Chapter 33 Menstrual Disorders Flashcards
puberty can start as early as__
7 years old
__ hormone is involved in the initiation of puberty
leptin hormone
depot medroxyprogesterone acetate leads to reversible bone mineral density loss in adolescents
true
meds to improve clinical symptoms of fibroids
gonadotropin-releasing hormone ANTAGONISTS, aromatase inhibitors, and antiprogesterone agents
polycystic ovary syndrome is associated with metabolic disorders
true
premature ovarian failure (POF) is not equivalent with menopause
true
POF associated with
cardiovascular disease and endothelial dysfunction
leptin hormone may restore menses in pts with
hypothalamic amenorrhea
Normal menstrual cycle
early follicular phase late follicular phase ovulation early secretory (luteal phase) late luteal phase menstruation
release of negative feedback from __, __, and __ in early follicular phase allows an increase in gonadotropin releasing hormone (GnRH) pulse frequency
estradiol
progesterone
inhibin A
FSH rises, recruiting one follicle destined for ovulation
true
remainder of __ follicles recruited each month undergo atresia
primordial
a follicle is surrounded by 2 types of cells: granulosa and theca cells; FSH receptors in the granulosa cells increase
true
aromatization of androgens in granulosa cells begin
true
granulosa cells proliferate, and inhibin/activin production (mainly inhibin b) rises
true
increased estrogen from dominant follicle leads to proliferation of the endometrium and starts to negatively inhibit FSH secretion
true
LATE FOLLICULAR PHASE
LH levels rise , stimulating androgen production in the
theca cells
endometrium continues to thicken in the
late follicular phase
Ovulation occurs 34-36 hours after onset of LH surge
true
LH surge results in the following besides ovulation:
- resumption of meiosis in the oocyte (not completed until fertilization has occurred)
- luteinization of granulosa cells
- production of prostaglandins and progesterone within the follicle.
LUTEAL PHASE / early secretory
progesterone levels rise rapidly secreted from newly developed corpus luteum.
corpus luteum degenerates __ after ovulation in the absence of HCG
9-11 days
abnormal bleeding in adolescents. average age of onset of puberty is
9-10 years
sequence of puberty:
- accelerated growth
- breast development
- adrenarche
- menarche
Menarche occurs within — after thelarche when breast development has reached tanner stage 5
2-3 yrs
With sufficient levels of — endometrial lining thickens and first menses occurs
Estrogen
By age –, –% of females will have reaches menarche
Age 15, 98% reached menarche
Evaluation of irregular menses in adolescents
Confirm normal pelvic anatomy with exam and us
Basic lab tests
Hcg, tsh, CBC, plt
If menorrhagia is primary complaint, additional labs fibrinogen, prothrombin time, ptt, bleedin time, Bon willebrands factor antigen, rustic erin c cofactor, platelet aggregation studies
Von willebrands most common condition in adolescents
13%
Treatment of abnormal bleeding in adolescents
Ocp, progestins, depot medroxyprpgesterone acetate,
Adolescents intermenstrual bleeding
Pregnancy Anatomical abnormalities Anovulation Infection Malignancy Hormonal therapy Chronic systemic diseases Cervical or vaginal bleeding
– is most common complication associated with fibroids secondary to —
Postpartum hemorrhage; secondary to decreased uterine contractioity
Endometrial polyps incidence rate —
10-25%
Polyps are rare in women
20s
Diagnosis of polyp
Sis rate of 93%
Hysteroscopy can also used as diagnostic tool and treatment
World health organization WHO separates amenorrheic PTs in 3 groups
Who 1: no evidence of endogenous estrogen, normal or low fsh, normal prolactin, no evidence of lesion in hypothalamus pituitary region
Who 2
Evidence of estrogen production, normal prol and fsh
Who 3
Elevated serum fsh (gonadal failure)
Who 1 disorders
Most common is hypothalamic amenorrhea. Fsh near normal,high fsh/lh ratio(as seen in prepubertal girls).
Causes of hypothalamic amenorrhea:
Stress: increase in corticotrophin releasing hormone (Crh) which inhibits gonadotropin secretion
Anorexia and bulimia: changes leptin, neuropeptide y, melanocortins, and Crh lead to low levels o gonadotropin
Excessive exercise: in competitive sports have a 3fold higher risk of hypothalamic amenorrhea
Female
Sthle triad
Amenorrhe
Abnormal eating
Osteoporosis
Hypothalamic amenorrhea causes by low body weight can be reversed
Gain weight. Based on higher bmi and lower cortisol level over time
Other causes of who1 disorders
Kallman syndrome - absence of Gnrh and anosmia
Adrenal hyperplasia - adrenal insufficiency deficient gonadotropin production, and impaired response to gnrh)
Who2 disorders
Pcos
Clinical or biochemicl evidence of hyperandrogenemia
Ovulating dysfunction
Presence of polycystic ovaries
When pcos suspected work up includes
Bp, bmi, androgen levels , 17 hydroxyprogesterone ( r/o no classical congenital adrenal hyperplasia), screening for cardio metabolic disorders including fasting lipids and gtt and pelvi us
Treatment for anovulation/pcos
Restore normal menstrual cycles and normalize bmi through diet and exercise.
Ocps first line treatment in PTs not ttc. Act as anti androgens, estrogen increases sex binding globulins, progesterone suppresses lh which decreases testosterone production, inhibits 5 alpha reductase activity in skin. Regulates
Menses
In cases o prolonged heavy bleeding as a result I anovulation any low dose oc can be used
Twice a day for at least 5-7 days until bleeding slows followed by one pilldaily
Occasionally bleeding is unresponsive to progestins or oc, bleeding might be secondary to a
Very thin denuded endometrium rather than a thickened endometrium.
In these cases high dose estrogen can be given:
- 25mg conjugated equine estrogens or
- 0 mg micronized estradiol every 4-6 hrs x24hrs followed by one pill a day for next 7-10 days
Who3 disorder
Premature ovarian failure
Turner syndrome
Gonadal dysgenesis
Pituitary
Premature ovarian failure
Amenorrhea in presence of hypergonadotropic hypogonadism prior to 40
Dx 4 months of amenorrhea and 2menopausal levels of fsh sufficient
Premature ovarian failure is distinct from menopause 50% will have resumption of ovarian function after the diagnosis; 5-10% will spontaneously conceive after diagnosis
True
Turner syndrome
45xo
Short stature, web neck, shield chest, renal abnormalities, autoimmune disorders 50% hypothyroidism) cv disorders, hypergonadotropic hypoestrognic amenorrhea
Need echo
If uterus is absent on exam what should be ordered
MRI, karyotyping , serum testosterone
If uterus is present
Pregnancy test, fsh, prolactin, tsh
Most prolactin adenomyosis successfully treated with
Dopamine agonists
Bromocriptine
Cabergoline - fewer side effects and more effective at normalizing prolactin levels
Surgery rarely indicated
Women with pig should start hormone therapy replacement to prevent bone loss and cardiovascular complications
Low dose estrogen 100ug estradiol patch, 2mg oral micronized estradiol or 1.25mg conjugated equine estradiol
Transdermal estradiol often preferred route. It avoids first pass effect on liver
True. If pt has uterus also then what
Cyclic progesterone 10mg of medroxyprpgesterone acetate or 200mg of oral micronized progesterone given 12 days each month if uterus is present
cylic progesterone therapy 5-10mg of medroxyprogesterone acetate or 200mcg of micronized progetserone how is it used?
2 weeks every month will be sufficient for restoring menses and protecting the endometrium if contraception is not desired. in addition to stabilizing endometrium and causing monthly endometrial shedding, progesterone also protects the endometrium.
progesterone
stimulates 17b hydroxysteroid dehydrogenase and sulfotransferase activities that convert estradiol to estrone sulfate.
hypogonadotropic, hypogonadism
Hypogonadism is a condition in which the male testes or the female ovaries produce little or no sex hormones. Hypogonadotropic hypogonadism (HH) is a form of hypogonadism that is due to a problem with the pituitary gland or hypothalamus.
in cases of prolonged bleeding, any low dose OCs can be used how?
bid daily for at least 5-7 days until bleeding slows.
if endometrium is denuded, may give
- 25mg conjugated estrogens or
2. 0 mg micronized estradiol every 4-6hrs x 24 hrx followed by one pill a day for the next 7-10days
provera challenge test
Progestin challenge, or progesterone withdrawal test is a test used in the field of obstetrics and gynecology in order to evaluate a patient who is experiencing amenorrhea. Due to readily available assays to measure serum estradiol levels, this test is now rarely used.[1] The test is performed by administering progesterone orally in the form of medroxyprogesterone acetate (Provera), or intramuscularly. If the patient has sufficient serum estradiol (greater than 50 pg/mL) then withdrawal bleeding should occur 2-7 days after the progestin is finished, indicating that the patient’s amenorrhea is due to anovulation. However, if no bleeding occurs after progesterone withdrawal, then the patient’s amenorrhea is likely to be due to either a) low serum estradiol, b) hypothalamic-pituitary axis dysfunction, c) a nonreactive endometrium or d) a problem with the uterine outflow tract, such as cervical stenosis or uterine synechiae (Asherman’s syndrome). In order to distinguish between hypoestrogenism or a uterine outflow tract problem/nonreactive endometrium, estrogen may be administered followed by a course of progestin in order to induce withdrawal bleeding. If the patient experiences withdrawal bleeding with the combined estrogen/progestin therapy, then the amenorrhea is likely due to low estrogen.[2]
fertility and gonadal failure
there is no proved method of restoring fertility in POF patients. what labs should draw for POF:
ovarian markers such as anti-mullerian hormone (AMH), inhibin B, and antral follciel count may provide more accurate assessment of follicular quantity as compared to FSH alone.
for POF, infertility treatments such as gonadotropin stimulation have little if any results
true
donor oocyte ivf / adoption should be discussed
true
CHRONIC MENORRHAGIA most common causes
anovulation, endometrial distortion (fibroids, polyps, IUDs, tumors), and adenomyosis
a __ and __ should be done in everyone who presents with abnormal bleeding why?
pregnancy test and pelvic US. most common cause of a sudden change from regular menses is a complication of pregnancy.
check CBC to r/o anemia
true
if __ is confirmed, additional workup includes
BMI, FSH, prolactin, TSH, androgens
hyperandrogenemia and anovulation should raise suspicion for
polycystic ovary syndrome
an endometrial biopsy should be performed if
- a patient is anovulatory and 40 years or older
- has had a long duration of exposure to unopposed estrogen regardless of age
- is postmenopausal.
ANOVULATION results in amenorrhea in 20-30% of the time and ___ in 30% of the time
menorrhagia
anovulation is abnormal bleeding resulting from prolonged exposure to estrogen - in the absence of progesterone, which leads to an unstable ___.
endometrium.
most common cause of adult onset anovulation are
- ovarian dysfunction (50%)
- hypothalamic dysfunction 35% - abnormalities in body composition and weight, stress and strenuous exercise.
- pituitary disease 15%
methods to detect ovulation
- basal body temperature - prior to ovulation morning bbt 98 a biphasic pattern is almost always associated with ovulation.
- Luteal serum progesterone - greater than 3mg/mL always associated with normal seretory endometrium
- LH surge - detected by lab values or LH detection kit: ovulation occurs 34-36 hrs after the onset of an LH surge, 10-12 hrs after teh LH peak.
- ultrasound changes: follicular growth, rupture and formation of corpus luteum.
treatment :
- oral contraceptives are first line therapy to regulate menses, they are easily tolerated and protect the endometrium.
- cyclic progtins are also sufficient to protect the endometrium if OCs are not tolerated or contraception is not desired.
- occasionally, bleeding is unresponsive to progesterones / combination oral contraceptives because bleeding may be secondary to a very thin or denuded endometrium rather than a thickened unstable endometrium; in these cases; high dose estrogen therapy can be used in both oral and iV forms: 1.25mg conjugated estrogens or 2.0mg micronized estradiol every 4-6 hrs x 24 hrs followed by one pill a day for the next 7-10days.
- Norethindrone IUD (mirena) - significantly decreases menorrhagia.
- NSAIDS - decreases prostaglandin synthesis in the endometrium and can reduce blood loss by 20-50%. should be stated on first day of menses and continued for at least 5 days.
- antifibrinolytic - more effective than NSaIDS and cyclic progestins in reducing blood flow. only take 1-2 days before menses and for the first 2 days of the menses.
- endometrial ablation / destruction of endometrium.
- gonadotropin releasing hormone agonists - limit to 6 months to 1 year given risk of irreversible bone loss.
