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Women's Health Theory > Bleeding Across the Lifespan > Flashcards

Bleeding Across the Lifespan Flashcards

1
Q

Definition: normogonodotropic

A

normal amounts of gonadotropic hormones (GnRH, FSH, LH)

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2
Q

What produces GnRH?
What produces FSH/LH

A
  1. Hypothalamus produces GnRH
  2. Anterior pituitary produces FSH/LH
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3
Q

Define: Hypergonadotropic

A

higher than normal amounts of gonadotropic hormones produces

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4
Q

Define: Hypogonadotropic

A

lower than normal amounts of gonadotropic hormones produces

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5
Q

Define: Hypogonadism

A

lower than normal amounts of gonadal hormones (estrogen, progesterone, testosterone) produced

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6
Q

Define: Hyperprolactinemia

A

higher than normal amount of prolactin produced

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7
Q

What is more common primary or secondary ammenorrhea?

A

Secondary

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8
Q

Most common causes secondary amenorrhea

A

1) pregnancy
2) PCOS
3) hypothalamic amenorrhea
Other: hyperprolactinemia, POI

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9
Q

Risk factors of hypothalamic amenorrhea

A

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)

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10
Q

RF hyperprolactinemia

A

i. Tumors
ii. Empty sella syndrome (ESS)
iii. Cushing’s disease
iv. Sheehan syndrome

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11
Q

RF POI

A

i. Genetics
ii. Autoimmune
iii. Chemo/radiation
iv. Environment
v. Galactosemia (galactose deficiency)

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12
Q

Outflow disorders: primary amenorrhea

A

imperforate hymen, labial agglutination, transverse vaginal septum

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13
Q

General s/s outflow disorder

A

Cyclical abdominal pain arising from accumulated menstrual blood

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14
Q

S/s Mullerian anomalies & agensis (i.e. uterine anomalies)

A

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

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15
Q

Outflow disorder: secondary amenorrhea cuases

A

Asherman’s syndrome (scarring from procedure, hemorrhage, or infection)

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16
Q

Genetic conditions that cause primary amenorrhea

A

-Androgen insensitivity syndrome (AIS)
-Turner syndrome
-Pure gonadal dysgenesis

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17
Q

Do pituitary adenomas cause primary or secondary amenorrhea?

A

Both

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18
Q

What is POI?

A

depletion of oocytes before age 40

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19
Q

S/S POI

A

-high FSH
-irregular menses
-VMS
-Estradiol in menopausal level

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20
Q

consequences of female athlete triad?

A

early low bone density increases the risk of osteoporosis later in life

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21
Q

Sequelae of POI

A

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

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22
Q

Parameters of primary amenorrhea

A
  1. no menses by age 15 with normal growth and development of secondary sexual characteristics
  2. No menses 3 years past breast development
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23
Q

Parameters of secondary amenorrhea

A

Absence of menses for 3 cycle intervals or 6 months in a woman who has previously menstruated

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24
Q

ROS for amenorrhea

A
  1. Constitutional: hot flashes, night sweats
  2. Skin hair nails: lanugo  anorexia; hirsutism & acne  hyperandrogenism
  3. Eyes: visual changes
  4. Breasts: tenderness, galactorrhea
  5. Thyroid problems
  6. Cyclic pelvic pains?
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25
Q

Tanner staging review (primary amenorrhea) starting with Tanner 2 - 5

A

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

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26
Q

Findings of Turner syndrome

A

Short stature, neck webbing, pigeon chest

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27
Q

Labs for amenorrhea

A

Pregnancy test
Serum prolactin
FSH/LH
TSH
estradiol –> for POI

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28
Q

Amenorrhea with low FHS/LH - what do you start to think

A

functional hypothalamic amenorrhea

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29
Q

Amenorrhea with normal FHS/LH - what do you start to think

A

Consider outflow track obstruction

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30
Q

Amenorrhea with elevated FSH/LH - what do you start thinking

A

POI

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31
Q

Physiologic causes of amenorrhea

A

-pregnancy
-breastfeeding
-contraception
-peri/menopause

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32
Q

outflow tract disorders that cause primary amenorrhea

A
  1. Asherman’s  acquired scarring
  2. Transverse vaginal septum
  3. Imperforate hymen
  4. Cervical stenosis
  5. Labial agglutination (low estrogen stage)
  6. Congenital anomalies (mullerian anomalies & agenesis)
  7. Androgen insensitivity syndrome
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33
Q

HPO axis disorders that cause amnorrhea

A

Hypothalamic: eating disorders, weight loss, stress, THBI

Pituitary: hyperprolactinemia, prolactinoma, ESS, medications

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34
Q

Endocrine gland disorders that can cause amenorrhea other than hypothalamus or pituitary

A

adrenal disease
delay of puberty
cushing syndrome
PCOS
thyroid disease

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35
Q

What happens in functional hypothalamic amenorrhea?

A
  1. There is decreased GnRH secretion  therefore no LH surge from anterior pituitary – anovulation
    a. See low serum estradiol
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36
Q

What comprises the female athlete triad

A

3 components: low energy, menstrual dysfunction, low bone density

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37
Q

What is a normal prolactin level?

A

<30

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38
Q

what happens with pituitary amenorrhea? (prolactin, GnRH, LH/FSH, estrogen)

A

Increased prolactin inhibits GnRH  which means no LH/FSH  anovulation (low estrogen)

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39
Q

What can cause elevation of prolactin?

A

breastfeeding/stimulation, altered metabolism d/t liver or kidney failure, ectopic production, medications [OCs, antipsychotics, antidepressants, anti-HTN, opiates, steroids]

40
Q

What is considered hyperprolactinemia

A

> 100

41
Q

Ovarian causes of amenorrhea

A

1) PCOS
2) POI
3) gonadal dysgenesis (most commonly seen with Turner’s sydrome)

42
Q

When do you perform a progestin challenge?

A

FSH/LH normal and no identifiable cause of amenorrhea

43
Q

How does a progestin challenge work?

A
  • 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
44
Q

+ WDB means

A

patent outflow tract AND endogenous estrogen present

45
Q

(-) WDB means

A

outflow tract abnormality and/or inadequate estrogen production

46
Q

What do you do after a failed progestin challenge?

A

Estrogen & progestin challenge

47
Q

How is an estrogen/progestin challenge performed?

A

PO administration of COC for 21 days OR can do PO estrogen for 21 days followed by PO progestin 7-10 days

48
Q

+ E/P WDB means

A

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

49
Q

(-) E/P WDB means

A

outflow track obstruction

50
Q

Tx for outflow tract disorders (partial imperforate hymen or labial agglutination)

A

estrogen cream and aquaphor

51
Q

Tx pituitary adenoma (pharmacologic)

A

prolactinomas: dopamine agonist (bromocriptine)

52
Q

Tx: POI

A

Estrogen supplementation

53
Q

When do you see surgical interventions?

A

1) Asherman’s syndrome
2) pituitary adenomas

54
Q

Define: AUB

A

alteration in the volume, pattern and or duration of menstrual flow – arising from the uterus

55
Q

What is the most common reason for gyn referrals?

A

AUB!

56
Q

Define: Menorrhagia

A

heavy or prolonged bleeding at REGULAR intervals

57
Q

Define: metrorrhagia

A

irregular intervals or bleeding between menses

58
Q

Define: menometrorrhagia

A

irregular intervals AND heavy/prolonged flow

59
Q

Oligomenorrhea

A

greater than normal intervals (>35 d)

60
Q

Age group 13-18: most common cause of AUB

A

Immature HPO axis
iatrogenic d/t BC
Pregnancy

61
Q

Age group 19-39: most common cause of AUB

A

Pregnancy
Structural lesion: fibroid/polyp
adenomyosis
PCOS

62
Q

Age group 40+ - menopause: most common cause of AUB

A

Anovulation d/t menopause
endometrial hyperplasia
endometrial atrophy
endometrial CA

63
Q

Age group post-menopausal: most common cause of AUB

A

malignancy
iatrogenic (d/t hormone therapy)
atrophy

64
Q

Leiomyoma RF

A

black
smokers
nulliparous
long menstrual cycle

65
Q

Malignancy RF

A

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

66
Q

Iatrogenic RF

A

amphetamines, anticoagulants, aspirin, antipsychotics, SSRIs, NSAIDs, neuroleptics, marijuana alcohol, corticosteroids (prednisone), tamoxifen, herbs/supplements, LNG-IUD, covid vaccine (can cause shift in menstrual cycle)

67
Q

S/s: Polyps

A

Bright red
painless
Bleeding/spotting

68
Q

S/s: malignancy

A

AUB
PMB

69
Q

S/s: coagulopathy

A

bruise easily
frequent nose bleeds
hx PP hemorrhage
bleeding with sx or dental work
Fhx

70
Q

S/s: ovulatory dysfunction

A

no moliminal signs
irregular heavy menses

71
Q

S/s: endometrial dysfunction

A

HPO intact
menses/ovulation occur regularly
normal steroid hormones (estrogen, progesterone, testosterone)

72
Q

S/s: endometritis (chronic/acute)

A

Chronic: PID, uterine and cervical motion tenderness
Acute: postpartum or post-abortion

73
Q

S/s: anovulation

A

unpredictable cycle length
bleeding patterns
frequent spotting
frequent/unpredictable heavy bleeding
monophasic basal body temperature
no moliminal signs

74
Q

When do you consider removing polyps?

A

When individuals are older because there is a chance of malignancy

75
Q

What can leiomyomas impact?

A

fertility

76
Q

Pertinent history for abnormal genital/uterine bleeding

A

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

77
Q

Leiomyoma PE - what to look for?

A

pelvic exam – give us an idea if the uterus is enlarged

Need US to confirm

78
Q

When would you perform an EmBx?

A

-malignancy
-AUB

79
Q

When would you perform an TVUS?

A

-polyps
-leiomyoma
-malignancy (post menopausal lining cut off is 4 mm)
First line diagnostic for: ovarian mass, uterine fibroids and polyps

80
Q

When would you perform a saline infusion sonohystogram (SIS)?

A

polyps visualization

81
Q

When would you perform an hysteroscopy?

A

-polyps
-when embx is insufficient to r/o malignancy

82
Q

When would you perform a dilation and curettage?

A

-malignancy
-AUB: when embx not sufficient

83
Q

When would you perform an MRI?

A

adenomyosis - might see asymmetric thickening of the mymetrium

84
Q

What labs do you order for coagulopathy?

A

[Pt, Ptt, platelets, +/- fibrinogen, thrombin time]
also potentially consider BUN, Cr

85
Q

What labs do you order for AUB

A

urinalysis, pregnancy test, TSH, STI, Wet mount, Pap

86
Q

Differentials: bleeding from vulva/vagina

A

a. Genitourinary syndrome of menopause (GSM) – loss of
ruggae
b. Vaginitis: yeast, atrophy, trich, BV
c. Trauma
d. Vaginal carcinoma
e. Foreign body

87
Q

Differentials: bleeding from cervix

A

a. Infection (cervicitis)
b. Polyps
c. Cancer
d. Condyloma

88
Q

Differentials: bleeding from fallopian tubes

A

a. Salpingitis/PID
b. Tumors

89
Q

Differentials: bleeding related to ovaries

A

a. Benign/malignant tumors
b. Ruptured follicular or corpus luteum (CL) cysts
c. Adnexal torsion (so much pain!!)

90
Q

Differentials: obstetric related bleeding

A

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!

91
Q

PALM COEIN

A
  • 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”
92
Q

Management: adenomyosis

A

-IUD
-Progesterone

93
Q

Management: HMB (heavy menstrual bleeding)
-stabilize lining
-acute bleeding
-cycle the endometrium
-before period

A

-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

94
Q

Heavy and prolonged menstrual bleeding
-initial treatment
-maintenance therapy

A

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

95
Q

How to definitively diagnose adenomyosis

A

hysterectomy with histologic exam

96
Q

Procedures for HMB?

A

-ablation
-hysterectomy
-aspiration

97
Q

Patient education for HMB

A
  1. Avoid use of aspirin/aspirin containing products during week prior to menses
  2. Avoid increased heavy activity during the days of heaviest flow
  3. Hot tubs can increase flow
  4. Use pads vs tampons if possible
  5. Change tampons frequently
  6. Increase Fe in diet/take supplemental

Women's Health Theory (7 decks)

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