Gynaecology: Medical School Crash Course

Introduction to Gynecology

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Contents Preface............................................................................................................................................ 1 Chapter 1 Menstruation .............................................................................................................. 3 Menstruation Basics ................................................................................................................... 3 Dysmenorrhea ............................................................................................................................ 4 Emotional Aspects of Menstruation ........................................................................................... 6 Menstrual Bleeding .................................................................................................................... 6 Menstrual Disorders ................................................................................................................... 7 Breastfeeding and the Menstrual Cycle ..................................................................................... 8 Feminine Hygiene ...................................................................................................................... 8 Key Takeaways .......................................................................................................................... 9 Quiz ............................................................................................................................................ 9 Chapter 2 Premenstrual Syndrome and Premenstrual Dysphoric Disorder ....................... 13 Premenstrual Syndrome ........................................................................................................... 13 Premenstrual Dysphoric Disorder ............................................................................................ 15 Premenstrual Tension Syndrome ............................................................................................. 17 Treatment of PMDD ................................................................................................................ 17 Key Takeaways ........................................................................................................................ 18 Quiz .......................................................................................................................................... 19 Chapter 3 Amenorrhea.............................................................................................................. 23 Follicular Phase ........................................................................................................................ 23 Ovulatory Phase ....................................................................................................................... 24 Luteal Phase ............................................................................................................................. 25 Puberty ..................................................................................................................................... 25 Causes of Amenorrhea ............................................................................................................. 26 Diagnosing Amenorrhea .......................................................................................................... 29 Treatment of Amenorrhea ........................................................................................................ 29 Key Takeaways ........................................................................................................................ 31 Quiz .......................................................................................................................................... 31 Chapter 4 Hyperprolactinemia and Galactorrhea ................................................................. 35 Hyperprolactinemia Basics ...................................................................................................... 35 Causes of Hyperprolactinemia ................................................................................................. 37 Treatment of Hyperprolactinemia ............................................................................................ 38 Galactorrhea ............................................................................................................................. 39 Causes of Galactorrhea ............................................................................................................ 39 Key Takeaways ........................................................................................................................ 39 iv

Quiz .......................................................................................................................................... 40 Chapter 5 Abnormal Uterine Bleeding .................................................................................... 44 Abnormal Uterine Bleeding Basics.......................................................................................... 44 Signs and Symptoms of Abnormal Uterine Bleeding or AUB ................................................ 46 Diagnosing Abnormal Uterine Bleeding .................................................................................. 46 Treatment of Abnormal Uterine Bleeding ............................................................................... 47 Key Takeaways ........................................................................................................................ 49 Quiz .......................................................................................................................................... 49 Chapter 6 Endometriosis ........................................................................................................... 53 Endometriosis Basics ............................................................................................................... 53 Signs and Symptoms of Endometriosis.................................................................................... 53 Risk Factors for Endometriosis ................................................................................................ 55 Etiology and Physiology of Endometriosis .............................................................................. 55 Location of Endometriomas ..................................................................................................... 57 Diagnosis of Endometriosis ..................................................................................................... 58 Treatment of Endometriosis ..................................................................................................... 59 Key Takeaways ........................................................................................................................ 61 Quiz .......................................................................................................................................... 61 Chapter 7 Cervical Cancer ....................................................................................................... 64 Cervical Cancer Basics ............................................................................................................ 64 Causes of Cervical Cancer ....................................................................................................... 65 Screening for Cervical Cancer ................................................................................................. 66 Diagnosis of Cervical Cancer................................................................................................... 67 Treatment of Cervical Cancer .................................................................................................. 67 Prevention of Cervical Cancer ................................................................................................. 68 Key Takeaways ........................................................................................................................ 68 Quiz .......................................................................................................................................... 69 Chapter 8 Endometrial Cancer ................................................................................................ 72 Signs and Symptoms of Endometrial Cancer .......................................................................... 72 Factors that influence the Risk of Endometrial Cancer ........................................................... 72 Diagnosis of Endometrial Cancer ............................................................................................ 74 Treatment of Endometrial Cancer ............................................................................................ 75 Screening for Endometrial Cancer ........................................................................................... 76 Key Takeaways ........................................................................................................................ 77 Quiz .......................................................................................................................................... 77 Chapter 9 Ovarian Cancer ........................................................................................................ 80 Ovarian Cancer Basics ............................................................................................................. 80 v

Signs and Symptoms of Ovarian Cancer ................................................................................. 82 Diagnosis of Ovarian Cancer ................................................................................................... 82 Treatment of Ovarian Cancer ................................................................................................... 84 Key Takeaways ........................................................................................................................ 86 Quiz .......................................................................................................................................... 86 Chapter 10 Vulvar Cancer and Vaginal Cancer ..................................................................... 89 Vulvar Cancer Basics ............................................................................................................... 89 Vaginal Cancer ......................................................................................................................... 92 Risk Factors for Vaginal Cancer .............................................................................................. 93 Metastasis of Vaginal Cancer................................................................................................... 94 Clinical Presentation ................................................................................................................ 95 Vaginal Melanoma ................................................................................................................... 95 Sarcoma Botryoides of the Vagina .......................................................................................... 96 Endodermal Sinus Tumor ........................................................................................................ 96 Vaginal leiomyosarcoma .......................................................................................................... 96 Treatment of Vaginal Cancer ................................................................................................... 96 Surgical Staging of Vaginal Cancer ......................................................................................... 97 Complications and Follow Up ................................................................................................. 98 Prognosis of Vaginal Cancer.................................................................................................... 98 Key Takeaways ........................................................................................................................ 98 Quiz .......................................................................................................................................... 99 Chapter 11 Sexually Transmitted Diseases ........................................................................... 102 Chlamydia .............................................................................................................................. 102 Genital Warts ......................................................................................................................... 102 Genital Herpes........................................................................................................................ 103 Gonorrhea............................................................................................................................... 103 Syphilis................................................................................................................................... 104 Human Immunodeficiency Virus or HIV .............................................................................. 104 Trichomoniasis ....................................................................................................................... 105 Pubic Lice............................................................................................................................... 105 Scabies.................................................................................................................................... 105 Key Takeaways ...................................................................................................................... 106 Quiz ........................................................................................................................................ 106 Chapter 12 Breast Cancer ....................................................................................................... 109 Breast Cancer Basics .............................................................................................................. 109 Risk Factors for Breast Cancer .............................................................................................. 110 Signs and Symptoms of Breast Cancer .................................................................................. 111 Screening for Breast Cancer................................................................................................... 112 Types of Breast Cancer .......................................................................................................... 113 Treatment of Breast Cancer ................................................................................................... 115 vi

Reducing the Breast Cancer Risk ........................................................................................... 116 Prognosis for Breast Cancer ................................................................................................... 117 Key Takeaways ...................................................................................................................... 118 Quiz ........................................................................................................................................ 118 Chapter 13 Menopause ............................................................................................................ 122 Overview of Menopause ........................................................................................................ 122 The Menopausal Transition.................................................................................................... 124 Menopause and the Heart ....................................................................................................... 126 Menopause and Breast Cancer ............................................................................................... 126 Menopause and the Central Nervous System......................................................................... 126 Markers for Menopause ......................................................................................................... 127 Hormone Replacement Therapy ............................................................................................ 127 Key Takeaways ...................................................................................................................... 128 Quiz ........................................................................................................................................ 128 Summary .................................................................................................................................... 132 Course Test Questions .............................................................................................................. 134 Course Test Answers.............................................................................................................. 161

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Preface This course is designed to be a relatively broad discussion on the topic of gynecology.

Gynecologists must care for the healthy woman with minor gynecological problems as well as the sick woman who has life-threatening problems such as the various kinds of gynecological cancers seen in women. Both well gynecological care and the care of sick women with gynecological problems will be discussed.

The first chapter of the course is a discussion of menstruation, which is a natural phenomenon that happens from the age of about twelve to the age of about fifty. Normal menstruation takes place every twenty-eight days and may or may not be associated with premenstrual symptoms, which might be debilitating to some women.

The second chapter of the course covers the topic of premenstrual syndrome and premenstrual dysphoric disorder. This can be a problem of both young and old menstruating women who have both physical and psychological symptoms related to the premenstrual state. There are medications that can be given to women who suffer from premenstrual syndrome and premenstrual dysphoric disorder as well as lifestyle changes that can happen as a result of hormonal changes.

The third chapter of the course is a thorough discussion of the topic of amenorrhea. The most common cause of amenorrhea is pregnancy although there are a host of other mental and physical things that can be associated with amenorrhea in women of all ages.

The fourth chapter of the course a discussion of both hyperprolactinemia and galactorrhea, which is the most common symptom women complain of when the prolactin level is too high. The various causes of hyperprolactinemia will be discussed as well as the most common reasons why a woman would have this problem.

Abnormal uterine bleeding is the main topic in the fifth chapter of this course. Abnormal uterine bleeding can happen to young women or older women and may represent mild menstrual difficulties or a serious underlying gynecological problem. The various causes of abnormal uterine bleeding will be covered in this chapter as there are many possible underlying problems that can cause this symptom.

Endometriosis is discussed in the sixth chapter of this course. Endometriosis has several symptoms associated with it, some of which are mild, while others are severe and debilitating.

The woman with endometriosis can suffer from infertility as a major problem or can only have dyspareunia or pain with intercourse.

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Cervical cancer is the topic of discussion in the seventh chapter of this course. Cervical cancer can affect young women who become infected with the human papillomavirus and is rarely a problem affecting women who were never infected with the virus.

Endometrial cancer, on the other hand, is a disease mainly of older women and is discussed in the eighth chapter of this course. Women who have had years of unopposed estrogen run the risk of endometrial hyperplasia and endometrial cancer that will manifest itself as abnormal vaginal bleeding and pelvic pain.

Ovarian cancer is the focus of the ninth chapter. Women with ovarian cancer are diagnosed usually in the later stages of the disease process and are very ill, even after being treated maximally for the disorder. The death rate from endometrial cancer is very high because many women aren’t diagnosed until they have advanced cancer.

Vulvar and vaginal cancer are discussed together as part of the tenth chapter of this course.

Women who have these types of cancer face extremely disfiguring surgery and chemotherapy— both things that will prolong their life if they are done soon enough to help the woman before the cancer metastasizes.

Sexually transmitted diseases and their treatments are the focus of the eleventh chapter of this course. Women can get sexually transmitted diseases from having sexual contact with many different sexual partners or having unprotected sex with an individual who transmits the disease to them.

Breast cancer is the main topic in the twelfth chapter of this course. Breast cancer affects mainly women over the age of forty but can affect younger women who carry the various genes associated with breast cancer that can be inherited and may result in breast cancer at a very young age.

The thirteenth and concluding chapter of the course is a discussion of the menopausal process.

Women go through menopause at about the age of fifty, after which they have no menstrual periods and begin to have an increased risk for several various kinds of diseases, such as osteoporosis and coronary artery disease. The treatment of menopausal symptoms is a major part of this last chapter on gynecology.

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Chapter 1 Menstruation This chapter is devoted the topic of menstruation. The ability to menstruate is something a woman experiences for much of her lifetime. Teens begin menstruating at about the age of twelve and have relatively regular menstrual cycles until the age of about fifty-one, when a grown woman goes through menopause. In this chapter, we will discuss the basics of menstruation, including the hormonal milieu that encompasses this monthly cycle.

Menstruation Basics Most women refer to menstruation as their “monthly” or their “period”. It involves the periodic loss of blood and endometrial lining tissue from inside the uterus through the vagina. While most girls begin menstruating as early as the age of eleven, it is normal to menstruate for the first time as late as fifteen years of age. In some parts of the world, girls begin to menstruate at the age of eight. The beginning of menstruation is called menarche. The typical length of the menstrual cycle in regularly ovulating women is about twenty-eight days, although a woman’s menstrual period can be as close together as twenty-one days or as far apart as forty-five days. Bleeding during the period can range from two to seven days. Periods continue throughout the woman’s lifetime until menopause unless there is a health problem or the woman becomes pregnant.

Menstruation is under the control of the pituitary gland. The pituitary gland secretes a follicle stimulating hormone that causes the ovaries to secrete estrogen. Under the influence of estrogen, the uterine lining thickens in preparation for a possible implantation of a fertilized ovum. The pituitary gland also secretes luteinizing hormone, which results in the release of at least one mature ovum that travels down the fallopian tube where it may or may not be fertilized with male sperm cells. The progesterone level is high in the latter half of the menstrual cycle, which causes maturation of the endometrial lining. At the end of a two-weeks, if there is no pregnancy, the ovary ceases its output of progesterone and estrogen, and bleeding ensues.

Menstruation is generally not a painful or uncomfortable event, although up to eighty percent of women will have at least one menstrual-related symptom. Typical symptoms include facial acne, breast tenderness, abdominal bloating, fatigue, emotional irritability, and changes in mood.

These can become severe enough to interfere with the woman’s daily activities, resulting in premenstrual syndrome or premenstrual dysphoric disorder, discussed in a later chapter. About twenty to thirty percent of women will experience premenstrual syndrome, while up to eight percent of women will suffer from premenstrual dysphoric disorder.

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The first day of the menstrual cycle is day the woman first begins to bleed from the vagina and the last day of the menstrual cycle is the day prior to the next bleeding episode. The main reason why the menstrual cycle occurs is the rise and fall of the female reproductive hormones. This cycle causes an initial thickening of the uterine lining and development of the egg in the ovaries.

The egg is released from one or both ovaries at about the fourteenth day of the cycle. The uterine lining remains thickened and the lining of the uterus becomes mature during the last fourteen days of the menstrual cycle in preparation for implantation, should the egg become fertilized. In the absence of a fertilized egg, the uterine lining breaks down and the next menstrual cycle begins.

The first menstrual period is associated with physical changes such as the development of the secondary sexual characteristics and an increase in height. This is called menarche and occurs between the ages of twelve to fifteen, although it can happen earlier in life in countries where the nutrition is good and girls are not malnourished at this point in their lives. When a woman refers to her last menstrual period or LMP, she is referring to the first day at which she began to bleed in the most recent cycle. While most menstrual periods are twenty-eight days in length, healthy women can have menstrual periods that are as far apart as forty-five days. Having menstrual periods further apart than this means that the woman has oligomenorrhea.

Periods occur on a regular basis except during pregnancy and breastfeeding until perimenopause, which is the few years in a woman’s life that results in a decline in fertility and an increase in menstrual irregularity. This can go on for many years until the woman enters menopause at about the age of fifty-one, although the range of time for normal menopause is about forty-five to fiftyfive years of age. If a woman doesn’t have her period and is not actively pregnant or menstruating, this is called amenorrhea. Menstruation can occur during lactation; however, the fertility level is lower than if the woman wasn’t lactating. The average time for periods to resume after pregnancy is about four to six weeks but can be much longer if the woman is breastfeeding.

The change in hormones is what affects both the menstrual cycle and the symptoms associated with having a menstrual period. Most women will experience menstrual cramping that can happen in the last few days of the menstrual cycle or upon the onset of menstruation. Usually, these are mild cramps that can get better with acetaminophen or a nonsteroidal anti-inflammatory medication. Breast swelling and tenderness also occur before the menstrual period and are directly related to mild fluid retention.

Dysmenorrhea The experience of pelvic cramping with the menstrual period is also called dysmenorrhea. It occurs a day or so before the actual menstrual bleeding and continues into the first day or two after bleeding starts. The cause of menstrual cramping is ischemia of the uterine lining and 4

contractions of the uterine muscle. There are spiral arteries in the endometrial lining that constrict just before bleeding starts, resulting in a lack of blood flow to this tissue. This is what allows the uterine lining to begin to separate from the uterine myometrium and slough off. The myometrium responds to the presence of ischemic endometrium by contracting spasmodically.

The result is the expulsion of blood and endometrial tissue out of the uterus through the cervix.

The contractions are caused by an influx of prostaglandins, that are released by the woman’s endocrine system.

Painful cramping caused by the release of prostaglandins is known as “primary dysmenorrhea”.

It begins in the teenage years, usually a few years after menarche, and is associated with the time in a teenage girl’s life when she begins to ovulate. Treatments that can help this type of pain include birth control pills and nonsteroidal anti-inflammatory (NSAID) medications. The NSAID medications block prostaglandin production so the periods are less painful. Birth control pills block ovulation so there is less uterine lining to expel and less menstrual pain. Period bleeding tends to be of a shorter duration as well.

The main risk factors for primary dysmenorrhea in teenagers and young women include having extremely lengthy periods, heavy periods, being a smoker, and having a family history of dysmenorrhea. The main treatment for this besides medications includes aerobic exercise, which seems to decrease the cramping pain by an unknown mechanism. Pregnancy seems to result in less dysmenorrhea after giving birth and older women have less dysmenorrhea when compared to younger women. Up to fifteen percent of women will have painful menstrual cramps that interfere with activities of daily living.

Secondary dysmenorrhea can be defined as menstrual pain secondary to a known physical problem. The most common causes of secondary dysmenorrhea include uterine fibroids, endometriosis, congenital malformations of the uterus, IUD insertion, and uterine adenomyosis.

Rarely, cancers can cause secondary dysmenorrhea. Women with endometriosis can have birth control pills, which will suppress the endometriomas and will decrease the pain.

The main symptoms experienced when a woman has dysmenorrhea include low back pain, thigh pain, pelvic pain, hip pain, nausea, diarrhea, and constipation. The pain begins a few days before the onset of menstrual bleeding and lasts for a day or so after the bleeding begins. If the pain is severe or does not follow a typical pattern, the woman needs to be further evaluated for another cause of the symptoms, such as a disorder causing secondary dysmenorrhea. If the pain and bleeding happen at any time other than when expected, the cause may not be related to menstruation at all and may represent a spontaneous abortion or an ectopic pregnancy. A pregnancy test must be done and treatment should be started immediately, particularly if the bleeding is heavy.

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Some women have extremely strong psychological and emotional symptoms related to dysmenorrhea and these secondary symptoms can interfere with the woman’s quality of life.

Symptoms that have been known to be linked to dysmenorrhea include migraine headaches, anxiety, and depression. Severe dysmenorrhea is mostly a condition of young women between the ages of thirteen and nineteen, when at least two-thirds of women suffer from this problem. In addition to NSAID therapy and birth control pills, there are some herbal remedies that have been used to manage these symptoms.

Emotional Aspects of Menstruation The hormones that affect menstruation can also affect a woman’s emotional state. Emotions tend to be most affected in the week or two before the menstrual bleeding starts and they tend to improve just as the bleeding begins. Common emotional symptoms associated with menstruation include extreme tension, irritability, episodes of crying, and changes in mood. Concentration and memory also can be impaired during this time. Some women will experience clinical depression or clinical anxiety—both of which may require medical intervention or psychiatric care.

The majority of the emotional symptoms related to menstruation are mild enough to be called premenstrual syndrome. About twenty to thirty percent of women will have this problem. About three to eight percent of women will have symptoms severe enough to qualify as having premenstrual dysphoric disorder. In extremely rare cases, a woman can suffer from menstrual psychosis. Stress in normal women can result in amenorrhea, indicating that there is a strong association between a woman’s emotions and her menstrual status.

Menstrual Bleeding The amount of menstrual bleeding varies from woman to woman but is about two-and-a-half tablespoons or about thirty-five milliliters. The flow looks like blood but is fluid that is only partly blood, partly serous fluid, and partly endometrial lining cells. Cervical mucus and vaginal secretions are also a part of the menstrual flow. Menstrual fluid is generally reddish-brown, being darker than the blood that can be found in a woman’s veins.

Menstrual blood is completely harmless except when a woman has a bloodborne illness, in which case the blood can pass a bloodborne disease. There are no toxic substances in the menstrual flow because it is designed originally to be where an embryo implants. For this reason, it is relatively purified and is as safe as the blood in the woman’s bloodstream. Only about half of menstrual flow is blood, which contains chloride, iron, phosphate, calcium and sodium. There are proteins in the menstrual flow as well.

Adult women will notice blood clots during the time of menstrual bleeding. The clots may be actual blood clots or pieces of degraded endometrial lining. Some women confuse this tissue 6

with products of conception but rarely is this the case. Blood clotting is always possible but is designed not to occur in women because plasmin, an enzyme in the endometrial tissue, keeps the menstrual blood from clotting. While some iron is lost through menstrual bleeding, it is rare to have iron deficiency anemia just because of menstruation.

Menstrual Disorders There are several menstrual disorders that can affect a woman. Each disorder represents a problem with some aspect of the menstrual cycle. For example, oligomenorrhea is a menstrual disorder that means a woman is having infrequent periods. The menstrual condition known as hypomenorrhea means the woman has extremely light periods or episodes of menstrual bleeding that are short in duration. Women with polymenorrhea have periods that are more often than every twenty-one days apart. The menstrual disorder known as hypermenorrhea involves having period bleeding that is extremely heavy or periods that last a long time. Dysmenorrhea is a condition of very painful bleeding, while metrorrhagia involves having spotting between periods that don’t rise to the level of an actual period. Absent periods altogether mean that the woman has no periods at all.

Dysfunctional uterine bleeding is a hormonal menstrual problem in which the woman bleeds abnormally in any one of several ways. Women with dysfunctional uterine bleeding do not ovulate normally or don’t ovulate at all. Often the problem in this type of bleeding abnormality is a hormonal condition, but it can indicate the presence of uterine fibroids or other gynecological problems. As there can be bleeding at any point in pregnancy, all women with abnormal vaginal bleeding who are of childbearing years should have a pregnancy test as part of the workup.

Many women want to control the frequency of menstruation or the amount of bleeding per menstrual cycle. The best way to do this is to take some form of hormonal birth control pills.

Most hormonal birth control pills contain estrogen that is taken for twenty-one days of the cycle along with a small amount of progesterone. There is a seven-day break in which no pills are taken or the woman takes a placebo pill containing no hormones whatsoever. It is during this time that the woman has her menstrual period. Besides controlling the frequency of the periods, birth control pills prevent pregnancy with less than a ten percent failure rate with ordinary use.

In the last fifteen years, there has been the development of extended cycle combined birth control pills that prevent periods from happening at all. Progesterone implants can also be used that decrease the frequency of periods to only about three to four periods per year. The mini-pill contains progestin only and is taken continuously so that no periods occur. In this way, the woman has control over when she would like to have her period. This practice is referred to as menstrual suppression.

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Breastfeeding and the Menstrual Cycle The act of breastfeeding results in a negative feedback loop that suppresses the pulsatile secretion of gonadotropin releasing hormone, or GnRH, and luteinizing hormone, or LH. Depending on the amount of breastfeeding the woman does and how much the hormones are suppressed, there will most likely be a complete suppression of follicular development. With lesser degrees of breastfeeding, the hormones will be less likely to cause ovulation but there will be some follicular development. With even lesser degrees of breastfeeding, normal menstruation may again occur after pregnancy.

The more suckling that occurs, the greater is the chance of lactation amenorrhea and suppression of ovulation. Women who regularly breastfeed their infant will have a resumption of menstrual periods at an average of fourteen months after giving birth. This is believed to be due to the production of prolactin, which increases in response to suckling behavior. While fourteen months is the average time in which the period resumes in a breastfeeding mother, it can resume as soon as two months postpartum or as late as forty-two months postpartum.

Feminine Hygiene One of the most common issues facing the menstruating woman is the management of the bleeding itself. Women can use medications to slow the amount of bleeding or can use undergarments and other feminine hygiene products that help keep the clothing clean and free of menstrual blood. There are fortunately several products available to manage bleeding, some of which are disposable while others are reusable.

Sanitary napkins can be reusable or disposable. In developing countries, reusable sanitary napkins are the norm, while in developed countries, most women make use of disposable sanitary napkins. The disposable products are packed with wood pulp or gel-like material that is bleached and lined with plastic. There is adhesive used to attach the pad to the underwear with some products having “wings” that prevent soiling of the underwear.

Tampons are disposable cylindrical products that are designed to be inserted directly into the vagina and replaced as they fill with blood. They are made from rayon and cotton in most cases, while some contain just fleece that is bleached white. Padettes are small wads of cotton or rayon fleece and are placed just inside the inner labia to staunch the flow of bleeding. Some women use disposable menstrual cups that are placed just inside the vagina to catch the menstrual flow

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before it exits the vagina. They are made of a soft plastic material that is comfortable for a menstruating woman to wear.

Reusable items for menstrual flow include reusable cloth pads made from terrycloth, flannel, organic cotton or other natural materials. They are used and washed after the period is over with.

Menstrual cups are made from plastic and are shaped like a bell. They absorb about a half-day worth of menstrual flow. They are removed when the woman goes to the toilet and emptied out before being re-inserted into the vagina. These products are made from silicone and can be used for a minimum of five years. Ideally, they should be sterilized with boiling water after the end of the menstrual flow each month.

Sea sponges are used in some parts of the world to absorb menstrual flow. They are washed after the period is over with and hold up for several menstrual periods. Padded underwear can be made and worn that will soak up menstrual bleeding without having to use a pad. At night, some women use an item known as a draw sheet, which is a blanket or towel worn at night to decrease the flow while the woman sleeps.

Key Takeaways • • •

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The average age of menarche is twelve in most developed countries, while it occurs later in countries that have worsened nutritional status.

The average age of cessation of menstruation in developed countries is fifty-one, although the range is from forty-five years to fifty-five years.

Menstruation is under the control of the pituitary gland, which releases both luteinizing hormone and follicle stimulating hormone. The female reproductive tract responds to these hormones and the lining of the uterus is either built up or shed, depending on the woman’s hormonal status at any given point in the cycle.

The condition of painful menses is called dysmenorrhea. Women can have primary dysmenorrhea, which has no known etiology, or secondary dysmenorrhea, which has its origins in some physical disorder.

Quiz 1. The female patient is being evaluated as part of a teen well-child visit. At what age does the doctor tell the patient that menarche is happening too late in life? a. Twelve b. Fourteen c. Fifteen d. Sixteen

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Answer: d. Normal menarche in developed countries is between eleven and fifteen years of age. If it happens later than this, it is considered a late onset of menarche.

2. A nineteen-year-old woman carries the diagnosis of primary dysmenorrhea. What is the most likely etiology behind her symptoms? a. No gynecological pathology b. Polycystic ovarian disease c. Endometriosis d. Uterine fibroids Answer: A nineteen-year-old with primary dysmenorrhea will most likely have no gynecological pathology on examination.

3. A thirty-year-old female has secondary dysmenorrhea from endometriosis. What treatment will most likely resolve the symptoms? a. Acetaminophen b. Ibuprofen c. Oral contraceptive medication d. Simple hysterectomy Answer: c. The best treatment for secondary dysmenorrhea from endometriosis is oral contraceptive medication. The other treatments will be ineffective in managing menstrual pain from endometriosis.

4. The woman has a normal menstrual cycle. On what menstrual day is she most likely to ovulate? a. Day ten b. Day fourteen c. Day seventeen d. Day twenty-one Answer: b. The woman with a normal menstrual cycle will most likely ovulate on day fourteen of the cycle.

5. A woman has a normal menstrual cycle. On what menstrual day is she likely to start her menstrual flow?

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a. Day one b. Day five c. Day ten d. Day fourteen Answer: a. The time in a woman’s cycle in which the menstrual flow starts is on day one.

6. The condition in which a woman has extremely painful menses is known as what?

Oligomenorrhea Hypermenorrhea Dysmenorrhea Amenorrhea Answer: c. The gynecological condition in which a woman has extremely painful menses is known as dysmenorrhea.

7. The condition in which a woman has a complete absence of menstrual bleeding is known as what? a. Oligomenorrhea b. Hypermenorrhea c. Dysmenorrhea d. Amenorrhea Answer: d. The condition in which a woman has a complete absence of menstrual bleeding is called amenorrhea.

8. A woman is exclusively breastfeeding her infant. At what postpartum month is she likely to resume having her menstrual period? a. Six months b. Ten months c. Twelve months d. Fourteen months Answer: d. A woman who is exclusively breastfeeding will have a resumption of her menstrual period at an average of fourteen months postpartum.

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9. A menstruating woman desires a reusable method of controlling menstrual bleeding that will hold several hours of menstrual bleeding, even on heavy days. What choice of feminine hygiene product should she use? a. Draw sheet b. Tampon c. Sea sponge d. Menstrual cup Answer: d. The menstrual cup is a reusable silicone cup that is inserted into the vagina and absorbs about a half-days-worth of menstrual flow before being emptied, washed, and reused again.

10. A woman has a condition in which her menstrual flow happens sooner than every twentyone days. a. Menorrhagia b. Hypermenorrhea c. Polymenorrhea d. Metrorrhagia Answer: c. A woman who has menstrual periods sooner than every twenty-one days apart has a menstrual disorder known as polymenorrhea.

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