Menstrual disorders

Dysmenorrhea (menstrual pain)

• Before or during menstruation

• Primary dysmenorrhea

  • Abnormal prostanoid secretion/↑ prostaglandin (PGF2-⍺) ➔ stronger contraction ➔ painful, spasmodic cramps, first days of menstruation

  • Young onset, typically peaks on 1st day of menses

  • N/V/D, fatigue, headache (prostaglandins)

• Secondary dysmenorrhea from PID, IUD, fibroids, endometriosis, ovarian cysts, IBD

  • Typically older onset

  • Absence of N/V/D, fatigue, headache (prostaglandins)

  • TX with NSAIDs and dual oral contraceptives

Amenorrhea

Primary amenorrhea (never had period)

• Absence of menarche at 15yo despite development of 2° sex characteristics OR

• Absence of menarche at 13yo without 2° sex characteristics

  • Hypogonadotropic hypogonadism

    • Prader-Willi syndrome, sports, stress, eating disorders ➔ ↓ GnRH

  • Hypergonadotropic hypogonadism

    • Turner syndrome ➔ GnRH released but ovaries don't produce estrogen/progesterone

Secondary amenorrhea (had period but doesn't have now)

• >3 mo with previously regular cycle, >6mo with previously irregular cycle

  • MCC pregnancy

  • Meds, hypo/hyperthyroid, hyperprolactinemia, adrenal insufficiency, excessive exercise

Amenorrhea DX: Get HCG, FSH, LH, prolactin, thyroid function, testosterone

Premenstrual syndrome (PMS)

• Dyspareunia, breast tenderness, ABD pain, GI, bloating, weight gain, migraine, drowsy, mood

  • During luteal phase: 5 days before menstruation for at least 3 consecutive cycles

• TX with diet and exercise and dual oral contraceptives

• NSAIDs for sx

Premenstrual dysphoric disorder (PMDD)

• Severe affective sx/behavioral changes ➔ clinically significant life disturbances present for most of preceding year

  • Depressed mood, labile, anxiety, anger, sleep disturbance, ∆ appetite, pain, headache

• Start with diary to record sx for year

• TX with dual oral contraceptives and/or

• Fluoxetine (SSRI) either continuously or day 14 of cycle and stopped at start of menses

Menopause

• Menstruation permanently stops (~45-55yo)

• ↓ follicles ➔ ↓ estrogen/progesterone ➔ ↑ GnRH ➔ ↑ LH/FHS ➔ irregular menses

• ↑ estrone synthesis

• ↑ LDL and ↓ HDL ➔ ↑ risk of coronary artery disease

• ↓ estrogen ➔ osteoporosis

• SSX

  • Mental: Mood swings, sleep disturbance, anxiety, ↓ libido

  • Autonomic: Hot flashes/sweating, vertigo, headache

  • Atrophic: ↓ breast size, vaginal and urinary tract atrophy ➔ ↑ UTI

• DX

  • Peri-menopause: from first sx to 1year after menopause

    • Labs may be useful: ↓ estrogen/progesterone/inhibin B, ↑ FSH (>30)

    • Hot flashes (MC sx)

  • Pre-menopause: from first irregular periods to last period

  • Menopause: DX after 12mo of amenorrhea

    • Always check TSH since hyperthyroid can present similarly

• TX

  • Vaginal estrogen creams

  • Osteoporosis prevention (exercise, Vit D)

  • Severe sx, premature menopause, or s/p oophorectomy

    • Short-term hormone replacement

      • Estrogen alone only if hysterectomy

        • Unopposed estrogen ➔ endometrial hyperplasia ➔ ↑ risk of endometrial cancer, VTE, cardiovascular disease, gallbladder disease

      • Estrogen/progesterone (never give unopposed estrogen to a woman with her uterus still present)

        • ↑ risk of breast cancer

      • Hormone replacement CI: breast/endometrial cancer, liver disease, hyperlipidemia, CAD, VTE hx

        • ↑ risk of breast cancer

    • Can use Selective Estrogen Receptor Modulators: tamoxifen, raloxifene

    • Can add SSRI