22: Menstrual cycle abnormalities

Question 1

Primary dysmenorrhea defined

thought to be due to ?

Answer 1

severe pain with menses that cannot be attributed to any identifiable cause, pain and cramping during menstruation that interferes with normal activities and requires OTC or prescription medication.
-thought to be due to increased levels of prostaglandins, typically before age 20

Question 2

most primary dysmenorrhea is managed with ?

Answer 2

NSAIDs (antiPGs) and/or contraceptive steroids in pill (OCPs), patch, or ring form. TENS units, heating pads, exercise, massage, acupuncture, and hypnosis may also help.
-sx typically not useful

Question 3

Secondary dysmenorrhea is painful menses due to an identifiable cause such as ?

Answer 3

adenomyosis, endometriosis, fibroids, cervical stenosis, or pelvic adhesions

Question 4

PMS and PMDD represent a multifactorial disease spectrum with physiologic and psychological components including

Answer 4

headache, weight gain, bloating, breast fluctuation, irritability, fatigue, and a feeling of being out of control.

Question 5

In order to make the diagnosis of dysmenorrhea, symptoms must occur when?

Answer 5

in the second half of the menstrual cycle with at least a 7-day symptom-free interval during the first half of the menstrual cycle.
-must occur in at least two consecutive cycles.

Question 6

PMS/PMDD treatments

Answer 6

SSRIs (Prozac-fluoxetine, Zoloft-sertaline), OCPs (Yaz with drospirenone), as do diet modification, exercise, and vitamin supplementation (calcium, vitamin D, vitamin B6, and magnesium), carb-rich drinks

Question 7

The normal menstrual cycle occurs, on average, every 28 days (range, 21 to 35 days) and lasts 3 to 5 days with ?of blood loss per cycle

Answer 7

30 to 50 mL

Question 8

Menorrhagia ? Metrorrhagia ? menometrorrhagia ?

Answer 8

regular bleeding that is heavy or prolonged (more than 7 days, 80mL/cycle, 24 pads/day).
bleeding between periods
heavy or prolonged irregular bleeding

Question 9

most common causes of heavy or prolonged bleeding include ?

Answer 9

polyps, fibroids, adenomyosis, cancer, and pregnancy complications.

Question 10

The most common causes of oligomenorrhea (periods >35 days apart) include ?

Answer 10

chronic ovulation, PCOS, and pregnancy.

Question 11

The initial evaluation of abnormal uterine bleeding should include ?

Answer 11

history and physical, laboratory tests (pregnancy test, TSH, prolactin, ± FSH), endometrial biopsy (for women 45 and older), and pelvic US

Question 12

DUB is a diagnosis of ?

It is thought to be secondary to ?, and is therefore more prevalent in ?

Answer 12

exclusion when no other source for abnormal bleeding can be identified.
2/2 to anovulations or oligoovulation, more common in adolescents and perimenopausal women, if reproductive age think PCOS

Question 13

Most women with DUB can achieve menstrual regularity using ?

Answer 13

a daily monophasic birth control pill, patch, ring, or by use of cyclic progestins when estrogens are contraindicated.

Question 14

In cases of acute hemorrhage, ? can be used to stop acute bleeding. DUB that is not responsive to medical therapy may require surgical treatment with ?

Answer 14

IV estrogens and high-dose oral estrogens, OCP taper

D/C, Mirena IUD, endometrial ablation, or, rarely, hysterectomy.

Question 15

The most common cause of postmenopausal bleeding is ?

Other causes ?

Answer 15

vaginal/endometrial atrophy

other causes: cancer of the upper and lower genital tract, endometrial polyps, exogenous hormonal stimulation, and bleeding from nongynecologic sources (rectal bleeding from hemorrhoids, anal fissures, rectal prolapse, low GI tumors).

Question 16

All postmenopausal women with an ? or ? should have an endometrial biopsy to rule out endometrial hyperplasia and cancer.

Answer 16

endometrial stripe greater than 4mm or persistent bleeding

Question 17

treating primary dysmenorrhea with OCPs: mechanism of relief is either ?

Answer 17

either secondary to the cessation of ovulation or due to the decrease in endometrial proliferation leading to decreased prostaglandin production

Question 18

common causes of abnormal vaginal bleeding

Answer 18

adenomyoma, adenomyosis, endometrial polyps, uterine firoid, endometrial hyperplasia and cancer, cervical polyps

Question 19

imaging pelvic adhesions

how to treat?

Answer 19

not visible on pelvic US, CT, MRI

• will occasionally respond to the antiprostaglandins
• diagnosed and treated via laparoscopy, may need laparotomy

Question 20

hypotheses of PMS/PMDD etiologies

Answer 20

abnormalities in response to estrogen–progesterone changes, disturbance in the RAAS, excess PG and prolactin production, psychogenic factors, interaction between the serotonin and cyclic changes in the ovarian steroids

Question 21

PALM-COEIN etiology of AUB

Answer 21

PALM (structural causes)
Polyps
Adenomyosis
Leiomyomas
Malignancy and hyperplasia
COEIN (non-structural)
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified

Question 22

Teenagers with menorrhagia should be evaluated for ?

Answer 22

primary bleeding disorders such as von Willebrand disease, idiopathic thrombocytopenic purpura (ITP), platelet dysfunction, and thrombocytopenia from malignancy.

Question 23

hypomenorrhea causes

Answer 23

hypogonadotropic hypogonadism (athletes, anorexia), atrophic endometrium: Asherman’s syndrome (intrauterine adhesions or synechiae), congenital malformations, infection, and intrauterine trauma, OCPs, Depo-Provera, and the progestin-containing IUDs, endometrial ablation, outlet obstruction

Question 24

oligomenorrhea causes

Answer 24

(greater than 35 days apart)

hyperprolactinemia, thyroid disorders, PCOS, chronic anovulation, and pregnancy

Question 25

besides women older than 45, who should get an EMB with oligomenorrhea ?

Answer 25

Obese patients with prolonged oligomenorrhea
-increased risk of endometrial hyperplasia and cancer due to the peripheral conversion of androgens into estrogens in their adipose cells.

Question 26

adenomyosis treatment

Answer 26

combo OCPs, levonorgestrel-containing IUD (Mirena), Endometrial ablation or resection (may increase risk of pain/bleeding)

Question 27

Endometrial hyperplasia treatment

Answer 27

progestin therapy if no cytologic atypia and occasionally with D&C or hysterectomy when atypia is present

Question 28

Anovulation treatment

Answer 28

menstrual regulation with NSAIDs, estrogens and/or progestins and weight loss

Question 29

a new antifibrinolytic agent, has been shown to decrease menstrual blood loss and is FDA approved for the treatment of menorrhagia

Answer 29

tranexamic acid (Lysteda)

Question 30

ablation modalities

Answer 30

laser, roller bar/barrel, hydrothermal balloon, cryoablation, bipolar radiofrequency, microwave, and hydrothermal ablation (circulating hot water)
Success: reduction in uterine blood flow (NOT amenorrhea) and patient satisfaction

Question 31

how anovulatory cycles cause bleeding

Answer 31

the ovary produces estrogen but no corpus luteum is formed, and thus no progesterone is produced–>continuous estrogen stimulation of the endometrium without the usual progesterone-induced bleeding–>endometrium continues to proliferate until it outgrows its blood supply, breaks down, and sloughs off in an irregular fashion

Question 32

anovulation likely to occur when

Answer 32

adolescence, perimenopause, lactation, and pregnancy. Pathologic anovulation occurs in hypothyroidism, hyperprolactinemia, hyperandrogenism, and POI/PMOF.

Question 33

in DUB cases check for evidence of anovulation how ?

Answer 33

basal body temperature, ovulation prediction kits (at-home tests for detecting the LH surge in urine), midluteal (day 21 to 23) serum progesterone level, EMB showing a decidualized or luteal phase endometrium (evidence of ovulation and progesterone effect upon the endometrium)

Question 34

For chronic DUB, nonhormonal therapy with ? has been shown to decrease menstrual blood loss by 20% to 50%

Answer 34

NSAIDs (e.g., 800 mg ibuprofen TID × 5 days)

+/- estrogen/progesterone therapy

Question 35

If an ovarian mass is identified, these tumor markers should also be considered

Answer 35

Ca-125, LDH, hCG, AFP, CEA, inhibin, and estradiol

Question 36

endometrial cancer is usually treated with

Answer 36

TAHBSO performed in conjunction with possible lymph node dissection, radiation, or chemotherapy therapy