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MED: Women’s Health/Reproductive System > Amenorrhea > Flashcards

Amenorrhea Flashcards

1
Q

What is the menstrual cycle controlled by?

A

Menstrual cycle controlled by hormones produced by the hypothalamus, pituitary, and ovary.
Hypothalamus produces gonadotropin releasing hormone (GnRH)
Pituitary gland produces FSH and LH
Stimulates ovary to produce estrogen
After ovulation, ovary primarily produces progesterone

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2
Q

what is primary amenorrhea?

A

No menarche by age 16 with signs of pubertal development (breasts/pubic hair)
No onset on pubertal development by 14 yo

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3
Q

What is secondary amenorrhea?

A

Secondary Amenorrhea:
Absence of menstruation for 3 months or more in a previously menstruating woman of reproductive age
Absence of menstruation for 9 or more months in a woman with previous oligomenorrhea

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4
Q

What are common causes of primary amenorrhea?

A 
Chromosomal abnormalities
Hypothalamus abnormalities
Pituitary problems
Reproductive organ abnormalities
Structural abnormalities
Pregnancy (uncommon)
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5
Q

what is are the common causes of secondary amenorrhea? what is the most common?

A 
pregnancy is most common. other causes: 
Thyroid abnormalities
Pituitary abnormalities
Medications (inc. contraceptives)
Breast-feeding
Stress
Illness
Excessive exercise/low body weight
Polycystic Ovarian Syndrome (PCOS)
Premature menopause
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6
Q

Why should you eval a patient who has amenorrhea?

A 
Inability to conceive - anovulation
Lack of estrogen - osteoporosis
excess exercise
Eating disorders - life threatening
Pregnancy - early care, statutory rape
Pituitary tumors - life and sight threat
Adrenal or ovarian tumors
Psychosocial issues - related to body and menses
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7
Q

What info is important to gather from the patient’s history?

A 
Menarche and menstrual history
Sexual history
Medications or illicit drug use
Exercise - Weight Loss - Nutrition
Stress
Illness (chemo treatment)
Genetic defects
Infertility
Menarche history of mother and sisters
Growth delays
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8
Q

What labs are important for amenorrhea?

A 
Labs:
-Pregnancy test  (urine/serum)
-LH, FSH, Prolactin, TSH, T4, testosterone, progesterone, estrogen, DHEAS and Serum 17-hydroxyprogesterone (adrenal hyperplasia, Cushing's syndrome, PCOS/masculinizing ovarian tumors)
Diagnostics:
-Pelvic U/S (include transvaginal)
-MRI - head
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9
Q

What is Turner’s Syndrome?

A

Turner’s Syndrome: Genetic condition occurs only in females

  • 45 XO karyotype
  • Neck webbing, short stature
  • Congenital heart defects
  • No development of ovaries
  • Absence of secondary sexual characteristics - breast buds possible
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10
Q

How should you eval for Turner’s syndrome?

A

Pelvic exam
LH and FSH both HIGH
Karyotyping–> 45 XO karyotype
Pelvic U/S - reproductive organs and kidneys (see no development of ovaries)
EKG and echocardiogram (heart defects common)

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11
Q

What are the complications of Turner’s syndrome?

A

Complications:

  • Heart defects – coarctation, aortic valve disease, aortic dissection
  • Kidney abnormalities – horseshoe kidney
  • HTN / CVD
  • Obesity
  • Diabetes
  • Cataracts
  • Arthritis
  • Scoliosis
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12
Q

How do you treat Turner’s Syndrome?

A

Exogenous Estrogen

Human Growth Hormone

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13
Q

Describe delayed puberty:

A 
Common - 20%
Under stature and delayed bone age (wrist joint xray)
Positive family history
Diagnosis by exclusion and follow-up
Good prognosis - late developer
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14
Q

Is delayed puberty a primary or secondary cause of amenorrhea?

A

primary

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15
Q

What is a good way to use diagnostic imaging to check on delayed puberty? How about history questions to ask?

A

can use wrist joint X-ray to examine hand
could ask about a family history
THIS IS A DIAGNOSIS OF EXCLUSION

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16
Q

Describe Congenital Adrenal Hyperplasia:

A

-Inherited disorder
-Decreased cortisol and aldosterone production due to lack of enzyme needed
-Increased androgen production (male characteristics)
—>Puberty - voice deepens, facial hair
Ovaries, uterus, fallopian tubes present
–>possibly ambiguous genitalia
If severe type, can be fatal in newborn

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17
Q

What will you see on lab results that is suggestive of Congential Adrenal hyperplasia?

A
  1. Aldosterone and cortisol levels (LOW)
  2. High urinary 17-ketosteroids
  3. Electrolyte panel (“salt wasting” - low Na+, high K+)
  4. Karyotyping
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18
Q

How do you treat Congenital Adrenal Hyperplasia?

A
  1. Cortisol
  2. Reconstructive surgery of genitals (1-3 mo)
  3. Education and side effects of long-term steroid therapy
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19
Q

What is a Mullerian Defect?

A

Malformation of genital tract

absent hormone in embryonic development

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20
Q

What do you normally see with a Mullerian Defect?

A 
Normal breasts, pubic hair, normal external genitalia
Normal female range testosterone level
Absent vagina - normal ovaries
Karyotype 46-XX
15-30% skeletal and middle ear anomalies
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21
Q

What is the treatment for Mullerian Defect?

A

Treatment: Create vagina

***You may need to be aware of the skeletal and middle ear problems, could cause hearing issues or easily broken bones.

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22
Q

Is Mullerian Defect a Primary or Secondary amenorrhea?

A

primary

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23
Q

What is Outflow Tract Obstruction?

A

There are 2 types:

  1. Primary:
    Imperforate hymen
2. Secondary:
Secondary to curettage from surgery, to control heavy bleeding after delivery or abortion – “Asherman’s Syndrome”
walls of uterus become adherent
Cervical Stenosis
Fibroids
Polyps
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24
Q

How can Hyperprolactinemia cause amenorrhea?

A

It is a secondary cause. Causes include:

  1. Pituitary tumor (prolactinoma)
  2. Hypothyroidism
  3. Medications - antidepressants, antipsychotics, opiates, oral contraceptives
  4. Stress
25
Q

What are the signs and symptoms of hyperprolactinemia?

A

Galactorrhea, infertility, amenorrhea

26
Q

What labs are needed to diagnose hyperprolactinemia?

What is the treatment?

A

Prolactin level, TSH, MRI of pituitary gland

Treatment: Medical (dopamine agonists), surgical, radiation

27
Q

Describe Hypothyroidism:

A 
Signs/Sxs:
-Dry skin, fatigue, coarse hair, goiter, weight gain, "cold", memory problems, amenorrhea, constipation
Evaluation:
-TSH, free T4
Treatment:
-Levothyroxine
28
Q

What is Cushing’s syndrome?

A

Glucocorticoid excess:
1. Endogenous: secreted by the adrenal cortex
or
2. Exogenous: long-term steroids

29
Q

What are the signs and symptoms of Cushing’s?

A

Truncal obesity, moon facies, buffalo hump, amenorrhea, osteoporosis, hirsutism, acne, abdominal striae, HTN

30
Q

How do you evaluate for Cushing’s?

A

Corticotropin Releasing Hormone stimulation test
Dexamethasone suppression test
24-hour urine free cortisol level

31
Q

What is the treatment for Cushing’s?

A
  • Surgery if pituitary adenoma or adrenal tumor discovered

- Decrease steroid use if possible (if not, treat effects aggressively)

32
Q

What labs will be elevated in Premature Ovarian Failure?

what other signs/symptoms are present?

A

FSH AND LH LEVELS HIGH!!
Hot flashes, menopausal sxs, and increased risk of osteoporosis (so may have breaks).
(check TSH, glucose, and cortisol levels to help rule out other diseases)

33
Q

What is the treatment for Premature Ovarian Failure?

A

Oral contraceptives may help

34
Q

What is often the first sign of an eating disorder?

A

amenorrhea

35
Q

How do you want to evaluate for an eating disorder?

What is the treatment?

A

CBC, Electrolytes, TSH, free T4, FSH, LH
tx: Increase body weight
Not easy, intensive therapy and counseling
Family needs to be involved

36
Q

What is the female athlete triad?

A

Weight loss, Amenorrhea, Osteoporosis

Treatment:
Oral contraceptives
Ca+ and Vit D intake
Exercise moderation

37
Q

Describe PCOS

A

a common hormonal disorder among women of reproductive age. The name of the condition comes from the appearance of the ovaries in most, but not all, women with the disorder — enlarged and containing numerous small cysts located along the outer edge of each ovary (polycystic appearance)

38
Q

How do patients with PCOS present?

A 
Amenorrhea or oligomenorrhea most common
Obesity
Masculine body type
Hirsutism, acne
Glucose intolerance
39
Q

Describe what causes PCOS:

A

Underlying defect not well understood - prime underlying abnormality most likely pituitary
Increased GnRH secretion resulting in increased LH and LSH/FH ratio
Increased ovarian androgen production
Lack of ovulation, leads to endometrium with unopposed estrogen
Hyperinsulinemia is an independent contributory factor, association between POS and DM

40
Q

What is the workup for PCOS?

A

Exam:
Possibly enlarged ovaries

Evaluation:
Labs: lipids, fasting glucose, LH and LH/FSH ratio (3:1 - high probability), testosterone level, prolactin
Pelvic U/S: multiple ovarian follicles - “Pearl Necklace”

41
Q

What is the treatment for PCOS?

A

Treatment:
-Oral contraceptives or progestin-only
-Spironolactone (off-label) - androgen receptor antagonist
-Metformin - oral antidiabetic agent
reduces insulin resistance, may help with fertility
-GnRH analogs - Lupron
-Referral to Endocrinologist

42
Q

What is the first thing you should do for amenorrhea?

A

PREGNANCY TEST!!

if negative, then progesterone challenge

43
Q

What is the progesterone challenge?

A

10mg of progesterone for 10 days
If bleed…
1. amenorrhea due to anovulation
(consider PCOS, idiopathic–> may benefit from OCs)

If NO bleed…

  1. add estrogen to P by way of oral contraceptives.
    - –> if bleed= patient lacks sufficient estrogen, think ovarian failure or hypothalamic dysfunction
  2. if still no bleed –> then get LH, FSH, TSH, and prolactin level.
44
Q

In secondary amenorrhea, and no bleeding after progesterone challenge or estrogen being added…then what can you do?

A

-LH/FSH ratio > 3 = PCOS
-FSH >40 = premature ovarian failure, menopause
-Increased prolactin level = MRI, r/o pituitary tumor
-Increased TSH = Hypothyroidism
-Decreased FSH and LH = hypothalamic or thyroid malfunction
-Stress, weight loss, excessive exercise, eating disorder
(Treatment based on underlying disorder)

45
Q

What is dysfunctional uterine bleeding?

A

abnormal uterine bleeding in terms of quantity, frequency, duration, or regularity in the ABSENCE of pelvic disease, pregnancy, or medical illness.

46
Q

When is DUB most common? What is the most common cause?

A

Most common at menarche and peri-menopause
>90% due to anovulatory cycle
Patient usually presents with irregular and/or heavy flow affecting their lifestyle

DIAGNOSIS OF EXCLUSION

47
Q

What kind of diagnosis is DUB?

A

diagnosis of exclusion

48
Q

What is hypermenorrhea?

A

cycles regular and normal duration, blood loss excessive

49
Q

what is menorrhagia?

A

interval normal, excessive duration and flow

50
Q

what is metrorrhagia?

A

interval irregular, duration and flow excessive

51
Q

What is menometrorrhagia?

A

interval irregulation, duration and flow excessive and intermenstrual bleeding

52
Q

oligomenorrhea:

A

interval is >35 days

53
Q

polymenorrhea:

A

interval is <21 days

54
Q

hypomennorrhea:

A

cycles regular, blood loss abnormally decreased

55
Q

What are the two most common causes of DUB?

A

Anovulatory – estrogen breakthrough bleeding

  • Estrogen production unaccompanied by cyclic leutinizing hormone production leads to unopposed estrogen
  • Peri-menopause – gradual ovarian failure

Ovulatory

  • Persistent progesterone production
  • Prematurely decreased progesterone
  • Mid-cycle spotting due to decreased estrogen following ovulation
56
Q

What are some contributing factors to DUB?

A

Anxiety and stress
Body habitus (Obesity, anorexia)
Somatization
Smoking (Heavier periods)

57
Q

How do you treat DUB?

A 
Combination oral contraceptives
Cyclical progesterone (21-day cycle)
D&C
Endometrial Ablation
Hysterectomy
58
Q

In what patient population is OC considered high risk?

A

smokers older than 35

59
Q

Post-menopausal bleeding needs…

A

endometrial biopsy and U/S

MED: Women’s Health/Reproductive System (14 decks)

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