Menstrual Disorders (Blakenship)
Tanner Stages of Puberty
Stage 1: Around Age 8
Stage 2: Ages 9-11
Development of pubic hair and breast buds
Stage 3: > age 12
Acne, Armpit hair, and Height increase at a faster rate.
Stage 4: ~ Age 13
The first period occurs
Normal Menstruation
1st day of bleeding = 1st day of cycle
The average length of 21-35 days
Bleeding occurs for 2-7 days
Hypomenorrhea → Less than the average 28-day cycle.
Primary Amenorrhea
3 Different Criteria:
Secondary sex characteristics have not developed by age 13.
Breasts, pubic hair, facial hair, voice changes
Treatment: consider estrogen therapy w/o progestin to mimic gradual maturation.
Menses have not occurred 5 years after initial breast development.
Menses have not occurred in patients 15 years or older.
Causes:
Chromosomal/genetic abnormalities
+Breasts and -Uterus
Mullerian Agenesis 46XX
Embryonic underdevelopment (Androgen Insensitivity 46XY)
Causes the uterus not to develop
Hypothalamus/pituitary gland issues
-Breast and +uterus
Elevated FSH/LH:
Ovarian Causes
Primary ovarian insufficiency
Turners syndrome (Gonadal Dysgenesis 45X0)
No development of the ovaries
Normal/Low FSH and LH:
Hypothalamus-pituitary failure
Athletes or Anorexia
Lack of reproductive organs
-Breasts and -Uterus
Rare, Usually a defect in testosterone synthesis
Intrabdominal testes are likely present.
Outlet obstruction
+Breast and +Uterus
Outflow obstruction (Bleeding can’t get out)
Transverse Vaginal Septum
Imperforate Hymen
Secondary Amenorrhea:
Previously menstruating patient now with 3+ months of no menses (POI)
Causes:
Pregnancy is the most common cause
Intrauterine
Asherman’s (scar tissue from surgery/infection/D&C in the uterus)
Tx: Estrogen to stimulate endometrial regeneration
Hypothalamic
35% of causes
Normal/low FSH and LH
Stress, excessive exercise, eating disorders
Tx: Clomiphene → Stimulates FSH, LH, Estrogen
Pituitary
Prolactinoma, Low FSH+LH, and high prolactin
Prolactin inhibits GnRH
MRI of Pituitary Sella to diagnose
Tx: Remove with Surgery
Hyperprolactinemia
Tx: Dopamine Agonists (Cabergoline and Parlodel/ or surgery)
Ovarian
40% of causes
PCOS (increase in LH and FSH)
Give progesterone
Withdrawal bleeding → ovarian cause (anovulatory or oligo ovulatory) showing there is enough estrogen.
No withdrawal bleeding → Hypoestrogenic
HTP failure or uterine cause (Asherman’s)
Adrenal Tumors (hyperplasia)
POI (Elevated FSH)
PCOS
Hyperandrogenism (Elevated Testosterone → LH/FSH ratio doubles)
“string of pearls”
Can be caused by insulin resistance (can present with DMT2, Obesity, HTN)
Metformin can help with menstrual frequency by reducing insulin
Tx:
Spironolactone → Hirsutism (must be given with OCP due to teratogenicity)
Infertility → Clomiphene
Oligomenorrhea:
>35 days between cycles, fewer than 9 cycles a year.
It can be caused by anything mentioned above.
Antipsychotics increase prolactin.
Dysmenorrhea:
Primary: Reccruent, crampy, lower abdominal pain that occurs during menses with no demonstrable disease that could account for the symptoms.
Common in adolescents and young adults.
Due to an increase in Prostaglandins (causing painful uterine muscle wall activity)
Typically 1-2 years after the onset of mencarche in teens.
Tx: 3-6 months of NSAIDS ± Contraceptives. (Celecoxib)
Inhibit and prohibit prostaglandin-mediated uterine activity.
Secondary: Similar pain symptoms but has a disorder that accounts for their symptoms. *PELVIC PATHOLOGY!
Ex: Endometriosis, adenomyosis, uterine fibroids
Women >25 years old.
Large uterus on an exam, pain with intercourse, resistance with common treatments.
Endometriosis:
Ectopic Endometrial tissues, the ovaries are the most common sites.
>25% of causes of infertility
Definitive dx → LAP
Triad of symptoms:
Cyclic premenstrual pelvic pain
Dysmenorrhea
Dyspareunia (Pain during sex)
Dyschezia (pain during defecation)
Tx: OCPs and NSAIDS
Random Definitions of Uterine Bleeding
Frequent bleeding: <24 days
Infrequent bleeding: >38 days
Absent: Primary/Secondary Amenorrhea
Age Factors:
18-25: cycle variation > 9days
26-41: Variation > 7 days
42-45: Variation > 9 days
Prolonged Menstrual Bleeding: Consistently lasting >8 days
Heavy: Interferes with patients phsycial, social, emotional, and QOL.
Abnormal Uterine Bleeding:
Chronic Anovulation (90%)
Hypothalamus-pituitary axis disruption
This happens in the young and perimenopausal
Unopposed Estrogen
Irregular bleeding/shedding of the uterine lining since there is no ovulation and endometrium outgrows its blood supply.
Ovulatory
Prolonged Progesterone Secretion
Intermenstrual Bleeding (Metrorrhagia)
Hard to distinguish between frequent cycles
Cyclical Midcycle (midcycle drop in estradiol just after ovulation)
Acyclical → Cervicitis, polyps, fibroids, post-coital bleeding, cancer.
ALWAYS ASSESS HEMODYNAMIC STABILITY/CBC
Also, ask about prior procedures or pathologies the patient might have had
Or about infections and medications she is taking.
Menorrhagia → Heavy or prolonged bleeding @ normal intervals
Polymenorrhagia → Frequent menstrual cycle, < 21 days.
Menometrorrhagia → Excessive uterine bleeding occurs irregularly
Combination of Menorrhagia and Metrorrhagia
Post-Coital Bleeding → Bleeding after intercourse.
Concern for PID, STI, atrophic vaginitis-menopause
Tx:
Acute Severe → High dose IV or OCPs
Anovulatory → OCPs/Progesterone only if CI estrogen.
Ovulatory → OCPs
Hysterectomy
Endometrial Ablation
Iron
Abx (Pelvic inflammatory disease) → Ceftriaxone, Doxy, ± Flagyl
Surgery → Revision of scar, removal of fibroids, hysterectomy
Adenomyosis:
Hyperplasia of endometrial tissue within the myometrium (muscular layer of the uterine wall)
Menorrhagia and dysmenorrhea
Tender “BOGGY” but symmetrical uterus
Tx: Hysterectomy
Uterine Fibroids (Leiomyoma):
Smooth muscle layer tumor → growth with estrogen production (therefore would decrease with menopause)
Most common in 30s, >35 yrs, and in Black women
Bleeding is the most common presentation.
Most common cause of hysterectomies, or myomectomy to preserve fertility.
PE: Large irregular hard palpable mass in abdomen or pelvis during bimanual.
Tx:
Leuprolide → GnRH agonist that will inhibit GnRH when given continuously.
Hysterectomy
Premenstrual Syndrome (PMS):
Physical and behavioral symptoms that occur repetitively in the second half (Luteal) phase of the menstrual cycle and interfere with the woman’s life.
Premenstrual dysphoric disorder (PMDD) → severe form of PMS
Anger, irritability, etc...
Functional Impairment
Affective symptoms:
Depression, Anxiety, Irritability
Somatic symptoms:
Breast pain, bloating, Headache, swelling
Impairs functioning and stops with menses or after the bleeding stops.
Tx: Goals → improving functioning and relieving symptoms.
Lifestyle (exercise)
CBT
SSRIs
COCs
Typically do 1 year and then reassess
Refractory: Can consider GnRH agonist therapy with estrogen-progestin add-back.
Post-Menopausal Bleeding (PMB):
Any uterine bleeding in a menopausal patient
CARDINAL SIGN OF ENDOMETRIAL CARCINOMA
Can also be benign (polyps or atrophy)
Greater occurrence in the first 12 months of amenorrhea following menopause.
Most often from hypotrophy/Atrophy.
Causes:
Fibroids → most common pelvic tumors in females
Infection → treat with abx.
Proliferative/Secretory Endometrium
Active estradiol secretion (by adipose tissue) or exposure to exogenous estrogens.
Diagnosis:
TVUS, Biopsy, Eval of the cervix (determine cervix vs uterine cause)
Recurrent bleeding → D&C, further biopsy
Endometiral Carcinoma:
4th most common cancer in females in US, most common gyn malignancy
50-60yr peak
More common in postmenopausal
Presents with vaginal bleeding
PMB + Endometrial thickness >4-5mm → Need a biopsy
Risk factors: age, nulliparity, increase in estrogen exposure.