Amenorrhea and Uterine Bleeding Flashcards
Abnormal Uterine Bleeding
bleeding outside normal physiologic menstruation
- includes both dysfunctional uterine bleeding and structural bleeding
Normal Menses
Duration - 2-7 days
Flow 3 hrs
Normal Cycle
Menses (day 0 to 8)
Proliferative (day 8-14) -> predominance of estrogen over progesterone –> building endometrium
Secretory/Luteal (day 14) -> begins after ovulation -> progesterone production, stabilize endometrium
Menorrhagia
normal intervals, but prolonged or excessive
Metrorrhagia
irregular and more frequent intervals but amount is variable
Menometrorrhage
prolonged and variable amounts
Oligomenorrhea
menses interval greater than 35 days
Polymenorrhea
menses interval less than 24 days
Intermenstrual bleeding
bleeding between regular periods
Midcycle spotting
just prior to ovulation from declining estrogen
Postmenopausal bleeding
bleeding in woman at least 1 year after cessation of cycles
Amenorrhea
lack of bleeding for 6 months or longer
- overall prevalence 3% - not due to pregnancy, lactation, or menopause
Primary amenorrhea
no spontaneous uterine bleeding by age 14 in absence of secondary sex characteristics
Secondary amenorrhea
absence of menstrual bleeding for 6 months in woman with prior menses
Compartment I
disorders of outflow tract
- imperforate hymen
- Ashermans Syndrome - destruction of endometrium (D&C, ablation, infection)
- Mullerian Anomolies - absent uterus, no vaginal orifice
- Testicular Feminization - 46 XY
Compartment II
disorders of ovary
- Turner Syndrome - 46 XO - follicles undergo apoptosis (higher FSH, lower estrogen)
- Mosaicism
- Gonadal agenesis
- 17 alpha-hydroxylase deficiency
Compartment III
disorders of Anterior Pituitary
- Adenoma (hyperprolactinemia)
- Empty Sella Syndrome
- Sheehans syndrome
- Hypopituitarism
- Hypothyroid
- Infiltrative (sarcoidosis/hemochromotosis)
Compartment IV
disorders of CNS or hypothalamus
- tumors
- craniopharyngioma
- stress -> increased cortisol -> decreased FSH/LH
- hypothalamic amenorrhea -> high corticotropin releasing hormone -> inhibits GnRH
Evaluation of Amenorrhea
Menstrual history -> age, previous patterns
Reproductive history -> BCPs, ob/gyn procedures, preg?
General Medical history -> meds, illnesses, drugs
Family History -> sisters, mom
Social history
Physical Exam
COMPLETE PHYSICAL
- androgen excess, estrogen deficiency or excess
Labs
RULE OUT PREGNANCY - hCG Prolactin FSH TSH hypogonadism? -> testosterone, 17-hydroxyprogesterone, DHEA
Treatment of Amenorrhea
NEED CLEAR DIAGNOSIS
- hypothyroid
- ovarian failure
- pituitary tumor
- hypothalamic amenorrhea
Causes of abnormal bleeding
Pregnancy Medications Benign Genital Tract Pathology Malignant Genital Tract Pathology Systemic diseases Iatrogenic
Anovulatory Bleeding
more unpredictable
disturbance of normal HPO axis
progesterone deficient/estrogen dominant state
more common in extremes of reproductive years
no ovulation –> no corpus luteum –> endometrium instability leading to erratic bleeding
