Obstetrics and Gynecology/Menstrual Disorders

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Dysmenorrhea[edit | edit source]

Definition[edit | edit source]

  • Pain on menstruation.

Epidemiology[edit | edit source]

  • Over 70% of women experience dysmenorrhea at some point.

Etiology, Risk Factors, and Pathophysiology[edit | edit source]

Primary dysmenorrhea

  • Results from production of prostaglandins within 48 hours of menstruation that stimulates the myometrial cells to contract.

Secondary dysmenorrhea

  • The result of a pathologic condition
    • Endometriosis, adenomyosis, cervical stenosis, vaginitis, psychological disturbance

Management[edit | edit source]

  • Birth control pill
  • GnRH analogues
  • NSAIDs (effective in 80% of women)

Amenorrhea[edit | edit source]

Definitions[edit | edit source]

  • Primary amenorrhea: failure to menstruate by 16 years of age with secondary sexual characteristics; failure to menstruate by 14 years of age without sexual characteristics; failure to mensturate with 2 years of sexual maturation.
  • Secondary amenorrhea: failure to menstruate for 6 months with formerly normal menses; oligomenorrhea with less than 9 cycles per year.

Etiology, Pathophysiology, and Risk Factors for Amenorrhea[edit | edit source]

Etiologies include

  • Müllerian agenesis (MRKH syndrome) in 10%
  • Androgen insensitivity in 5%
  • Imperforate hymen in 0.1%
  • Transverse vaginal septum in 1/80000
  • Ashermann's syndrome
  • Enzymatic deficiency
  • Premature ovarian failure
  • Pituitary tumours
  • FSH/LH mutations
  • Pituitary space-occupying lesions
  • Pituitary necrosis
  • Inflammatory/infiltrative pituitary disease
  • Pharmacologic prolactin stimulators
  • Stress induced amenorrhea
  • Isolated gonadotropin deficiency
  • Infections
  • Chronic disease
  • Hypothalamic tumours
  • Adrenal, thyroid, ovarian endocrine disease
  • Metastatic carcinoma

Clinical Presentation and Diagnostic Approach[edit | edit source]

  • Pregnancy must always be excluded.
  • Measure FSH and prolactin
    • If FSH is low or normal
      • Chronic anovulation
      • Anatomic defect (Müllerian agenesis)
    • If FSH is elevated
      • Ovarian failure
    • If prolactin is elevated
      • MRI head for prolactinoma
  • Karyotyping may be performed for the following indications
    • High FSH in a patient under 30 years of age
    • Height <147cm
    • Ambiguous genitalia (congenital adrenal hyperplasia)
    • Absent uterus

Management[edit | edit source]

Primary amenorrhea

  • Restore ovulation with estrogen and progesterone
  • Reassurance

Secondary amenorrhea

  • Treat the underlying cause