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Menstrual cycle

Follicular phase

• Day one of the cycle begins with menses
• Estrogen increases causing the uterine lining to thicken
• Follicular stimulating hormone (FSH) increases, stimulating the follicles
• On day two or three of the cycle one follicle in the ovary becomes dominant
• About day 14 a surge in luteinizing hormone (LH) causes the dominant follicle to release its egg. Ovulation

Luteal Phase

• The follicle changes into the corpus luteum which secretes progesterone
• The high level of progesterone and estrogen are important for creating the thickened lining of the uterus for implantation of the fertilized egg.
• If no implantation takes place within two weeks there is a dramatic drop in progesterone and estrogen resulting in the shedding of the uterine lining.

Amenorrhea

Primary amenorrhea

• Female with no secondary sex characteristics and no menstruation by age 14
• Female with secondary sex characteristics and no menstruation by age 16

Clinical Presentation

• No secondary sexual characteristics
• Breast development but no pubic or axillary hair
• Normal secondary sexual characteristics

Differential Diagnosis

• Imperforate hymen
  • A completely sealed hymen will prevent menstrual flow
• Gonadal agenesis or dysgenesis
  • Hypoplastic dysfunctional ovaries
• Turner syndrome
  • 45,X
• Androgen insensitivity
  • Genetically male child who is phenotypically female
• Cervical agenesis
  • Prevents menstrual flow
• Mullerian agenesis
  • Uterus never develops
• Tumor of pituitary or hypothalamus
  • This will affect LH and FSH production

Labs and Studies

• Blood work
  • FSH
  • LH
  • Beta HCG
  • Estrogen
  • Prolactin
  • Testosteron
• Imaging
  • U/S
    • Pelvic
    • Transvaginal
    • Thyroid
  • CT/MRI
    • Hypothalamus
    • Pituitary
• Karyotype

Treatment

• Based on underlying cause
  • Imperforate hymen
    • Surgical correction
  • Androgen insensitivity
    • Removal of the testis due to elevated risk of testicular cancer

Secondary amenorrhea

• No menstruation over a 6 month period
• In a patient with oligomenorrhea (infrequent menstrual periods) secondary amenorrhea is defined as a 12 month period without menses
• Pregnancy is the most common reason for secondary amenorrhea!

Clinical Presentation

• Significant weight change
• Change in exercise pattern
• Signs of polycystic ovarian syndrome
  •  Hirsutism
  • Obesity
  • Virilization
• Galactorrhea
  • Milk from the breast which is not associated with childbirth

Differential Diagnosis

• Pregnancy is the most common reason for secondary amenorrhea
• Anorexia
• Stress
• Polycystic ovarian syndrome
• Tumor of hypothalamus or pituitary
• Sheehan syndrome – damage to the pituitary secondary to ischemia during childbirth
• Asherman syndrome – intrauterine adhesions and scarring
• Premature ovarian insufficiency

Labs and Studies

• Blood work
  • FSH
  • LH
  • Beta HCG
  • Estrogen
  • Prolactin
  • Testosteron
  • Imaging
    • U/S
      • Pelvic
      • Transvaginal
      • Thyroid
  • CT/MRI
    • Hypothalamus
    • Pituitary

Treatment

Based on underlying cause

Dysmenorrhea

Primary Dysmenorrhea

• Painful menstruation without pathologic findings. Generally considered to be caused by excessive prostaglandin production. Incidence decreases with age and parity.

Clinical Presentation

• Low, medial abdominal pain radiating to back and inner thighs
• Cramping
• Nausea and vomiting
• Diarrhea
• Flushing
• Typically lasts from 1–3 days
• Unremarkable physical exam

Labs and Studies

• History and physical should be enough for a diagnosis for primary dysmenorrhea

Treatment

• The first line of treatment should be a course of NSAIDs beginning a few days before menses and continuing for a few days to reduce prostaglandin production
• Prevention of ovulation
  • Oral contraception
  • IUD
  • Depo Provera shot

Secondary dysmenorrhea

• Painful menstruation with pathologic findings.

Differential Diagnosis

• Endometriosis
• Pelvic inflammatory disease
• Pelvic pain
• Cervicitis
• Fibroids

Clinical Presentation

• Pain not necessarily correlated to the beginning of menses
• Bloating
• Menorrhagia (heavy menstrual bleeding)
• Dyspareunia (pain with sexual intercourse)
• Palpable uterus/fibroid/mass

Labs and Studies

• Pelvic U/S
• Hysteroscopy
• Laparoscopy
• MRI

Treatment

• NSAIDS
• Oral contraceptives may help with endometriosis
• Surgery
  •  D&C
  • Hysterectomy
  • Fulguration of endometriosis

Premenstrual Syndrome (PMS)

• There is an association between PMS, postpartum depression and perimenopausal depression
• Symptoms occur during the second phase of the menstrual cycle and are elevated with menstruation.

Clinical Presentation

• Bloating
• Swelling
• Breast pain
• Constipation
• Mood and psychological problems
  • Irritability
  • Anxiety
  • Depression
  • Food cravings
  • Aggressiveness
  • Changes in sleep patterns
• Symptoms occur during the luteal phase
• There must be no symptoms during the follicular phase

Labs and Studies

• Patient history and daily charting of symptoms

Treatment

• Diet modification
  • Increase complex carbohydrates
  • Increase calcium and vitamin D
  • Avoid high sugar foods
  • Avoid alcohol
  • Avoid caffeine
  • Decrease salt intake
• Regular exercise
• Emotional support and stress reduction
• Consider depression as primary diagnosis
• Medications
  • Selective serotonin reuptake inhibitors (SSRI)
  • Oral contraception
  • Diuretics
    • Spironolactone 100 mg daily during luteal phase
  • NSAIDs

Menopause

• Typically diagnosed after six months
• Average age is 51
• Premature menopause is younger than 40
• Consider all causes of secondary amenorrhea

Clinical Presentation

• Hot Flashes in 80% of cases
• Depression
• Irritability
• Insomnia
• Dysuria
• Vaginal dryness
• Dyspareunia
• Secondary amenorrhea

Labs and studies

• beta hCG (you never know)
• FSH > 30 mg/dl is diagnostic
• LH
• Prolactin
• TSH

Treatment

• Based on symptoms
• Changes in diet, exercise and stress reduction often are helpful
• Hormone replacement therapy (HRT) for premature menopause and hot flashes, insomnia and osteoporosis. Though risks include breast cancer and cardiovascular disease
• Vaginal estrogen cream for vaginal dryness and dyspareunia