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Gen Med: Ob/gyn > Amenorrhea/PCOS/Infertility > Flashcards

Amenorrhea/PCOS/Infertility Flashcards

1
Q

Define primary amenorrhea

A
  1. No menses by age 16

2. Hypothalamo-pituitary-gonadal axis is dysfunctional

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2
Q

Define secondary amenorrhea

A

No menses ≥ 6 mo in previously menstruating female

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3
Q

What are the categories of primary amenorrhea?

A
  1. No 2° sex characteristics
    A. Gonadal agenesis → GnRH deficency → puberty delay
  2. Breast development but no pubic or axillary hair
    A. Androgen insensitivity
  3. Normal 2° sex characteristics
    A. Imperforate hymen, transverse vaginal septum
  4. Incompletely developed sex characteristics
    A. Tumor of hypothalamus, pituitary, premature ovarian failure
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4
Q

What are the types of secondary amenorrhea

A
  1. Central – hypogonadotropic hypoestrogenic anovulation
  2. Uterine – severe scarring replaces functional endometrium
  3. Premature ovarian failure
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5
Q

What are the causes of secondary amenorrhea?

A 
1. Pregnancy is most common cause
2, Anorexia 
3, Excessive exercise
4. Severe stress
5. Acute wt loss (suppresses hypothalamus)
6. PCOS
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6
Q

What are the sxs of secondary amenorrhea?

A
  1. Absence of menstruation
  2. Vasomotor flushes
  3. Vaginal atrophy
  4. Hirsutism
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7
Q

How is the cause of amenorrhea diagnosed?

A
  1. Urine/serum HCG in reproductive age women

2. Serum FSH, estrogen, prolactin, testosterone levels, TSH

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8
Q

What are the levels of FSH in the different types of secondary amenorrhea?

A
  1. ↑ in ovarian failure

2. ↓ in hypothalamic or pituitary dysfunction/tumor

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9
Q

What are the levels of TSH in the different types of secondary amenorrhea?

A
  1. ↑ in hypothyroidism

2. ↓ in hypothalamic or pituitary dysfunction/tumor

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10
Q

What are the levels of Total testosterone in the different types of secondary amenorrhea?

A

↑ in ovarian androgen producing tumor

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11
Q

What are the levels of prolactin in the different types of secondary amenorrhea?

A

if elevated, needs MRI of sella turcica R/O adenoma

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12
Q

What does the treatment of amenorrhea depend on?

A
  1. Depends on underlying cause of amenorrhea

A. 1° vs. 2°

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13
Q

What is the a progesterone challenge?

A
  1. Medroxyprogesterone (Provera) 5-10 mg QD x 5 days
    A. (+) menses → sx’s not due to estrogen deficiency or outflow obstruction
    B. (-) menses → check gonadotropin levels
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14
Q

When are OCPs given to treat amenorrhea?

A
  1. OCP if (-) progesterone challenge & normal estradiol/FSH levels
    A. (-) menses suggests endometrial abnormality
    -Asherman’s syndrome
    -Congenital outflow obstruction
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15
Q

What is clomiphene used for?

A

Clomiphene (Clomid) 50-100 mg po qd x 5 days (max 6 cycles)-ovarian stimulation if pregnancy desired

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16
Q

When is spironolactone indicated in amenorrhea?

A
  1. Spironolactone (Aldactone) 100-200 mg po QD – inhibits androgens
    A. Treats hirsutism
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17
Q

When is surgery indicated for amenorrhea?

A
  1. Refer for tumor evaluation & removal
    A. Ovarian
    B. Pituitary
    C. Adrenal
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18
Q

What pt education may be necessary for amenorrhea?

A
  1. Bleaching, electrolysis, plucking, waxing for excess hair growth (hirsutism)
  2. Treatment of excessive hair growth is slow & typically minimally responsive
  3. Risk/benefits/alternative to OCP’s
  4. Risk of endometrial CA assoc. w/obesity, unopposed estrogen
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19
Q

What is the pathophys of PCOS?

A

hypothalamic-pituitary dysfunction & insulin resistance

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20
Q

What can PCOS cause?

A
  1. Most common cause of androgen excess & hirsutism

2. ↑ Risk for endometrial hyperplasia & CA due to unopposed estrogen stimulation

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21
Q

What are the characteristics of PCOS?

A
  1. Bilaterally enlarged polycystic ovaries
  2. Amenorrhea
  3. Oligomenorrhea
  4. Infertility
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22
Q

What factors may contribute to PCOS?

A
  1. Hereditary
  2. Chronic low grade inflammation
    A. Stimulates androgen production
  3. ↑ Insulin 2° to resistance
23
Q

What are the sxs of PCOS?

A
  1. Truncal obesity
  2. Hirsutism
  3. Male-pattern baldness
  4. Menstrual irregularity (most common)
  5. Infertility
  6. Intractable acne
  7. Impaired glucose tolerance in 30% of pts
24
Q

What are the potential complications of PCOS?

A
  1. Type II Diabetes
  2. HTN
  3. Hyperlipidemia
  4. CAD
  5. Metabolic syndrome
  6. Nonalcoholic steatohepatitis — a severe liver inflammation caused by fat accumulation in the liver
  7. Infertility
  8. Sleep apnea
  9. Depression & anxiety
  10. DUB
  11. Endometrial cancer
  12. Gestational DM
  13. Pregnancy-induced 14. HTN
25
What are the dx studies for PCOS?
1. HCG 2. Pelvic USN A. May demonstrate characteristic “string of pearls” appearance w/in ovaries 3. ↑ LH:FSH ratio 4. ↑ Lipids 5. Insulin resistance A. 2 hr GTT 6. Serum dehydroepiandrosterone sulfate (DHEA-S) A. R/O adrenal source of hyperandrogenism
26
How is PCOS dxed?
``` 1. 2 out of 3 of following required to make Dx: A. Oligomenorrhea B. Hyperandrogenism -Acne -Hirsutism -Male-pattern hair loss -↑ serum testosterone C. Polycystic ovaries on USN ```
27
What is seen on ovarian USN with PCOS?
"string of pearls"
28
How is PCOS treated?
``` 1. Wt reduction A. Improves lipids, glucose & fertility 2. Hirsutism A. Tx w/androgen lowering agents -OCP -Spironolactone (Aldactone) -Eflornithine (Vaniqa) cream 3. Infertility A. Clomiphene citrate (Clomid) 4. Hyperlipidemia A. Statins 5. Insulin resistance A. Metformin ```
29
Define infetility
Inability of a couple to conceive after 1yr of unprotected intercourse
30
What are the risk factors for infertility?
1. Hx pelvic surgery 2. Hx PID 3. Testicular atrophy/gonadal dysgenesis 4. Cervical stenosis 5. cervicitis
31
What are the types of female infertilty?
1. Ovulatory dysfunction 2. Structural 3. Cervical
32
What is the pathophys of ovulatory dysfunction?
1. dec Quantity/quality of oocytes | 2. Begins ~ 30 yr w/rapid decline after 40 yr
33
What is the pathophys of structural infertility?
1. Tubal obstruction 2. Adhesions 3. Asherman’s syndrome 4. Fibroids 5. Uterine malformations 6. Endometriosis
34
What is the pathophys of cervical infertility?
1. Hx abnormal Pap smears 2. Hx of conization/cryotherapy 3. Postcoital bleeding
35
What are the types of male infertility?
1. Dec sperm production | 2. Dec semen emission
36
What is the pathophys of dec sperm production infertility?
1. Heat/fever 2. Drugs/toxins A. Anabolic steroids B. ETOH C. Recreational drugs 3. Deletions on Y chrom. 4. Endocrine disorders A. Hypothalamic-pitutary-gonadal axis 5. GU disorders A. Cryptorchidism B. Infection C. Trauma D. Mumps orchitis E. Varicocele
37
What is the pathophys of dec semen emission infertility?
1. Retrograde ejaculation into bladder due to DM 2. Neurologic disorders 3. Prostatectomy 4. Obstruction A. Vas deferens or epididymis
38
What ovulation testing is used for female infertility?
1. BBT A. Confirms ovulation retrospectively 2. Ovulation kits predict ovulation A. Detects LH surge occurring 24-36h prior to ovulation
39
What imaging is used for female infertility?
1. Pelvic USN 2. Hystero-salpingogram A. Radiopaque dye injected into uterus & fallopian tubes to evaluate patency
40
What labs are used for female infertility?
1. FSH/LH 2. Estradiol 3. Prolactin 4. TSH 5. Progesterone
41
How is the semen analyzed in male infertility?
1. Volume 2. Viscosity 3. pH 4. Fructose 5. Gross/microscopic appearance 6. WBC’s 7. Sperm count 8. Motility 9. % normal morphology
42
What are normal semen volume results?
Nl volume 2-6 ml, can be ↓ in problems w/accessory glands (seminal vesicles & prostate)
43
What are the semen viscosity results?
Thick viscosity indicates infection of prostate & seminal vesicles
44
What are the semen pH results?
Nl pH is alkaline; if acidic, problem w/seminal vesicle function
45
What are the semen fructose results?
1. Produced by seminal vesicles, energy for sperm | 2. If fructose low, problem w/blockage at ejaculatory duct
46
What are the semen gross microscopic results?
Clumping poor indicator as sperm are not free to travel through cervical canal
47
What are the semen WBC results?
Few are normal, a lot indicate an infection
48
What are the semen sperm count results?
49
What are the semen motility results?
Graded A-D (A= fast, D= non-motile)
50
What are the semen percent normal morphology results?
15% should have nl morphology
51
How is infertility treated medically?
1. Metformin w/ PCOS 2. Clomiphene (Clomid) A. Males –spermatogenesis -25 mg po QD x 25 days/mo B. Females-stimulates ovulation -50-100 mg po qd x 5 days up to 6 cycles 3. Bromocriptine or Cabergoline A. ↓ prolactin levels if high → ovulation 4. Human Chorionic Gonadotropin (hCG) injection A. Hormone similar to LH, triggers release of the eggs 5. Artificial Insemination 6. IVF
52
How is infertility treated surgically?
``` 1. Laparoscopy A. Ablation of endometriosis 2. Lysis of adhesions 3. Removal of fibroids 4. Hysteroscopy and D&C A. Evaluate inside of uterus for structural abnormalities B. Endometrial polypectomy ```
53
Define AI
1. Intrauterine insemination A. Donor sperm B. Donor oocytes

Gen Med: Ob/gyn (13 decks)

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