1 · Menstrual Cycle & Menstrual Disorders

Cervicitis: mucopurulent discharge, friable cervix , postcoital bleeding; usually chlamydia/gonorrhea (NAAT); treat empirically (ceftriaxone + doxycycline) and the partner.
Cervical dysplasia: from HPV 16 &amp; 18 ; affects the transformation zone ; smoking is a cofactor. HPV vaccine at 11\u201312 (can start at 9).
Pap screening: start at age 21 ; every 3 years 21\u201329 ; every 5 years with co-testing (Pap+HPV) 30\u201365 . ASC-US/LSIL \u2192 reflex HPV; HSIL/CIN 2\u20133 \u2192 colposcopy \u2192 LEEP/cryotherapy.

The cycle that anchors everything — and the four disorders (amenorrhea, dysmenorrhea, PMS, AUB) built on top of it.

Phase	What happens
Follicular (day 1 = 1st day of bleeding)	FSH → follicle growth; estradiol rises, builds endometrium
Ovulation	Estradiol surge → LH surge → ovulation (~day 14)
Luteal	Corpus luteum → progesterone ↑ (secretory endometrium); if no pregnancy, progesterone falls → menses

Type	Definition & causes
Primary	No menses by age 15 (or 13 with no secondary sex characteristics). Causes: Turner (XO), androgen insensitivity (breasts, no uterus), imperforate hymen, Müllerian agenesis, constitutional delay.
Secondary	Previously menstruated, now absent ≥3 months. #1 = pregnancy; also PCOS, thyroid disease, hyperprolactinemia, weight loss/exercise (hypothalamic), Asherman.

⭐ Any secondary amenorrhea → check a pregnancy test first. Then TSH and prolactin before deeper workup.

Dysmenorrhea — Primary: begins with menarche, no pelvic pathology, prostaglandin-mediated; peaks ~24 h after onset. Treat: NSAIDs, OCPs. Secondary: new/older onset from a structural cause (endometriosis, adenomyosis, fibroids, PID, IUD) — treat the cause.
PMS/PMDD: symptoms in the luteal phase, resolve at onset of menses; PMDD causes functional impairment (treat with SSRIs).
Abnormal uterine bleeding — FIGO PALM-COEIN: PALM (structural) = Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia; COEIN (non-structural) = Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not-classified. Workup: hCG, CBC, TSH, pelvic US; endometrial biopsy if >45 or risk factors. Treat: OCPs/progestins/LNG-IUD, tranexamic acid; surgery for structural causes.