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OSD_Repro > Amenorrhea & Ovulation > Flashcards

Amenorrhea & Ovulation Flashcards

1
Q

Primary vs. Secondary Amenorrhea?

A

Primary:
No menses in a women who has never menstruated by
- 13 w/out secondary sexual characteristics or
- 15 w/ normal secondary sexual characteristics

Secondary:
Absence of menses after establishment of menstruation for reasons other than pregnancy, lactation or menopause.
- must be absent for at least 3 of previous menstrual intervals or 6 months

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2
Q

3 common, “normal causes” of Amenorrhea?

A

1) Pregnancy
2) Normal Menopause
3) Lactation

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3
Q

Compartment I - causes of Amenorrhea?

A

Asherman’s Syndrome (7%)

Compartment = Uterus → Menses

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4
Q

Compartment II - causes of Amenorrhea?

A

Primary:

  • Gonadal dysgenesis (0.5%)
  • Ovarian failure/destruction (10%)
  • – (Premature Ovarian Failure)

Secondary: Related to multiple karyotype abnormalities

Compartment = Ovary (E & P)

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5
Q

Compartment III - causes of Amenorrhea?

A

Prolactinoma (7.5%)
- also: Sheehan’s syndrome, Empty Sella syndrome, Hemochromatosis, & Sarcoidosis

Compartment = Ant. Pituitary (LH, FSH, TH)

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6
Q

Compartment IV - causes of Amenorrhea?

A
  • Anovulation (28%)
  • Anorexia (10%)
  • Chronic Stress (10%)
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7
Q

When to think Amenorrhea is caused by Compartment IV issue?

A

– Normal Pituitary (Prolactin, TH)
– Low to normal gonadatropins
– Failure to demonstrate withdrawal bleed

(Dx of exclusion)

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8
Q

How to Anorexia & Stress cause Anovulation?

A

↑ CRH & ↑ Endorphins → ↓GnRH, ↑Cortisol, ↓TSH

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9
Q

How does a Prolactinoma cause Amenorrhea?

A

Increased prolactin causes increased dopamine which suppresses GnRH

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10
Q

Empty Sella Syndrome - what is it?

A

Congenital incompleteness of the diagphram of the sella turcica

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11
Q

Definition of “Premature Ovarian Failure”?

A

Amenorrhea with persistent elevated FSH levels and hypoestrogenism prior to the age of 40.

This affects 1% of women.

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12
Q

Compartment II- Iatrogenic causes?

A

Chemotherapy or radiation therapy
(w/ chemo, Alkylating agents, specifically)

  • Karyotype should be done in women <30 yrs b/c likely chromosomal issue w/ them
    (Turners, Mosaicism, etc.)
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13
Q

Premature Ovarian Failure - Tx?

A

Counselling is critical. Women lose their natural fertility. Will need oocyte donors or surogates.

Hormone replacement is critical for bone protection

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14
Q

GnRH, LH, FSH, E,P all being produced in a regular, orderly fashion, yet still no menses…
Where is the problem?

A

Compartment I - Uterus

can be absent, abnormal, or have blocked outflow

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15
Q

Asherman’s Syndrome - Tx?

A

Surgery – may need multiple procedures to produce desired menses and allow for future pregnancies

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16
Q

Asherman’s Syndrome - how is Dx made?

A

Hysterosalpingogram or saline u/s

17
Q

What is Asherman’s Syndrome?

A

Presence of intrauterine adhesions, typically caused by surgery (iatrogenic)

18
Q

What is Mayer-Rokitansky- Kuster-Hauser syndrome?

A

Complete vaginal agenesis

  • also in 95% of these cases the uterus is also absent
  • Ovaries typically normal
19
Q

Mayer-Rokitansky- Kuster-Hauser syndrome — Dx?

A

Physical exam or Ultrasound

MRI if ultrasound not available

20
Q

Most common obstructive condition of the female reproductive tract?

A

Imperforate Hymen

21
Q

Imperforate Hymen - pathology?

A

Inferior aspect of the vaginal plate fails to open – causing this defect

22
Q

Imperforate Hymen - Dx?

A

Dx typically made at birth
- infants will have mucocopos

  • if not @ birth, will be diagnosed at puberty with hematocolpos (pt will have pain and will see a bulging blue mass on vaginal exam)
23
Q

Female patient presents @ puberty w/ pain & a bulging blue mass on vaginal exam (hematocolpos). What is likely Dx?

A

Imperforate Hymen

though this is typically diagnosed @ birth

24
Q

Imperforate Hymen - Tx?

A

Surgery

25
Q

Transverse Vaginal Septum - Cause?

A
  • Incomplete vertical fusion of the caudal aspect of the sinus tubercle and sinovaginal bulbs
  • Can also be caused when the vaginal plate fails to canalize
  • Can be at any level of the vagina

(extremely rare)

26
Q

Which compartment is responsible for the majority of causes of amenorrhea?

A

Compartment IV

27
Q

What is the order of the algorithm in Amenorrhea workup?

A
  1. Pregnancy test
  2. Prolactin & TSH levels
  3. Progestin challenge
  4. FSH & LH

→ suspect Uterus

  • Stimulate uterus with E + P
  • Image uterus
  • If physical exam initially revealed blind pouch, would proceed to karyotype
28
Q

PCOS - Sx?

A

– Oligomenorrhea/ Amenorrhea
– Hyperandrogenism
– Polycystic Ovaries

29
Q

PCOS - ass’d metabolic findings?

A
  • Insulin Resistance
  • Hyperinsulinemia
  • Hyperandrogenism
  • – Hirsuitism
  • – Acanthosis Nigricans
  • Obesity
30
Q

PCOS - Dx?

A

The Diagnosis is Clinical!

• Patient must have 2/3 main features:

  • Oligomenorrhea
  • Hirsuitism
  • Polycystic Ovaries

• Oligomenorrhea is the hallmark symptom

31
Q

PCOS - ______ is the hallmark symptom.

A

Oligomenorrhea

32
Q

PCOS - ass’d lab findings?

A
  • Increased LH:FSH
  • Increased insulin levels (due to resistance)
  • Increased testosterone levels
  • Positive 2hr GTT or other diabetic screening

(though these are not req’d for Dx)

33
Q

PCOS increases risk of what 3 clinical events?

A
  • Endometrial cancer
  • CV disease
  • Diabetes
34
Q

PCOS - Tx?

A
  • Weight loss, diet, & exercise
    (10% or greater loss will initiate normal menses in 80% of women)
  • Oral Contraceptives (if not interested in pregnancy)
  • Antiandrogens: Spironolactone, finasteride or flutamide
    (avoid in pregnancy)
  • Metformin (if interested in pregnant or Diabetic — only deemed Diabetic after OCPs started & attempts made @ weight loss)
35
Q

Is Metformin a 1st-line agent in PCOS?

A

No, it should only be used in patients that:

  • want to get pregnant as it helps increase odds
  • are Diabetic (only deemed Diabetic after weight loss attempts are made & OCPs started)
36
Q

Surgical Tx for PCOS?

A
  • Ovarian Drilling
  • Ovarian Wedge Resection

(though both are controversial)

37
Q

By what mechanism does hypothyroidism cause amenorrhea?

  1. Low thyroxine
  2. High LH
  3. High dopamine
  4. High prolactin
A
  1. High prolactin
38
Q

Dx?

Amenorrhea with persistent elevated FSH levels and hypoestrogenism prior to the age of 40.

A

Premature Ovarian Failure

39
Q 
Dx?
Women w/ combo of 2/3 of these:
- Hirsuitism
- Oligomenorrhea
- Polycystic ovaries
A

Polycystic Ovarian Syndrome

OSD_Repro (15 decks)

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