Pediatrics in Primary Care: Exam 1 (Womens Health: Menstrual

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Pediatrics in Primary Care: Exam 1 (Womens Health: Menstrual Disorders) Download Full Version Please sign up to download full Version.

Primary Amenorrhea defined

absences of menstruation PRIMARY- no menstruation by age 13 without secondary sexual development or by age 15 with secondary sexual development

Secondary Amenorrhea defined

absences of menstruation; SECONDARY- absence of menstruation for 3-6 months or the duration of 3 typical menstrual cycles for the patient with oligomenorrhea (in a menstruating woman)

Causes of amenorrhea

1. Pregnancy 2. Hypothalamic-pituitary dysfunction 3. Ovarian dysfunction 4. Alteration of genital outflow tract

What is the most common cause of amenorrhea

pregnancy (s/s include breast fullness, weight gain, nausea, and urine/serum b-hcg)

Hypothalamic-Pituitary Dysfunction (1. Causes)

1. Functional (wt loss, exercise, obesity) 2. Drug-Induced (marijuana, psychoactive drugs, antidepressants) 3. Neoplastic (prolactin secreting pituitary adenoma) 4. Psychogenic (chronic anxiety) 5. Other (head injury/chronic medical issues)

Hypothalamic-Pituitary Dysfunction (2.


Diagnostic testing)

-LH -TSH -Prolactin levels (FSH and LH are typically in low ranges with this condition)

Ovarian Dysfunction (1. Causes)

1. Chromosomal related (e.g. Turners syndrome, X-chromosome long arm depletion, 'Saret's?' syndrome) 2. Other (premature natural menopause)

Ovarian Dysfunction (2. Diagnostic testing)

-FSH -LH (typically these levels are increased in these conditions)

Alteration of Genital Outflow Tract (1. Causes)

1. Congenital abnormalities (Imperforated hymen, Absence of the uterus or vagina)

Alteration of Genital Outflow Tract (2. Diagnostic

2. Pelvic exam

testing 3. Management)

3. Surgical correction, if possible

Asherman Syndrome (1. Definition 2. Cause 3.

1. Scarring of the uterine cavity

Diagnostic testing 4. Management)

2. D&C (Dilatation and curettage) 3. Hysterosalpingogram 4. Surgical lysis of adhesion performed via hysterectomy and D&C; Estrogen post procedure to stimulate endometrial regeneration; Balloon device may be placed to help keep uterine wall separated

Treatment of Amenorrhea

1. Progesterone Challenge Test 2. Management if pregnancy desired (Comid to induce ovulation) 3. Management if pregnancy not desired (Oral contraceptive pills to prevent endometrial hyperplasia)

Progesterone Challenge Test (1. Why used 2.

1. Used to determine whether or not the patient has adequate estrogen

Process 3. Results)

2. Medroxyprogesterone acetate (Provera) 10mg PO daily x 5-10 days (10-14 days per lecture) 3. +Bleeding (patient has estrogen present but is not ovulating) ddx: anovulation, PCOS -Bleeding (either the patient has very low estrogen levels or there is a problem with the outflow tract/anatomical problem)


frequent menstruation/bleeding, 21 days or less


prolonged/excessive uterine bleeding that occurs at regular intervals; loss of 80mL or more of blood, or bleeding longer than 7 days


bleeding b/w periods, irregular menstrual bleeding


frequent menstrual bleeding that is excessive and irregular in amount and duration

Abnormal uterine bleeding (AUB)/Heavy

PALM: Structural Causes:

(AUB/HMB) or Intermenstrual (AUB/IMB) (1.

1. Polp (AUB-P)


2. Adenomyosis (AUB-A) 3. Leiomyoma (AUB-L): Submucosal myoma or other myoma 4. Malignancy and hyperplasia (AUB-M) COEIN: Nonstructural Causes: 1. Coagulopathy (AUB-C) 2. Ovulatory dysfunction (AUB-O) 3. Endometrial (AUB-E) 4. Iatrogenic (AUB-I) 5. Not yet classified (AUB-N)

Abnormal Uterine Bleeding: (2.

1. Physical exam

Diagnostics/Screening Tests)

2. PAP- exclude cervical dysplasia 3. Serum B-Hcg (r/o pregnancy) 4. CBC with PLTS and Coags 5. TSH (r/o thyroid condition) 6. Prolactin (r/o pituitary adenoma) 7. FSH and LH (eval estrogen stimulation) 8. LFTs (r/o liver disease) 9. Transvaginal Pelvic U/S (r/o uterine/ovarian tumors) 10. Endometrial biopsy (r/o hyperplasia, atypia, and adenocarcinoma) 11. Saline infusion sonohysteroscopy (eval anatomy/r/o intracavity lesions, polyps, submucous fibroids) 12. Hysterectomy (r/o intracavity lesions, polyps, submucous fibroids)

Abnormal Uterine Bleeding: Once organic

Controlling the acute episode and prevention of reoccurrence

pathology has been ruled out, management should be aimed at...

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Abnormal Uterine Bleeding (3.

1. Hormonal management

Management/Treatment Categories)

2. Non-hormonal management 3. Surgical management

Abnormal Uterine Bleeding (4. Surgical

1. Hysterectomy: tx of choice when adenocarcinoma is diagnosed


2. Myomectomy: tx of choice for leiomyoma 3. Endometrial ablation: tx for treatment resistant menorrhagia or menometrorrhagia (***if performed, the patient CANNOT have a pregnancy; Make sure endometrial cancer is ruled out!!!!!; An endometrial biopsy (EMB) should be performed before hand) 4. Dilatation and Curettage: diagnostic and therapeutic

Abnormal Uterine Bleeding (5. Hormonal

1. Oral contraceptives cyclic, extended, or continuous regimen


2. Depo-Provera 3. Cyclic Provera 4. Cyclic Provera 5. Levonorgestrel- LNG IUS (Mirena IUD)

Abnormal Uterine Bleeding (6. Non-hormonal

Treat anemia: Iron supplement (diet rich in iron--green leafy's)


Abnormal Uterine Bleeding (What is the treatment

1. Myomectomy

of choice for leimyoma? What is the treatment of

2. Hysterectomy

choice when adenocarcinoma is diagnosed?)

Abnormal Uterine Bleeding (What is the treatment

-Endometrial ablation

for treatment resistant menorrhagia or

-(***if performed, the patient CANNOT have a pregnancy; Make sure endometrial cancer is ruled out!!!!!; An

menometrorrhagia? What needs to happen

endometrial biopsy (EMB) should be performed before hand)

before this occurs?)

Dysmenorrhea (1. Define)

painful menstruation

Dysmenorrhea (2. Types/Causes)

PRIMARY DYSMENORRHEA: -excess of prostaglandins, leading to painful uterine muscle activity -physical exam is NORMAL in primary dysmenorrhea (by definition, if physical exam is abnormal its considered secondary) SECONDARY DYSMENORRHEA: -clinically identifiable cause

Dysmenorrhea (3. S/S associated with Primary


Dysmenorrhea vs Secondary Dysmenorrhea)

-Moderate-severe nausea -Intermittent pain (spasmodic, colicky, labor-like, aching, heaviness, in low-mid abdomen, may radiate to back and down thighs, starts at onset of menstruation, lasts hours to days) -Vomiting/Diarrhea -Back pain -Fatigue -H/A SECONDARY DYSMENORRHEA: -Pain that lasts longer than a menstrual period -Pain that (may) start before menstrual period begins -Becomes worse during and persists after menstruation ends -Often occurs later in a woman's life

Dysmenorrhea (4. Diagnostic testin)

based on symptoms, history, and physical exam (secondary dysmenorrhea if physical exam is abnormal)

Dysmenorrhea (5. Incidence of Primary vs

Primary- late teens to early twenties and declines with age


Secondary- more common in women as they age NOTE: childbearing does not affect the occurrence of primary OR secondary dysmenorrhea

Causes of Secondary Dysmenorrhea

1. Extrauterine (e.g. endometriosis, tumors, inflammation) 2. Intramural (e.g. adenomyosis, fibroids) 3. Intrauterine (e.g. cervical stenosis, IUD's, cervical lesions, fibroids, polyps, infections)

Treatment for Primary Dysmenorrhea

1. NSAIDS (Ibuprofen/Naproxen) 2. Combined oral contraceptives (decrease endometrial prostaglandin and spontaneous uterine activities; may be taken in 28 days or extended cycle or Mirena, DepoProvera, Explanon) 3. Low level topical heat

Treatment for Secondary Dysmenorrhea

directed at the underlying condition

Premenstrual Syndrome (PMS) (1. Definition)

a group of physical, mood-related, and behavioral changes that occur in a regular, cyclic relationship to the luteal phase of the menstrual cycle

PMS (2. Incidence)

occurs in approximately 75-80% of women

PMS (3. Physical symptoms vs Behavioral

Physical (abdominal bloating, fatigue, breast swelling and pain, digestive upset, dizziness, headaches, acne,


and hot flashes) Behavioral (irritability, depressed mood, anxiety, tearfulness, hostility, and increase appetite)

Diagnostic Criteria for PMS

1. PMS- can be diagnosed if the patient reports at least one of the following affective and somatic complaint symptoms during the 5 days before menses in each of the three menstrual cycles -Affective Symptoms: depression, angry outburst, anxiety, irritability, confusion, social withdrawal -Somatic Symptoms: breast tenderness, abdominal bloating, headache, and swelling in extremities 2. These sx are relieved within 4 days of the onset of menses, without reoccurrence until at least cycle day 13; The symptoms are present in the absence of any pharmacologic therapy, hormone ingestion, or drug or ETOH abuse

PMS treatment

1. Diet recommendation (fresh, less processed foods) 2. Aerobic exercise 3. Calcium carbonate supplements (reduces H2O retention, pain, and food craving) 4. NSAIDS 5. Oral contraceptives

A 16 y.o. presents with menses every 16 days.


You correctly classify her bleeding as

An 18 y.o. woman complains of cyclic, sharp,

Primary Dysmenorrhea

cramps lower abdominal pain. Pelvic exam is normal. What type of dysmenorrhea is this?

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