Chapter 39: Amenorrhea and Abnormal Uterine Bleeding Flashcards
Amenorrhea
Absence of menstruation
Definition of abnormal uterine bleeding
Abnormal uterine bleeding: Difference in frequency, duration and amount of menstrual bleeding. Usually separated into two categories of abnormal bleeding associated with ovulatory cycles (usually organic) and bleeding due to anovulatory cycles.
Oligomenorrhea
Oligomenorrhea: Reduction of frequency of menses with cycle length over 40 days but less than 6 months
Hypomenorrhea
Hypomenorrhea: Reduction in the number of days or the amount of menstrual flow
Polymenorrhea
Polymenorrhea – Frequent menstrual bleeding (21 days or less in a cycle)
Menorrhagia
Menorrhagia – Prolonged excessive uterine bleeding that occurs at regular intervals (loss of 80 mL or more of blood that lasts for more than 7 days)
Metorrhagia
Metorrhagia: Irregular menstrual bleeding or bleeding between periods
Menometorrhagia
Menometorrhagia – Frequent menstrual bleeding that is excessive and irregular in
amount and duration
Primary vs secondary amenorrhea
Age 13 without menstruation without sexual characteristics or age 15 who hasn’t menstruated but has sexual characteristics
vs.
Menstruating woman who has not menstruated for 3 to 6 months or for the duration of three typical menstrual cycles for the patient with oligomenorrhea
General pathway cause of amenorrhea
Menstruation ceases when: Endocrine function along the hypothalamic-pituitary- ovarian axis is disrupted or an abnormality develops in the genital outflow tract (obstruction of the uterus, cervix, or vagina or scarring of the endometrium).
Most common cause of amenorrhea
Pregnancy
Functional causes of hypothalamic pituitary dysfunction
Weight loss, excessive exercise and obesity
Drugs that can cause amenorrhea due to hypothalamic pituitary dysfunction
Marijuanna, psychoactive drugs, and antidepressants
Neoplastic causes of amenorrhea due to hypothalamic pituitary dysfunction
Neoplastic: Prolactin secreting pituitary adenomas, craniopharyngioma, hypothalamic hamartoma
Psychogenic causes of amenorrhea due to hypothalamic pituitary dysfunction
Psychogenic causes: Chronic anxiety, pseudocyesis, anorexia nervosa
In hypothalamic pituitary dysfunction, what labs will we see?
Definitive method is to measure LH, FSH, and Prolactin levels in the blood. In these conditions, FSH and LH are in the low range. Prolactin
normal unless prolactin-secreting pituitary adenomas.
What labs will we see if there is an ovarian failure?
In ovarian failure, the ovarian follicles are either exhausted or are resistant to stimulation by FSH and LH. As the ovaries cease functioning, blood concentrations of FSH and LH rise in an attempt to wake em up.
Pts will show signs of estrogen deficieny.
Causes of ovarian failure
- Chomosomal (Turner-45X gonadal dysgenesis, X Chromosome, long arm deletion 46XXq5)
- Gonadotropin-resistant ovary syndrome (Savage syndrome)
- premature natural menopause
- Autoimmune ovarian failure (Blizzard syndrome)
How do we treat Asherman syndrome (rough dilation and curretage effect)
Tx: Lyse adhesions, but usually not much to help here. Estrogen to restore denuded areas of the endometrium.
Some cases, place a balloon or intrauterine device to keep the walls apart and stop the webbing from coming back
First step in treating amenorrhea
Progesterone challenge test: 10-14 day course of oral medroxyprogesterone acetate –> induces progesterone –> withdrawal –> bleeding within a week = anovulatory, no bleeding = hypoestrogenic or anatomic condition
How does hyperprolactinemia present? How do we treat it?
Hyperprolactinemia from prolactinoma in pituitary: Usually presents also with galactorrhea. Treat with bromocriptine dopamine agonist (dopamine inhibits prolactin).
5% of patients have hyperprolactinemia and galactorrhea = hypothyroidism
What do we do with patients who have amenorrhea but want kids?
Ovulation can be induced through clomiphene citrate, human menopausal gonadotropins, pulsatile GnRH, or aromatase inhibitors.
- In patients who are oligo-ovulatory or anovulatory like with PCOS, ovulation can be induced with clomiphene citrate.
- In patients who have hypogonadotropic hypogonadism, ovulation can be induced with pulsatile GnRH or human menopausal gonadotropins
What do we do about premature menstruation?
Premature menopause = Need estrogen supplementation
When we see bleeding without ovulation, what do we need to suspect?
Unlike hypothalamic amenorrhea who have low estrogen and thus never stimulate the endometrium or ovulation, those with oligoovulation or anovulation with abnormal uterine bleeding have constant non-cyclic blood estrogen concentrations that are high enough to to stimulate growth and development of the endometrium. Without ovulation though, progesterone changes never occur at the uterus, and the growing uterine layer just sloughs off unpredictably as parts of it run out of blood supply.
Chronic low stimulation vs chronic high stimulation of estrogen
i. Chronic low stimulation = light and infrequent bleeding
ii. Chronic high stimulation = heavy and frequent
What is a luteal phase defect and what do we see?
Luteal Phase Defect: Ovulation occurs but corpus luteum is not fully developed so you don’t get the protecting progesterone for the uterus, and even if conception occurs, the pregnancy won’t last.
We see a shortened menstrual cycle pattern
Treating anovulatory uterine bleeding
- Progesterone Test
- Give OCPs
- Test for endometrial cancer before endometrial ablation or hysterectomy.
