AUB/Puberty Flashcards
Prolonged heavy bleeding that may lead to anemia
Menorrhagia
Irregular bleeding between periods
Metrorrhagia
Prolonged, heavy irregular bleeding
Menometrorrhagia
Bleeding that occurs less than every 35 days
Oligomenorrhea
Bleeding that occurs more than every 21 days
Polymenorrhea
Structural causes of AUB
P- Polyps (intermenstrual bleeding)
A- Adenomyosis (chronic pain)
L- Leiomyomas (fibroids usually benign treat with Ulipristol)
M- Malignancy or Hyperplasia
Non-structural causes of AUB
C- Coagulopathy (Von Willebrand, hx of heavy bleeding since menarche)
O- Ovulatory dysfunction (irregular, short cycle) Normal for adolescents, will improve after 2 yrs
E- Endometrial causes
I- Iatrogenic (post-GYN surgery, HRT, contraceptives)
N- Not otherwise classified (PID, cervicitis, trauma, endometritis)
Non-pregnant bleeding that is irregular in timing, frequency, or flow
AUB
The most common cause of AUB during reproductive years
Abnormal pregnancy- threatened abortion, incomplete abortion, ectopic pregnancy
Labs and diagnostics with AUB
Physical exam along with : UPT/HCG CBC- for anemia Prolactin, FSH/LH, androgens Thyroid function Coag studies STI screening
Procedure to rule out endometrial hyperplasia or cancer in high-risk women >35 and in young women who are at extreme risk for endometrial hyperplasia/carcinoma
Endometrial biopsy
Most AUB is due to
Ovulatory Dysfunction
AUB is considered an _________ diagnosis
exclusion
Treatment for AUB is determined by
hemodynamic status and degree of anemia
Antifibrinolytic used to treat heavy bleeding
Tranexamic acid
True or False: Patients who are trying to conceive should not use tranexamic acid
False- TXA is safe to use while trying to conceive
Contraindications with use of tranexamic acid
history of clot
Treatment for menorrhagia
NSAIDs, mefenamic acid
This medication is contraindicated for patients with PUD or coagulation issues
Mefenamic acid
Treatment for irregular/light bleeding
Medroxyprogesterone acetate PO x 10 days. May repeat if successful.
Heavy bleeding <3months with normal HgB
Mild- observe patient, instruct to keep a menstrual calendar, encourage use of NSAIDs aka Antiprostaglandin (decreases menorrhagia)
Heavy, frequent bleeding every 1-3 weeks with mild anemia
Moderate- taper monophasic OCP (Ethinyl estradiol/norgestrel) AND an antiemetic; cycle 3-6 months
Limit and stabilize endometrial growth
Progestins
If estrogen use is contraindicated to control bleeding this medication is an alternative
norethindrone
Prolonged heavy bleeding with HgB <9
Severe- treat at home with taper OCP (Ethinyl estradiol/norgestrel) every 4 hours until bleeding subsides. Rx iron supplement and antiemetic
Intractable heavy bleeding treatment
GnRH agonist leuprolide IM monthly for up to 6 months (medical menopause) Requires 2-4 weeks to stop bleeding. DOES NOT stop bleeding acutely.
Admit to the hospital when HgB < than
7 and/or orthostasis, unable to tolerate PO
Treatment for bleeding unresponsive to medical therapy
levonorgestrel releasing IUD- Mirena
Endometrial ablation
Hysterectomy- last resort
95% of AUB/DUB in adolescents is due to
Anovulation
Injectable progesterone SE
weight gain, reduction in bone mineral density
1st measurable sign of puberty in girls
Growth spurt
1st measurable sign of puberty in boys
scrotal and testicular enlargement usually between 10-12 years old
Growth spurt begins ____ years earlier in girls
2
50% pubertal timing is related to
genetics and ethnicity
Peak height girls
11.5-12 years old
Peak height boys
13.5-14 years old
SMR- No breast or pubic hair
Stage 1
SMR- breasts are fully developed, contours distinct with the areola. Pubic hair inverted triangle pattern
Stage 5
SMR- breast buds present; straight, fine hair
Stage 2
SMR- Nipple/areola form separate mound; adult-like hair limited to area, not on thighs
Stage 4
SMR- Breasts/areola grow no separation between the contours of 2 breasts; hair is darker, coarse, curlier and spreads sparsely over
Stage 3
SMR- infantile state, genitalia increases slightly in size but little change in appearance; no true pubic hair
Stage 1
SMR- Penis is adult size; hair fully distributed
Stage 5
SMR- scrotal enlargement, change in color of scrotal skin; hair at the base of the penis
Stage 2
SMR- Penis has increased in length; hair spreads over the pubic symphysis more curly, coarse
Stage 2
SMR- Penis grows longer and width increases; hair adult in character but limited to area, not on thighs
Stage 4
Missing X chromosome, infertile
Turner Syndrome
Extra X chromosome, low sperm count, feminine physical characteristics
Klinefelter’s Syndrome
Pubertal development (more common in girls) occurring below the age limit set for normal onset of puberty that occurs before age 8 in Caucasian females and 7 in AA/Hispanic. Age of onset may be advanced by obesity.
precocious puberty
Obtain these lab values in girls who present with pubic and/or axillary hair but no breast development
Androgen levels and 17-hydroxyprogesterone
Central precocious puberty is an issue occurring with
Brain/Pituitary
Peripheral puberty is an issue occurring with
ovaries, testes, adrenals
Precocious puberty in boys occurs at what age?
less than 9
Signs of central precocious puberty in girls
breast development and tall for age
Obtain this imaging to determine bone age
Xray of left hand and wrist. If bone age >2yr older than age expected= peripheral puberty
If diagnosed with central precocious puberty, the clinician should order this study to rule out CNS lesions in boys
MRI of brain
True or False: Accelerated growth and skeletal maturation are indicative of final adult stature.
False: skeletal maturation advances at a more rapid rate than linear growth, final adult stature may be compromised.
Treatment for central puberty to increase final projected height
leuprolide IM monthly or histrelin subdermal implant replaced annually
With central precocious puberty, the clinician would expect LH/FSH levels to be increased or decreased?
Increased
Puberty is considered delayed in girls if no pubertal signs by age ____ or menarche by _____.
13, 16
With peripheral precocious puberty, the clinician would expect LH/FSH levels to be increased or decreased?
decreased
Puberty is considered delayed in boys if no pubertal signs by age ____ or >5yrs has elapsed since 1st sign without progress.
14
Central hypogonadism
HYPOgonadaltrophic
Brain issue
Decreased LH/FSH
Causes: stress, poor nutrition, excessive exercise, Kallmann Syndrome, hypothyroidism
Girls: prolactinemia
Boys: lesions; hyperprolactinemia
Treatment: determine if functional or permanent and refer to Endocrinology
Primary Gonadal Failure
HYPERgonadaltrophic
Testes/Ovary issue
Increased LH/FSH but decreased response
Girls: Turner Syndrome (XO) missing X chromosome
Boys: Klinefelter Syndrome (XXY) extra chromosome
Treatment: Monthly IM testosterone for boys and PO estrogen first then add progesterone after 18-24 months for girls
Constitutional Delay
MOST COMMON
50% of cases r/t family hx/ethnicity
Can be caused by excessive exercise or poor nutrition
Treatment: reassurance
This type of delay is diagnosed if short stature and normal growth velocity is shown on the growth chart
Constitutional growth delay
Why is the Estrogen component is necessary for the treatment in hypogonadal patients?
Promotes bone mineralization and prevents osteoporosis
Why is progesterone therapy needed in combination with estrogen in delayed puberty?
counteracts the effects of estrogen on the uterus; promotes endometrial hyperplasia
Undescended testes that affect 2-4% of male newborns, may lead to infertility and testicular malignancy if left untreated.
Cryptorchidism- surgical orchidopexy should be performed if descent has not occurred by 6-12 months
A common, self-limited condition that occurs in 75% of normal pubertal boys
Gynecomastia
Gynecomastia typically resolves in ____ years and is more common in _____ boys.
2, obese
Treatment for gynecomastia
Antiestrogens and aromatase inhibitors may be beneficial if initiated early.
