Download - Menarche to menopause
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Menarche to Menopause
DR.DIVYA JAIN
INDORE
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Menstruation Shedding the uterine lining
(endometrium) if pregnancy does not occur.
Necessary (in the absence of hormonal regulation) to insure the endometrium does not become hyperplastic.
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Normal Menstrual Cycles
Mature, ovulatory women– 28-29 day average– 21-36 day range– 2-7 days duration– 20-80 cc of blood loss per month
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Cycle Variation Women in their middle reproductive
years have the most predictable cycles More pronounced cycle to cycle
variability in the 5-7 years after menarche and 6-8 years before menopause
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Cycle Variation (cont.) Adolescents
– Majority range 21-48 days– Usually anovulatory
– Mean time from menarche until half the cycles are ovulatory depends upon the age of menarche
– 12 yrs 1yrs till half cycles are ovulatory– 12-13 3yrs– >13 4.5 yrs
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Cycle Variation (cont.) Perimenopause
– Cycles initially shorten– Ultimately (apparently) lengthen, as an
entire cycle will be skipped Average age of menopause is 51
– Cessation of menses for one year
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Abnormal Uterine Bleeding
Menorrhagia Oligomenorrhea Metrorhhagia Polymenorhhea Menometrorhhagia Oligomenorrhea Contact bleeding
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Terminology Amenorrhea—lack of menstrual bleeding
– Primary—no menses by age 16– Secondary—absence of 3 or more expected
menstrual cycles
Break-through bleeding (BTB) unexpected bleeding usually occurring while a woman is on exogenous hormonal medication (eg OCPs, patch, or ring)
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Terminology (cont.) Menorrhagia—heavy menstrual bleeding.
Prolonged or excessive menstrual blood loss with regular cycles
Metrorrhagia—irregular, frequent bleeding Menometrorrhagia—irregular menses with
prolonged or excessive blood loss Midcycle bleeding—light menstrual
bleeding occurring in ovulatory women at the midcycle estradiol trough
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Terminology (cont.) Oligomenorrhea-- menstrual
bleeding/menses occurring less frequently than 36 days apart
Polymenorrhea—frequent menstrual bleeding/menses occurring more frequently than 21 days apart
Contact bleeding/post-coital bleeding Dysmenorrhea- painful menstrual bleeding
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Impact on Health 75% of women experience physical changes
associated with menses PMS (Premenstrual syndrome) PMDD (Premenstrual dysphoric disorder) Direct and indirect health care costs
– Visits to ED, clinic, or office– Time lost from work
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PMS
Psychoneuroendocrine d/o with biological, social and psychological impacts
Up to 75% of women experience some level of recurrent sx
Up to 5% may experience severe sx and distress
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Common PMS Symptoms
Headache Breast pain Bloating Irritability Fatigue Crying
Abd pain Clumsiness Sleep alteration Labile mood Social withdrawal Libido change Appetite change
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Requisite Symptoms for PMDD Diagnosis
Depressed mood Anxiety/tension Mood swings Irritability Decreased interest Concentration
difficulties Fatigue
Appetite changes/food cravings
Insomnia/hypersomnia Feeling out of control Physical symptoms 5/11 symptoms
needed for diagnosis and
Sx disrupt daily functioning
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PMS/PMDD Tx Limit caffeine, tobacco, alcohol and
sodium Frequent high-complex carb meals CBT, stress management, aerobic
exercise
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Dysmenorrhea Painful menstruation- when pain
prevents normal activity and requires medication
Pain starts when bleeding starts Prostaglandin activity Emotional/psychological factors
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Dysmenorrhea tx NSAIDs, starting a day before period
– Ibuprofen, naproxen Anti-prostaglandins much less
effective after pain is established Continuous heat to abd OCPs for 6-12 months have lasting
benefit
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Ddx of Abnormal Uterine Bleeding
Blood Dyscrasias Anatomic causes of bleeding,
including pregnancy Anovulation Malignancy Non-uterine causes of bleeding
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AUB work-up Hx PE with cytology Pelvic ultrasound Endometrial biopsy Hysteroscopy D & C
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Leiomyomas (Fibroids) Benign neoplasms arising from uterine wall
smooth muscle cells 20-25% of reproductive age women Can be small to quite large, single or
multiple. Surrounded by pseudocapsule. Often asx, but can cause metrorrhagia,
menorrhagia, dysmenorrhea and infertility Cause unknown, but hormone responsive
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Fibroid Tx Depends on sx, age, parity,
reproductive plans, general health, and size/location of leiomyomas
GnRH agonists- to shrink fibroid OCPs control bleeding but do not treat
the fibroid Progestin-releasing IUD for multiple
small leiomyomata
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Fibroid Tx - Surgical Myomectomy- preserves fertility, high risk
for fibroid recurrence Hysterectomy- eliminates sx and chance of
recurrence. Also eliminates uterus. Uterine fibroid embolization (UFE)
– Embolic occlusion of uterine arteries– As effective as above, few recurrences, few
major complications
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Anovulation Patient History—very important to
diagnosis– Ovulatory cycles—consistent number of
days from beginning of one cycle to the next, breast tenderness, and dysmenorrhea usually present
– Anovulatory cycles—variation in number of days per cycle, no breast tenderness, and dysmenorrhea is not consistent from one cycle to the next
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DUB “Dysfunctional uterine bleeding” Abnormal uterine bleeding with
pathologic causes ruled out So..you’ve done all that stuff, and it’s
all okay Usually tx with hormones (ie OCPs) to
control bleeding
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Non-uterine causes Genital neoplasms of the vulva or vagina
– To avoid missing vaginal lesions, stainless steel speculum blades should be rotated on removal to fully evaluate the vaginal mucosa
– Better: use plastic speculum with good light source
Genital trauma/foreign objects Rectal bleeding or urinary tract source
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Evaluation History
– Menstrual pattern (duration, changes in quality, color of menses)
– Dysmenorrhea, mittleschmerz, breast changes
– Post-coital spotting– Dietary practices, change in weight,
exercise, stress– Evidence of systemic disease
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Evaluation (cont.) Physical Exam
– Vital signs, height, weight, body phenotype, BMI– Skin, hair (acne, hirsutism pattern)
– Fat distribution, striae
– Thyroid
– Breast exam to check for galactorrhea– Complete pelvic exam– Tanner stage for teens
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Evaluation--testing All patients:
– Pregnancy test– CBC with platelets– Recent Pap
Over 35 yrs:– Endometrial sample
Documented drop in hgb <10– PT, PTT
– Bleeding time
As indicated:– TSH– Prolactin– Testosterone– LH/FSH– 17-OH progesterone– Overnight
dexamethasone suppression test or 24 hr urinary free cortisol
– Hysteroscopy or ultrasound
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Acute Bleeding: Control Oral progestins:
– Micronized Progesterone 200 mg (Prometrium) or Medroxyprogesterone 10 mg (Provera) or Norethindrone 5 mg (Aygestin)
– 1 po q4 hrs or until bleeding stops, then– 1 qid x 4 days– 1 tid x 3 days– 1 bid x 2 weeks, then – Cycle monthly with progestin or low dose oral
contraceptive
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AUB Long Term Control Cycle with low dose OCP, patch, or vaginal
ring Cycle with a progestin, eg Prometrium Use of progestin-containing IUD (Mirena) Choice depends upon:
– Contraceptive need– Smoking status– Medical history– Patient preference
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Endometriosis Abnormal growth of endometrial tissue
in locations other than the uterine lining
3-10% of women of reproductive age 30% of infertile women
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E
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Tx Analgesics (ibu) Hormones
– OCPs or progestins
– Danazol- prevents gonadotropin release, inhibits midcyle LH and GSH. Androgenic side fx
– GnRH agonists (Lupron)- with continuous admin, suppresses gonadotropin secretion
Assisted reproduction when desired
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Amenorrhea Absence of menses Primary amenorrhea- no menses by age 16
with otherwise nl development Secondary amenorrhea- absence of
menses for 3 or more cycles or 6 months in a previously menstruating female– MC cause??– 3% in genl population– 100% under extreme stress
Examples?
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Tx Desiring pregnancy?
– Ovulation induction Not desiring pregnancy?
– If hypoestrogenic, combo tx with estrogen and progesterone to maintain bone density and prevent genital atrophy
– Normal progestin challenge: needs occasional progestin to prevent endometrial hyperplasia and cancer
– OCPs work well for either, and can decrease hirsutism
– Calcium, too!
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