B8-062 CBCL Female Missed Period Flashcards
[…] withdrawal leads to the bleeding and sloughing of endometrial tissue
progesterone
in hypergonadotrophic hypogonadism, FSH and LH levels are […]
normal
(ovary is not responding to produce estrogen/progesterone)
in hypogonadotropic hypogonadism, FSH and LH levels are […]
both low
(leads to insufficient estradiol/progesterone production in the ovaries)
how does elevated cortisol due to stress cause primary hypothyroidism?
decreased TRH and TSH
and inhibits the conversion of T4 to T3
how does stress impact the menstrual cycle and cause anemorrhea?
stress stimulates PVN in hypothalamus to increase CRH synthesis
CRH –> ACTH –> cortisol
Cortisol inhibits GnRH release —> decreased FSH –> decreased estrogen
how does hypothyroidism impact the menstrual cycle leading to amenorrhea?
low T3/T3 stimulates TRH release
TRH stimulates prolactin release
Prolactin stimulates CRH release
CRH inhibits GnRH release
–> decreased FSH —> decreased estrogen
how does hyperthyroidism impact the menstrual cycle leading to amenorrhea?
high T3/4 triggers SHBG
SHBG binds circulating estrogen
reduced free estrogen
how does starvation impact the menstrual cycle leading to amenorrhea?
reduced caloric intake –> reduced adipose mass –> reduced leptin
reduced leptin —> reduced kisspeptin –> reduced GnRH release
reduced GnRH –> reduced FSH –> reduced estrogen
reduced leptin and elevated FGF21 from the liver causes reduced […]
kisspeptin
2 causes of hyperprolactemia causing amenorrhea
pregnancy
breast feeding
(elevated prolactin inhibits GnRH)
what hormones are responsible for breast development? [2]
estrogen
progesterone
(from ovary, can be used to determine cause if one stage of Tanner development lags behind another)
what hormones are responsible for pubic hair development? [2]
androgens
DHEA
(from adrenal gland, can be used to determine cause if one stage of Tanner development lags behind another)
major causes of amenorrhea [6]
outflow obstruction
POI
pituitary
hypothalamic
physiologic
endocrine
medication classes that can cause amenorrhea [3]
antidepressants
antipsychotics
opiates
[what Tanner stage]
no pubic hair
flat chest with raised nipple
Stage 1 prepubescent
[what Tanner stage]
pubic hair appears
breast bud forms
Stage 2 (8-11.5 years)
[what Tanner stage]
coarsening of pubic hair
breast enlarges
Stage 3 (11.5-13 years)
[what Tanner stage]
coarse hair across pubis, sparing thigh
breast enlarges, raised areola
Stage 4 (13-15 years)
[what Tanner stage]
coarse hair across pubis and medial thigh
adult breast contour, areola flattens
Stage 5 (over 15 years)
in what Tanner stage do 2/3 of female reach menarche?
stage 4
definition of primary amenorrhea
no menarche by age 14 in the absence of pubertal development
OR
no menarche by 16 regardless of pubertal development
inadequate release of LH and FSH from the pituitary
hypogonadotropic hypogonadism
inadequate ovarian response to gonadotropins
hypergonadotropic hypogonadism
growth parameters important to assess in evaluation of primary amenorrhea [2]
BMI
short stature
absent breast development indicates inadequate […] production
estrogen
absence of uterus is caused by [2]
abnormal Mullerian development
XY karyotype
presence of uterus and breast with primary amenorrhea suggests [2]
obstruction of menstrual flow
HPO axis problems
what hormone levels are evaluated in primary amenorrhea?
androgens
thyroid
prolactin
treatment of hyper/hypogonadotropic hypogonadism
estrogen & progesterone therapy
absence of menses for > 6 months in previously menstruating female
secondary amenorrhea
secondary amenorrhea is generally caused by
disruption of HPO axis
clitoromegaly can result from excess
androgens
organic causes of secondary amenorrhea [5]
prolactinoma
hyper/hypothyroidism
PCOS
late onset congenital adrenal hyperplasia
virilizing tumors
what is considered a positive response to a progesterone challenge test?
bleeding that occurs within 2 weeks after progestin is given
usually occurs within 2-7 days
(more than light spotting)
what does positive response to a progesterone challenge test mean?
patient likely has anovulation
consider PCOS
what does negative response to a progesterone challenge test mean?
consider HPO axis or obstructive problem
treatment for PCOS
oral contraception
(restores regular menses, decreases testosterone, and protects against endometrial hyperplasia)
most common site of implantation in ectopic pregnancy?
ampulla
risk factors for ectopic pregnancy
tubal pathologies (scarring, PID)
previous ectopic pregnancy
IUD
IVF
implantation of the fertilized ovum in a site other than the uterus
ectopic pregnancy
suspect in patients with history of amenorrhea and lower than expected rise in hCG
ectopic pregnancy
diagnosis of ectopic pregnancy can be confirmed via
ultrasound
treatment for ectopic pregnancy
methotrexate (unruptured)
surgery (ruptured)
ectopic pregnancy implanted in the […] presents the highest risk of tubal rupture
isthmus
spontaneous abortion in the first trimester is most often caused by
chromosomal abnormalities
the process of menstruation is brought about by what hormonal change?
decreased progesterone
estrogen and progesteron stimulate […] development
breast
androgens and DHEA stimulate […] development
pubic hair
the most common cause of amenorrhea in women of child bearing age
pregnancy
primary amenorrhea in patients without secondary sex characteristics is typically due to
anovulation
[…] replacement therapy may be effective for female athletes suffering from hypothalamic amenorrhea
leptin
primary amenorrhea due to absence of the uterus is most likely a result of [2]
abnormal Mullerian development
XY karyotype
first line therapy in treating female athletes with hypothalamic dysregulation
modification of diet/exercise
a prolactinoma would cause […] prolactin and […] estrogen levels
high prolactin
low estrogen
a positive progesterone challenge test indicates a likely […] problem
anovulation
elevated levels of TRH lead to […] levels of prolactin
elevated
prolactin inhibits […] production by the hypothalamus
GnRH
classic clinical triad for ectopic pregnancy
abdominal pain
amenorrhea
vaginal bleeding
MOA of methotrexate
deplete embryo of folic acid
(stops growth)
in the case of inevitable SAB/misscarriage, the cervix would be […] and the POC passage would be […]
open
retained
in the case of missed SAB/misscarriage, the cervix would be […] and the POC passage would be […]
closed
retained
in the case of incomplete SAB/misscarriage, the cervix would be […] and the POC passage would be […]
open
partially passed
testes present, but external genitalia is feminized or atypical
46, XY androgen insensitivity syndrome
gonadal dysgenesis
female appearing genetic male (46, XY) is most commonly due to
androgen insensitivity syndrome
ovaries replaced by fibrous tissue
no ovarian estrogen secretion
(streak ovary)
turner syndrome (45, XO)
external female genitalia, uterus, and fallopian tubes develop normally until puberty when estrogen induced maturation fails
turner syndrome (45, XO)
acquired condition of having scar tissue in the uterus or cervix which impedes menstruation
Asherman’s syndrome
how does hypothyroidism cause galactorrhea?
low T4 and T3 lead to increased TRH and prolactin
increased prolactin causes excess milk production
insomnia, mood swings, and weight loss are symptoms associated with
hyperthyroidism
how does hyperthyroidism cause amenorrhea?
increased T3/4 increase hepatic production of SHBG
reduces amount of biologically active estrogen
b-hCG leves should double every […] hours in pregnancy
48
corticosteroids inhibit […] which causes amenorrhea
GnRH
hypogonadotrophic hypogonadism is characterized by […] E2 and […] FSH
low
low
how does stress cause amenorrhea?
stress increases CRH which increases ACTH and cortisol
cortisol decreases GnRH and FSH/LH
untreated imperforate hymen may lead to the development of
endometriosis
most common symptoms of imperforate hymen
abdominal pain
cramping
patients on dopamine antagonists can experience hyper[…]
hyperprolactinemia
(above 25 ng/ml)
scaring/adhesion within the uterus/endometrium often caused by procedures such as D&C or untreated STI
asherman’s syndrome
breastfeeding stimulates […] release, leading to amenorrhea
prolactin
grave’s disease and hyperthyroidism are characterized by […] TSH and […] free T4
low TSH
high free T4
anti-psychotics increase prolactin by blocking […] production
dopamine
risk factors for ectopic pregnancy
GYN surgery
smoking
PID or other scarring
prenatal exposure to DES
high levels of […] during pregnancy prevent menstruation
progesterone
