Transcript Secondary Amenorrhea - Pediatric Residency Program

DYSMENORRHEA, DUB, AND AMENORRHEA
AUGUST 2014
Pediatric Continuity Clinic Curriculum
Created by: M.Srikanthan
OBJECTIVES
Review the classification and management
dysmenorrhea
 Review the differential diagnosis and workup for
amenorrhea
 Determine which patients warrant a pelvic exam
and OB/GYN referral
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REGULAR MENSTRUAL CYCLE
Follicular phase
(estrogen)
 Ovulation
 Luteal Phase
(progesterone)
 Puberty
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Thelarche (Tanner 2
breast development)
 Pubarche (Tanner 2 pubic
hair)
 Menarche
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©2002 by American Academy of Pediatrics
CASE #1
A 15½-year-old girl came to the office with complaints of the
recent onset of painful menstrual periods. Menarche occurred
at the age of 13 years and except for an occasional mildly
uncomfortable menstrual period, she has not experienced
significant pain until recently. She described additional
symptoms that also had not been present previously,
including headache, loose stools, and breast tenderness. She
has tried several over-the-counter medications, including
acetaminophen, without significant relief. She has missed 3
days of school in the last 6 weeks because of these complaints.
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What are the differences between primary and secondary
dysmenorrhea and the differential diagnosis for each?
How would you manage this patient?
PRIMARY VS. SECONDARY DYSMENORRHEA
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Primary Dysmenorrhea: pain associated in the absence of
pelvic disease
Associated with headache, nausea, diarrhea
 Due to Prostoglandin E2 and F2a secretion resulting in increased
uterine contractility and upregulation of pain receptors
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Secondary Dysmenorrhea: Due to pathologic process
Congenital partial outflow obstruction
 Endometriosis
 PID
 Pregnancy complication
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RED FLAGS: persistent pain after 3-6 months of OCP use (risk
for endometriosis), pelvic pain/bleeding occurring midcycle, pain
with vaginal discharge (concern for PID)
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The physiologic basis :cell membrane
phospholipids, endomyometrial prostaglandins,
and leukotrienes.
After ovulation, in response to the production of
progesterone, fatty acids build up in cell membrane
phospholipids. Arachidonic acid and other omega-7
fatty acids are released and initiate a cascade of
prostaglandins and leukotrienes in the uterus
Low back pain occurring in association with
dysmenorrhea is due to referred pain from spinal
nerves.
Bloating may result from sensitivity to
progesterone, a smooth muscle relaxant, produced
in the second half of the cycle.
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Subsequent loose stools are a PG-mediated symptom.
Migraine or other headaches may be triggered by declining levels
of estrogen in the immediate premenstrual phase of the cycle
The pathologic mechanisms of pain associated with such causes
of secondary dysmenorrhea as uterine fibroids, endometriosis,
adenomyosis, and other pelvic pathologies may be somewhat more
specific to the pathologic entity.
MANAGEMENT
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Primary Dysmenorrhea
NSAIDs (inhibit PG synthesis)-starting 1 day before onset
on menses ,continue on day 1 and if needed on day 2.
 OCPs (eliminate ovulation and thin out endometrial lining)
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Secondary Dysmenorrhea
If initial therapy is ineffective, consider bimanual exam to
evaluate for cul-de-sac tenderness
 Consider OB/GYN referral if patient continues to have
significant pain despite 3-6 months of OCP use for
evaluation of endometriosis,fibroids
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Primary dysmenorrhea may result in significant
school absence and lost productivity, so
aggressive and evidence-based treatment is
warranted.
 If appropriate doses of NSAIDs do not control
symptoms after two to three cycles, a trial of
OCPs may be indicated.
 OCPs reduce menstrual pain by eliminating
ovulation and by thinning the endometrial
lining; when ovulation does not occur and the
endometrial lining is thinner, the synthesis of
prostaglandins is reduced.
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30- or 35-mcg ethinyl estradiol-containing pill may be
preferable to a 20-mcg formulation.
For adolescents whose external genitalia are normal
and who have classic symptoms of dysmenorrhea, a
pelvic examination is not required initially.
If initial therapy is ineffective, a bimanual
examination can be helpful; endometriosis can be
associated with mild posterior uterine/cul-de-sac
tenderness.
The cul-de-sac (pouch of Douglas) posterior to the
uterus is the most dependent portion of the pelvis
and, thus, the most likely site for pelvic
endometriosis.
CASE #2
You are seeing a 16-year-old girl because she has
not had a menstrual period in 6 months. She had
menarche at 12 years of age and her periods had
become progressively more irregular before
completely stopping 6 months ago. Her past
medical history is unremarkable and she is
currently asymptomatic.
 Discuss the differential diagnosis for primary vs
secondary amenhorrhea
 How would you work up this patient?
DEFINITION:
Primary Amenhorrhea:
 Lack of menses by the age of 15 years or by more
than 3 years after the onset of secondary sexual
development.
 Lack of any secondary sexual characteristics by
age 13 years also is abnormal and should be
investigated.
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Secondary Amenorrhea:
 3 consecutive months of amenorrhea after the
achievement of menarche or absence of 3 cycles
in 6 months.
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DIFFERENTIAL OF AMENORRHEA
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List:
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Central:
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Ovarian:
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Anatomical-outflow tract
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Others:
DIFFERENTIAL DIAGNOSIS FOR PRIMARY
VS SECONDARY AMENORRHEA
EVALUATION OF AMENORRHEA
CASE #3
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A 14-year-old girl is being evaluated for vaginal bleeding. Her
menarche was about 18 months ago, and her periods have occurred at
5- to 6-week intervals; the flow is variable and she has had no
dysmenorrhea. The current menstrual period has been heavier and
she had cramps at the start. She remembers passing a few clots about
2 cm in size. She denies sexual activity. On physical examination, she
is not pale, her heart rate is 68 beats/min, and her body mass index is
24. She is at sexual maturity rating 5 for pubertal development. She
has vague tenderness diffusely in her lower abdomen with no
guarding or rebound. A rapid pregnancy test result is negative, and
her hemoglobin level is 12.6 g/dL (126 g/L).
Of the following, the MOST likely explanation for the girl’s symptoms
is
A. a bleeding disorder
B. dysfunctional uterine bleeding
C. ectopic pregnancy
D. hypothyroidism
E. pelvic inflammatory disease
CASE #3
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A 14-year-old girl is being evaluated for vaginal bleeding. Her
menarche was about 18 months ago, and her periods have occurred at
5- to 6-week intervals; the flow is variable and she has had no
dysmenorrhea. The current menstrual period has been heavier and
she had cramps at the start. She remembers passing a few clots about
2 cm in size. She denies sexual activity. On physical examination, she
is not pale, her heart rate is 68 beats/min, and her body mass index is
24. She is at sexual maturity rating 5 for pubertal development. She
has vague tenderness diffusely in her lower abdomen with no
guarding or rebound. A rapid pregnancy test result is negative, and
her hemoglobin level is 12.6 g/dL (126 g/L).
Of the following, the MOST likely explanation for the girl’s symptoms
is
A. a bleeding disorder
B. dysfunctional uterine bleeding
C. ectopic pregnancy
D. hypothyroidism
E. pelvic inflammatory disease
B.
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Painless, irregular, or prolonged bleeding of
endometrial origin without any accompanying
structural disease is referred to as dysfunctional
uterine bleeding (DUB)
physiologic anovulation seen in early puberty with
immaturity of the hypothalamic-pituitary axis.
Pt is within 2 years of menarche, when anovulatory
bleeding is common.
menstrual interval is at the upper limit of normal,
and the fact that she has had no prior pain is
suggestive of DUB.
On average, ovulatory cycles start at 20 months
after menarche, and her history of new onset of
cramping suggests that her periods are now becoming
ovulatory.
CAUSES
Local:.
 vulva, vagina, cervix, uterus, or ovaries and may be
the result of trauma, foreign bodies, infections,
pregnancy-related, and rarely, estrogen-producing
ovarian tumors.
Systemic:
 bleeding disorders and thyroid disease.
 Hypothyroidism -irregular or prolonged bleeding,
hyperthyroidism -amenorrhea.
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Negative sexual activity, pregnancy test is
negative,PID or ectopic very unlikely
DYSFUNCTIONAL UTERINE
BLEEDING/ABNORMAL UTERINE BLEEDING
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DUB is abnormal bleeding not resulting from uterine
disease, medications, systemic illness, or pregnancy.
DUB is considered a diagnosis of exclusion.
Disorders affecting the hypothalamic-pituitary-ovarian
axis can mimic DUB
DUB/AUB DIFFERENTIAL DIAGNOSIS
PHYSICAL EXAM
PELVIC EXAM?
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Important for confirming normal anatomy,
isolating source of pain, ruling outlesions/masses,
and identifying sources of vaginal/uterine
bleeding
DUB WORKUP
*Pregnancy Test*
 CBC/with reticulocyte count
 TSH
 Coagulation Studies to r/o Von willebrand
disease
 Screening for Gonorrhea and chlamydia-causes
friability of uterine endometrium and cervixthereby increased bleeding
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DUB MANAGEMENT
Iron Supplementation
 Goal of medical therapy is to stop bleeding
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Nonsteroidal anti-inflammatory drugs such as ibuprofen
and naproxen sodium can help reduce blood loss
 combination oral contraceptive (COC) containing estrogen,
which promotes clotting and causes endometrial
proliferation, and progestin, which stabilizes the
endometrial lining
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WHEN TO REFER…
PREP QUESTION
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A 16-year-old girl reports a history of irregular menses. Her periods
have become progressively less frequent since menarche at 12 years
of age. Her last menstrual period was 4 months ago. She is not
sexually active and has had no galactorrhea. She is taking collegelevel classes in school, preparing for her college-entrance exams, and
helping care for her sick mother. On physical examination, her vital
signs are normal and her body mass index is 31. There are
inflammatory acne lesions on her face and back, hyperpigmented
velvety-appearing skin at the nape of her neck, and increased body
hair. Her thyroid gland is not enlarged, and the diameter of her
clitoris is 4 mm. Of the following, the condition MOST likely
responsible for this girl’s symptoms and signs is
A. dysfunctional uterine bleeding
B. emotional stress
C. hypothyroidism
D. pituitary adenoma
E. polycystic ovary syndrome
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E.
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The presence of acanthosis nigricans combined with obesity (body mass index >30
kg/m2),acne, and some increase in body hair described for the girl in the vignette as
well as irregular menses 3 years after menarche suggests the need for further
evaluation for polycystic ovariansyndrome (PCOS).
Diagnosis of PCOS, using the 2003 Rotterdam criteria, requires, in addition to
exclusion of related conditions, the presence of two of the following three criteria:
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1)oligo- or anovulation,
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2) clinical or biochemical signs of hyperandrogenism, and
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3) polycystic ovaries.
Oligo- or anovulation presents as irregular menses, and hyperandrogenism may
present as acne, increased body hair, and rarely, clitorimegaly (a transverse clitoral
diameter greater than 3 mm).
PREP QUESTION
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You are seeing a 16-year-old girl because she has not had a menstrual
period in 6 months. She had menarche at 12 years of age and her
periods had become progressively more irregular before completely
stopping 6 months ago. Her past medical history is unremarkable and
she is currently asymptomatic. She is on the cross country running
team and is planning on running a marathon in the next year. She
denies being sexually active or having any body image issues. Her
vital signs are normal, her body mass index is 19.5, and her sexual
maturity rating is stage 5. Results of the remainder of her physical
examination are unremarkable. The pregnancy test result is negative.
Additional tests, including a complete blood cell count, electrolytes,
thyroxine, thyroid-stimulating hormone, luteinizing hormone, and
follicle-stimulating hormone concentrations, yield normal results.
Of the following, the MOST important next step in the management
of this girl would be to have
A. begin combined oral contraception
B. increase her calcium and vitamin D intake
C. increase her overall nutritional intake
D. stop exercising till her menses returns
E. switch to a nonendurance sport
C
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negative energy balance in female athletes may lead to the female athlete
triad
amenorrhea,
osteoporosis, and
disordered eating.
at risk for osteoporosis because of low BMI and estrogen deficiency.
The return of menses signals an improvement in the hormonal status that, in
turn, will increase the bone mineral density (BMD). a combined oral
contraceptive is not as effective as increasing energy intake to improve BMD.
Calcium, vitamin D, and weight-bearing exercise are needed to achieve peak
bone mass in all adolescents, but requirements do not change with athletic
participation, and supplements will not influence the menstrual status.
Changing the type of sport or stopping exercising will reduce the energy output
and help achieve energy balance, but the initial approach should be to increase
energy intake.
If the girl is unable or unwilling to increase energy intake, exercise restrictions
may be required.
REFERENCES AND FUTURE READING
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Consultation with a Specialist: Dysmenorrhea. Pediatrics in
Review Vol. 27 No. 2 February 1, 2006. pp. 64 -71.
Menstrual Disorders. Pediatrics in Review Vol. 28 No. 5 May
1, 2007. pp. 175 -182
Dysfunctional Uterine Bleeding. Pediatrics in Review Vol. 23
No. 7 July 1, 2002
pp. 227 -233
Secondary Amenorrhea. Pediatrics in Review Vol. 27 No. 3
March 1, 2006
pp. 113 -114
Gynecologic Examination for Adolescents in the Pediatric
Office Setting. Pediatrics Vol. 126 No. 3 September 1, 2010 .
pp. 583 -590
Nelson Textbook of Pediatrics : Expert Consult (19th Edition).
Kliegman, Robert M. Stanton, Bonita St. Geme, Joseph
thank you