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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
Q

What are the dx studies for PCOS?

A
  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
Q

How is PCOS dxed?

A 
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
Q

What is seen on ovarian USN with PCOS?

A

“string of pearls”

28
Q

How is PCOS treated?

A 
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
Q

Define infetility

A

Inability of a couple to conceive after 1yr of unprotected intercourse

30
Q

What are the risk factors for infertility?

A
  1. Hx pelvic surgery
  2. Hx PID
  3. Testicular atrophy/gonadal dysgenesis
  4. Cervical stenosis
  5. cervicitis
31
Q

What are the types of female infertilty?

A
  1. Ovulatory dysfunction
  2. Structural
  3. Cervical
32
Q

What is the pathophys of ovulatory dysfunction?

A
  1. dec Quantity/quality of oocytes

2. Begins ~ 30 yr w/rapid decline after 40 yr

33
Q

What is the pathophys of structural infertility?

A
  1. Tubal obstruction
  2. Adhesions
  3. Asherman’s syndrome
  4. Fibroids
  5. Uterine malformations
  6. Endometriosis
34
Q

What is the pathophys of cervical infertility?

A
  1. Hx abnormal Pap smears
  2. Hx of conization/cryotherapy
  3. Postcoital bleeding
35
Q

What are the types of male infertility?

A
  1. Dec sperm production

2. Dec semen emission

36
Q

What is the pathophys of dec sperm production infertility?

A
  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
Q

What is the pathophys of dec semen emission infertility?

A
  1. Retrograde ejaculation into bladder due to DM
  2. Neurologic disorders
  3. Prostatectomy
  4. Obstruction
    A. Vas deferens or epididymis
38
Q

What ovulation testing is used for female infertility?

A
  1. BBT
    A. Confirms ovulation retrospectively
  2. Ovulation kits predict ovulation
    A. Detects LH surge occurring 24-36h prior to ovulation
39
Q

What imaging is used for female infertility?

A
  1. Pelvic USN
  2. Hystero-salpingogram
    A. Radiopaque dye injected into uterus & fallopian tubes to evaluate patency
40
Q

What labs are used for female infertility?

A
  1. FSH/LH
  2. Estradiol
  3. Prolactin
  4. TSH
  5. Progesterone
41
Q

How is the semen analyzed in male infertility?

A
  1. Volume
  2. Viscosity
  3. pH
  4. Fructose
  5. Gross/microscopic appearance
  6. WBC’s
  7. Sperm count
  8. Motility
  9. % normal morphology
42
Q

What are normal semen volume results?

A

Nl volume 2-6 ml, can be ↓ in problems w/accessory glands (seminal vesicles & prostate)

43
Q

What are the semen viscosity results?

A

Thick viscosity indicates infection of prostate & seminal vesicles

44
Q

What are the semen pH results?

A

Nl pH is alkaline; if acidic, problem w/seminal vesicle function

45
Q

What are the semen fructose results?

A
  1. Produced by seminal vesicles, energy for sperm

2. If fructose low, problem w/blockage at ejaculatory duct

46
Q

What are the semen gross microscopic results?

A

Clumping poor indicator as sperm are not free to travel through cervical canal

47
Q

What are the semen WBC results?

A

Few are normal, a lot indicate an infection

48
Q

What are the semen sperm count results?

A
49
Q

What are the semen motility results?

A

Graded A-D (A= fast, D= non-motile)

50
Q

What are the semen percent normal morphology results?

A

15% should have nl morphology

51
Q

How is infertility treated medically?

A
  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
Q

How is infertility treated surgically?

A 
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
Q

Define AI

A
  1. Intrauterine insemination
    A. Donor sperm
    B. Donor oocytes

Gen Med: Ob/gyn (13 decks)

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