Bleeding Across the Lifespan Flashcards
Definition: normogonodotropic
normal amounts of gonadotropic hormones (GnRH, FSH, LH)
What produces GnRH?
What produces FSH/LH
- Hypothalamus produces GnRH
- Anterior pituitary produces FSH/LH
Define: Hypergonadotropic
higher than normal amounts of gonadotropic hormones produces
Define: Hypogonadotropic
lower than normal amounts of gonadotropic hormones produces
Define: Hypogonadism
lower than normal amounts of gonadal hormones (estrogen, progesterone, testosterone) produced
Define: Hyperprolactinemia
higher than normal amount of prolactin produced
What is more common primary or secondary ammenorrhea?
Secondary
Most common causes secondary amenorrhea
1) pregnancy
2) PCOS
3) hypothalamic amenorrhea
Other: hyperprolactinemia, POI
Risk factors of hypothalamic amenorrhea
a. low/poor nutrition
b. Excessive exercise (female athlete triad)
c. Severe stress (cortisol connection)
d. Thyroid disease
e. Medication induced (dopaminergic)
f. Chronic illness (celiac disease)
RF hyperprolactinemia
i. Tumors
ii. Empty sella syndrome (ESS)
iii. Cushing’s disease
iv. Sheehan syndrome
RF POI
i. Genetics
ii. Autoimmune
iii. Chemo/radiation
iv. Environment
v. Galactosemia (galactose deficiency)
Outflow disorders: primary amenorrhea
imperforate hymen, labial agglutination, transverse vaginal septum
General s/s outflow disorder
Cyclical abdominal pain arising from accumulated menstrual blood
S/s Mullerian anomalies & agensis (i.e. uterine anomalies)
i. Ovulation usually occurs when ovaries present
ii. Secondary sex characteristics are present
iii. Potential for painful intercourse/sexual activity d/t vaginal deviations, absence of cervix (decreased mucous)
iv. Normal steroid hormone production
v. Difficulty getting pregnant
Outflow disorder: secondary amenorrhea cuases
Asherman’s syndrome (scarring from procedure, hemorrhage, or infection)
Genetic conditions that cause primary amenorrhea
-Androgen insensitivity syndrome (AIS)
-Turner syndrome
-Pure gonadal dysgenesis
Do pituitary adenomas cause primary or secondary amenorrhea?
Both
What is POI?
depletion of oocytes before age 40
S/S POI
-high FSH
-irregular menses
-VMS
-Estradiol in menopausal level
consequences of female athlete triad?
early low bone density increases the risk of osteoporosis later in life
Sequelae of POI
i. Vasomotor symptoms: hot flashes, vaginal dryness
ii. Urogenital atrophy
iii. Osteoporosis and fracture
iv. Increase in CV disease (estrogen is cardio-protective)
v. Increase in all-cause mortality consider estrogen supplementation
Parameters of primary amenorrhea
- no menses by age 15 with normal growth and development of secondary sexual characteristics
- No menses 3 years past breast development
Parameters of secondary amenorrhea
Absence of menses for 3 cycle intervals or 6 months in a woman who has previously menstruated
ROS for amenorrhea
- Constitutional: hot flashes, night sweats
- Skin hair nails: lanugo anorexia; hirsutism & acne hyperandrogenism
- Eyes: visual changes
- Breasts: tenderness, galactorrhea
- Thyroid problems
- Cyclic pelvic pains?
Tanner staging review (primary amenorrhea) starting with Tanner 2 - 5
Tanner 2 breast budding
Tanner 3 areola is becoming darker
Tanner 4 nipples and areolas are elevated and form an edge towards the breast
Tanner 5 fully formed
Findings of Turner syndrome
Short stature, neck webbing, pigeon chest
Labs for amenorrhea
Pregnancy test
Serum prolactin
FSH/LH
TSH
estradiol –> for POI
Amenorrhea with low FHS/LH - what do you start to think
functional hypothalamic amenorrhea
Amenorrhea with normal FHS/LH - what do you start to think
Consider outflow track obstruction
Amenorrhea with elevated FSH/LH - what do you start thinking
POI
Physiologic causes of amenorrhea
-pregnancy
-breastfeeding
-contraception
-peri/menopause
outflow tract disorders that cause primary amenorrhea
- Asherman’s acquired scarring
- Transverse vaginal septum
- Imperforate hymen
- Cervical stenosis
- Labial agglutination (low estrogen stage)
- Congenital anomalies (mullerian anomalies & agenesis)
- Androgen insensitivity syndrome
HPO axis disorders that cause amnorrhea
Hypothalamic: eating disorders, weight loss, stress, THBI
Pituitary: hyperprolactinemia, prolactinoma, ESS, medications
Endocrine gland disorders that can cause amenorrhea other than hypothalamus or pituitary
adrenal disease
delay of puberty
cushing syndrome
PCOS
thyroid disease
What happens in functional hypothalamic amenorrhea?
- There is decreased GnRH secretion therefore no LH surge from anterior pituitary – anovulation
a. See low serum estradiol
What comprises the female athlete triad
3 components: low energy, menstrual dysfunction, low bone density
What is a normal prolactin level?
<30
what happens with pituitary amenorrhea? (prolactin, GnRH, LH/FSH, estrogen)
Increased prolactin inhibits GnRH which means no LH/FSH anovulation (low estrogen)
What can cause elevation of prolactin?
breastfeeding/stimulation, altered metabolism d/t liver or kidney failure, ectopic production, medications [OCs, antipsychotics, antidepressants, anti-HTN, opiates, steroids]
What is considered hyperprolactinemia
> 100
Ovarian causes of amenorrhea
1) PCOS
2) POI
3) gonadal dysgenesis (most commonly seen with Turner’s sydrome)
When do you perform a progestin challenge?
FSH/LH normal and no identifiable cause of amenorrhea
How does a progestin challenge work?
- PO progestin 7-10 days (or IM 1 dose)
- Stimulates the endometrium to cause a withdrawal bleed
- WDB occurs 2-7 days after completion of progestin
+ WDB means
patent outflow tract AND endogenous estrogen present
(-) WDB means
outflow tract abnormality and/or inadequate estrogen production
What do you do after a failed progestin challenge?
Estrogen & progestin challenge
How is an estrogen/progestin challenge performed?
PO administration of COC for 21 days OR can do PO estrogen for 21 days followed by PO progestin 7-10 days
+ E/P WDB means
failure in the HPO axis
-recheck FSH/LH
o < 5 MRI for possible tumor
o WNL: hypothalamus or pituitary problem, PCOS
o Elevated FSH or LH POI
(-) E/P WDB means
outflow track obstruction
Tx for outflow tract disorders (partial imperforate hymen or labial agglutination)
estrogen cream and aquaphor
Tx pituitary adenoma (pharmacologic)
prolactinomas: dopamine agonist (bromocriptine)
Tx: POI
Estrogen supplementation
When do you see surgical interventions?
1) Asherman’s syndrome
2) pituitary adenomas
Define: AUB
alteration in the volume, pattern and or duration of menstrual flow – arising from the uterus
What is the most common reason for gyn referrals?
AUB!
Define: Menorrhagia
heavy or prolonged bleeding at REGULAR intervals
Define: metrorrhagia
irregular intervals or bleeding between menses
Define: menometrorrhagia
irregular intervals AND heavy/prolonged flow
Oligomenorrhea
greater than normal intervals (>35 d)
Age group 13-18: most common cause of AUB
Immature HPO axis
iatrogenic d/t BC
Pregnancy
Age group 19-39: most common cause of AUB
Pregnancy
Structural lesion: fibroid/polyp
adenomyosis
PCOS
Age group 40+ - menopause: most common cause of AUB
Anovulation d/t menopause
endometrial hyperplasia
endometrial atrophy
endometrial CA
Age group post-menopausal: most common cause of AUB
malignancy
iatrogenic (d/t hormone therapy)
atrophy
Leiomyoma RF
black
smokers
nulliparous
long menstrual cycle
Malignancy RF
age
obesity
unopposed estrogen
tamoxifen use
early menarche/late menopause
nulliparity
PCOS
chronic anovulation
infertility
Fhx colon cancer/lynch syndrome, cowden syndrome
Fhx endometrial, breast or ovarian CA, prior diagnosis of endometrial hyperplasia
Iatrogenic RF
amphetamines, anticoagulants, aspirin, antipsychotics, SSRIs, NSAIDs, neuroleptics, marijuana alcohol, corticosteroids (prednisone), tamoxifen, herbs/supplements, LNG-IUD, covid vaccine (can cause shift in menstrual cycle)
S/s: Polyps
Bright red
painless
Bleeding/spotting
S/s: malignancy
AUB
PMB
S/s: coagulopathy
bruise easily
frequent nose bleeds
hx PP hemorrhage
bleeding with sx or dental work
Fhx
S/s: ovulatory dysfunction
no moliminal signs
irregular heavy menses
S/s: endometrial dysfunction
HPO intact
menses/ovulation occur regularly
normal steroid hormones (estrogen, progesterone, testosterone)
S/s: endometritis (chronic/acute)
Chronic: PID, uterine and cervical motion tenderness
Acute: postpartum or post-abortion
S/s: anovulation
unpredictable cycle length
bleeding patterns
frequent spotting
frequent/unpredictable heavy bleeding
monophasic basal body temperature
no moliminal signs
When do you consider removing polyps?
When individuals are older because there is a chance of malignancy
What can leiomyomas impact?
fertility
Pertinent history for abnormal genital/uterine bleeding
i. LMP: normal for the patient? How were your past
menstrual periods?
ii. Menarche – age? Menopausal symptoms?
iii. Cycle length – regular?
iv. Duration (# flow days), amount – estimate the blood loss
and severity
v. Dysmenorrhea?
vi. Moliminal symptoms?
vii. Medications? Including contraception *helps to clue in if
ovulating
viii. Other sign/symptoms of hemostatic disorder
Leiomyoma PE - what to look for?
pelvic exam – give us an idea if the uterus is enlarged
Need US to confirm
When would you perform an EmBx?
-malignancy
-AUB
When would you perform an TVUS?
-polyps
-leiomyoma
-malignancy (post menopausal lining cut off is 4 mm)
First line diagnostic for: ovarian mass, uterine fibroids and polyps
When would you perform a saline infusion sonohystogram (SIS)?
polyps visualization
When would you perform an hysteroscopy?
-polyps
-when embx is insufficient to r/o malignancy
When would you perform a dilation and curettage?
-malignancy
-AUB: when embx not sufficient
When would you perform an MRI?
adenomyosis - might see asymmetric thickening of the mymetrium
What labs do you order for coagulopathy?
[Pt, Ptt, platelets, +/- fibrinogen, thrombin time]
also potentially consider BUN, Cr
What labs do you order for AUB
urinalysis, pregnancy test, TSH, STI, Wet mount, Pap
Differentials: bleeding from vulva/vagina
a. Genitourinary syndrome of menopause (GSM) – loss of
ruggae
b. Vaginitis: yeast, atrophy, trich, BV
c. Trauma
d. Vaginal carcinoma
e. Foreign body
Differentials: bleeding from cervix
a. Infection (cervicitis)
b. Polyps
c. Cancer
d. Condyloma
Differentials: bleeding from fallopian tubes
a. Salpingitis/PID
b. Tumors
Differentials: bleeding related to ovaries
a. Benign/malignant tumors
b. Ruptured follicular or corpus luteum (CL) cysts
c. Adnexal torsion (so much pain!!)
Differentials: obstetric related bleeding
a. Ectopic pregnancy
b. Spontaneous abortion
c. Implantation bleeding
d. Subchorionic hematoma
e. Gestational trophoblastic disease/molar pregnancy
f. Post-abortion/postpartum endometritis
(infection/inflammation of endometrium)
g. Hyperemia of cervix/post-coital spotting
h. Unexplained!
PALM COEIN
- PALM = visualizable structural sources of bleeding
- Polyps, adenomyosis, leiomyomas, malignancy
- COEI = unrelated to structural abnormalities
- Systemic disease, iatrogenic causes, disorders of the
HPO axis - Coagulopathy [von Willebrand {most common},
thrombocytopenia, leukemia, liver disease/renal
disease] Ovulatory dysfunction, Endometrial,
Iatrogenic - N – “not yet classified”
- Systemic disease, iatrogenic causes, disorders of the
Management: adenomyosis
-IUD
-Progesterone
Management: HMB (heavy menstrual bleeding)
-stabilize lining
-acute bleeding
-cycle the endometrium
-before period
-stabilize lining: pill, patch, ring
-acute bleeding: IV estrogen
-cycle the endometrium: (any combination of estrogen, progestin) w/ COCPs, patch, ring; suppress endometrium with continuous progestin, extended use COCPs, danazol & GnRH agonists
-before period: NSAIDs 24 hours before expected menses
Heavy and prolonged menstrual bleeding
-initial treatment
-maintenance therapy
1) aygestin taper (1 pill q 4 hrs for 24 hours and then taper)
2) “cascade” COCP
Maintenance:
-extended cycle COCP
-IUD (52 mg)
-medroxyprogesterone acetate and norethindrone ***still need birth control
How to definitively diagnose adenomyosis
hysterectomy with histologic exam
Procedures for HMB?
-ablation
-hysterectomy
-aspiration
Patient education for HMB
- Avoid use of aspirin/aspirin containing products during week prior to menses
- Avoid increased heavy activity during the days of heaviest flow
- Hot tubs can increase flow
- Use pads vs tampons if possible
- Change tampons frequently
- Increase Fe in diet/take supplemental
