- Combined OCP

- IUD - LNG 52 mg (Mirena)

- oral progestins

*consider NSAIDs, Tranexamic acid

If trying to conceive and pt has unknown AUB, can do a course of _______ or _________

educate the pt that __________

- combined OCPs or cyclic progestin therapy

- this may delay time to conception by several mths

if the source AUB is still unknown, refer to ___________

GYN

2 components to managing acute heavy bleeding episodes

1. evaluate and rule out organic pathology

2. focus on controlling the acute bleeding episode and prevention of future recurrences

pharm options for acute heavy bleedings episodes

- high dose combined oral contraceptives (generally bleeding subsides in 48hrs)

- high dose oral estrogen (If waiting 48hrs is unacceptable)

- progesterone (if suspected etiology of acute bleeding is from anovulation)

- tranexamic acid (acts as an antifibrinolytic agent = reduces bleeding)

give an example of a progesterone if suspected etiology of AUB is from anovulation

Medroxyprogesterone acetate

10-20mg TID x5-10dys

Pt who fails hormonal options or decline or should can use what? (Only if they are not at risk for clots)

tranexamic acid (acts as an antifibrinolytic agent = reduces bleeding)

pharm options to prevent future recurrences of AUB (5)

-IUD

-Oral contraceptive pills

-Progestin therapy (oral or IM)

-Tranexamic acid

-NSAIDs

if pharm tx for AUB fails OR hemodynamically unstable, consider

- Surgical mgt with dilation and curettage (D&C)

- uterine artery embolization - endometrial ablation

- or hysterectomy

The presence of physical and/or behavioral symptoms that occur repetitively in the second half (luteal phase) of the menstrual cycle and interferes with functioning

Premenstrual syndrome (PMS)

PMS requires ________ behavioral and/or physical symptoms

1-4

Mc behavioral symptoms of PMS and other sxs

Mood swings – most common

Anxiety, irritability, sadness, food cravings, diminished interest in activities, sensitivity to rejection

Mc physical symptoms of PMS

- Bloating, fatigue – most common

- breast tenderness, HA, hot flashes, dizziness

DSM – 5 defines PMDD as a severe form of PMS where ________, ________, _________ are prominent

anger, irritability, and internal tension

1 – 4 symptoms that interfere with functioning = _____

Must have 5 out of 11 symptoms with 1 core/affective symptom = _____

+ symptom-free follicular phase

PMS

PMDD

PMS/PMDD dx testing, 2 labs

CBC, TSH

tx for mild sxs of PMS

- Lifestyle interventions- stress reduction, exercise

- Supplements - Chasteberry

2 tx for mod-severe sxs of PMS/PMDD

- Combined OCP (Monophasic preferred)

- SSRI - continuous, luteal-phase only (start day 14 and d/c at menses onset), symptom-onset (beginning at the point of symptom onset until the first few days of menses)

painful menstruation that inhibits normal activities

Dysmenorrhea

excess in prostaglandins (PG E2 & F2-alpha) -> painful uterine muscle activity

Begins in adolescence after menstruation cycles are established

Primary dysmenorrhea

underlying etiology identified that causes painful mensuration. Occurs later in life.

Secondary dysmenorrhea

some causes of secondary dysmenorrhea

- Endometriosis, fibroids, adenomyosis, ovarian cysts, PID, pelvic adhesions, cervical stenosis, IUD, IBD, IBS, psychogenic disorders

Dysmenorrhea - Clinical Presentation

recurrent, crampy, lower abdominal/suprapubic pain that occurs with menses

recurrent mth-mth, spasmodic lower abdominal pain first 1-3 dys of menses

- Generally, diffuse in lower abdomen and suprapubic region w/ radiation to back

- Generally, with associated nausea, vomiting, diarrhea, HA

- Dyspareunia usually not present

- Tends to improve with advancing age

primary dysmenorrhea

- pain often lasts longer than menses (starts prior and persists after)

- Begins later in life and tends to worsen over time

+/- AUB/heavy bleeding

- Non-midline pelvic pain

- Usually no N/V/D/HA

- Presence of dyspareunia

secondary dysmenorrhea

What is the clinical diagnosis method for primary dysmenorrhea?

Clinical diagnosis of exclusion

What does pain that improves with NSAIDs or hormones suggest?

Primary dysmenorrhea

What should a pelvic examination for dysmenorrhea assess?

Masses, cervical discharge, focal tenderness

What is the purpose of the pelvic examination in dysmenorrhea evaluation?

To uncover possible causes of secondary dysmenorrhea

What laboratory tests may be included in the diagnostics for dysmenorrhea?

+/- NAAT CT/NG, UA