Abnormal Uterine Bleeding 2

Question 1

What conditions are ovarian failure, chronic anovulation w estrogen absent and w estrogen present?

Answer 1

failure = hyper hypo
absent = hypo hypo
present = eugonadotropic eugonadism

Question 2

Which chromosomal disorders can cause amenorrhea?

Answer 2

Turners or 46 XX or 46 XY gonadal dysgenesis

Question 3

What is fragile X syndrome?

Answer 3

X linked dominant CGG unstable repeat that expands over generations
hypermethylation FMR1
55-200 repeats = premutation, >200 = full
correlation w POF

Question 4

What iatrogenic or infectious causes are there for POF?

Answer 4

surgery, radiation, chemo

mumps oophoritis

Question 5

When should autoimmunity be considered as a cause of POF?

Answer 5

when no other source found - screen for other autoimmune disorders

Question 6

What are more minor causes of POF?

Answer 6

galactosemia (AR, 85% get POF)
enzymatic (17alpha hydroxylase def)
idiopathic

Question 7

What are the etiologies of chronic anovulation with estrogen low or absent (hypo hypo)?

Answer 7

functional
inherited hypothalamic-pituitary abnormalities - Kallman's syndrome (no sense of smell), idiopathic hypo hypo
hypothalamic-pituitary lesions
hyperprolactinemia
thyroid dz
chronic illness

Question 8

Will women with hypo hypo experience withdrawal bleeding after progesterone treatment?

Answer 8

no - endometrium thin b/c no estrogen stimulation

Question 9

What are the etiologies of chronic anovulation with estrogen present?

Answer 9

PCOS
hyperprolactinemia
thyroid dz
tumors (ovarian or adrenal) - production of excess estrogen or androgens can interfere w axis
chronic illness - ESKD, malignancy, malabsorption

Question 10

What are the Rotterdam criteria for diagnosing PCOS?

Answer 10

affected individuals must have two out of following three:

oligo- or anovulation (12 cysts of 10 ml) - only needs to be in 1

Question 11

What are the long-term health risks associated with PCOS?

Answer 11

oligo-anovulation: menstrual irregularities, infertility, endometrial hyperplasia/cancer
metabolic disorders: insulin resistance/diabetes, dyslipidemia/CV dz
pregnancy complications
depression, anxiety
sleep apnea
NAFLD

Question 12

What kinds of menstrual abnormalities are seen in pts with PCOS and oligo-anovulation?

Answer 12

pts can have long periods w no bleeding followed by severe menorrhagia at unpredictable intervals = estrogen withdrawal bleeding
ovarian androgens converted to estrogens resulting in negative feedback and endometrial thickening
bleeding does not equal ovulation!

Question 13

What are the features of hyperandrogenism in PCOS leading to hirsutism and acne?

Answer 13

LH:FSH = 2:1 or 3:1 - LH drives androgen production, abnormal feedback
not virilism!
intraovarian androgens rise and androgen dominant follicles fail to develop

Question 14

What factors can affect androgen action in PCOS?

Answer 14

end organ sensitivity
genetic differences in concentration of hair follicles or 5alpha reductase activity, androgen metabolism or receptor activity
reduced SHBG levels can elevate free testosterone levels and lead to normal total testosterone

Question 15

What pregnancy complications are pts with PCOS at risk for?

Answer 15

miscarriage (2X normal rate) - maybe increase in circulating insulin
gestational diabetes, pregnancy induced HTN, pre-ecclampsia

Question 16

How does the progesterone challenge test help distinguish between different causes of amenorrhea?

Answer 16

withdrawal bleed positive = estrogen present (PCOS)

withdrawal bleed negative = estrogen absent, check FSH

Question 17

What are the basic approaches to treatment of hormonal causes of abnormal menstrual bleeding?

Answer 17

treat underlying dz (dopamine agonist or TH replacement)
if not making estrogen, give it to protect against osteoporosis
if making or receiving estrogen, also need progesterone to control endometrial hyperplasia (OCPs)
ovulation induction if want to be pregnant
weight reduction if overweight
control insulin resistance and lipid abnormalities (metformin common)