Blueprints Obstetrics Ch22

Front 1

Primary Dysmenorrhea

Back 1

1. Diagnosis: Pain & Cramping during menstration w/o identifiable pathology.
2. Confirmation: Hx, no organic cx.
3. Next Step:
4. Mechanism: incr endometrial prostoglandins
5. Risk Factors: usu b4 20 yo, 50%, 10% incapacitated 1-3d
6. Complications: N, V, HA
7. Therapy: antiprostoglands + NSAIDS, OCPs (2ndary), TENS

Front 2

Secondary Dysmenorrhea

Back 2

D Dysmenorrhea due to a cause.
C
N
M , adhesions, adeno, cervical stenosis, endometriosis, fibroids
R
C
T stenosis - cervical dilation, laminaria tents

Front 3

Pelvic Adhesions

Back 3

D Secondary Dysmenorrhea
C
N
M
R cervicitis, pid, abscess, inflamm ds
C fixation of uterus into fixed position
T antiprostaglandins, laparoscopy (lyse) if necc

Front 4

PMS

Back 4

D Sx in 2nd 1/2 menstrual cycle
C
N
M unk (estrog / progest, RATD, Xs prostoglandin ..)
R 90% suffer, 5% incapacitated at some point in cycle
C
T 1/3 improve by diet modification, NSAIDS (xs prostaglandin theory), OCPs

RATD - renin angiotensin aldosterone pathway
OCPs support the ovulation, estrogen / progesterone imbalance theories

Front 5

Menorrhagia

Back 5

D Heavy or prolonged menstrual bleeding. Normal is 35 ml
C (> 7 days or 80 ml) 24 pads / 24 hr, hematocrit, iron studies
N
M
adenomyosis
DUB
endometrial hyperplasia
endrometrial polyps
endometrial or cervical CA
fibroids
pregnancy complications
primary bleeding disorders
R
C
T as for mechanism

Front 6

Metrorrhagia and Menometrorrhagia

Back 6

D Metrorrhagia: bleeding between periods
Menometrorrhagia: bleeding between periods > 80 ml

Front 7

Hypomenorrhea

Back 7

D light bleeding
C
N
M
hypogonadotropic hypogonadism in anorexics and athletes
Atrophic endometrium: Asherman's syndrome, IU adhesions, or
synechiae secondary to congenital defects or intrauterine trauma,
OCPs, Depo-Provera
Outlet obstruction
Congenital abnormalities.
R
C
T

Front 8

Polymenorrhea

Back 8

D < 21 days between periods.
C
N
M Anovulation
R
C

Front 9

Oligomenorrhea

Back 9

D Periods > 35 days apart
C
N
M disruption of pituitary-gonadal axis by abnormalities of:
hypothalamic
pituitary
gonadal systems.
systemic ds
R

Front 10

DUB

Back 10

D Diagnosis of exclusion (no menorrhagia, metrorrhagia, menometrorrhagia ..)
C H&P to R/O other causes. Basal temperature graph for ovulation confirmation.
Ovulation also confirmed by home LH (urine surge) detection.
Ovulation also confirmed by d 23-25 serum progesterone.
Ovulation gold std confirmation: endometrial sampling
N
M Most pts are anovulatory w/ disruption of HPG leading to continuous estrogen stimulation of endometrium
Endometrium then sloughs when it outgrows its blood supply.
Usually occurs near menarche and menopause
R
C
T OCPs, progesterone cycle, NSAIDs for ovulatory DUB, D&C, heat ablation, hysterectomy is definitive

HPG - hypothalamus pituitary gonadal axis

Front 11

Postmenopausal Bleeding

Back 11

D Vaginal bleeding more than 12 months p menopause.
C
N
M
lower and upper genital tract
tumors
exogenous hormones
rectal bleeding (hemorrhoids, fissure, prolapse)
lower GI
uretrethral caruncles
R
C Cancer is this age group is more likely.
T

Front 12

MC source of lower genital tract bleeding ?

Back 12

Vaginal atrophy

Front 13

MC causes of postmenopausal bleeding ?

Back 13

Exogenous hormones

Front 14

Upper genital tract causes of post-menopausal bleeding.

Back 14

exogenous hormones (MC)
cervical ca
endometrial hyperplasia
endometrial polyps
endometrial ca