Dunn: Amenorrhea, etc. Flashcards
hematocolpos
imperforate hymen
–> retained menstruation in a female who has reached puberty
Thelarche
is the onset of female breast development.
Pubarche
is the appearance of sexual hair.
Adrenarche
is the onset of androgen-dependent body changes such as growth of axillary and pubic hair, body odor, and acne.
Menarche
is the onset of menstruation.
Tanner stage - Breast
Stage 1: Prepubertal
Stage 2: Breast bud stage with elevation of breast and papilla; enlargement of areola
Stage 3: Further enlargement of breast and areola; no separation of their contour
Stage 4: Areola and papilla form a secondary mound above level of breast
Stage 5:Mature stage: projection of papilla only, related to recession of areola
Tanner stage-Pubic Hair
Stage 1: Prepubertal (can see velus hair similar to abdominal wall)
Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis or along labia
Stage 3: Darker, coarser and more curled hair, spreading sparsely over junction of pubes
Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs
Stage 5: Adult in type and quantity, with horizontal distribution (“feminine”)
Primary amenorrhoea
Failure to menstruate by age 16
Secondary amenorrhoea
Absence of menstruation for >6 months
Primary Amenorrhea – Common Causes
Constitutional delay Chromosomal e.g. 45XO, 46XY Pituitary tumour e.g craniopharyngioma Congenital adrenal hyperplasia Genital tract anomaly (Plus all the causes of secondary amenorrhoea)
Primary Amenorrhoea – Clues to diagnosis
Constitutional delay
Chromosomal e.g. 45XO, 46XY Pituitary tumour e.g craniopharyngioma Congenital adrenal hyperplasia Genital tract anomaly Secondary sexual characteristics slow Stigmata of Turners S
Visual field defect
Virilisation
Imperforate hymen
Primary amenorrhoea – Diagnostic steps
Height, weight and BP Evaluate secondary sexual characteristics Look for signs of androgen excess Do visual fields Chromosomes FSH, LH and E2 Maybe HydroxyPROG, Androgens, PRL, TSH Maybe CT pituitary
Secondary amenorrhoea – Common causes
Hypothalamic
- “Stress”
- Weight loss/gain (Anorexia)
- Post Pill and Depo Provera
PCO Syndrome (1:20 women)
Premature Menopause
- Idiopathic
- Iatrogenic
- Resistant ovary syndrome
Hyperprolactinaemia
- Physiological
- Pituitary adenoma
- Drug-induced
Remember also pregnancy & progestins!
Secondary amenorrhoea – Uncommon causes
Kallman’s Syndrome Sheehan’s Syndrome Cushing’s Syndrome Other Pituitary Tumors Post encephalitis/trauma Thyroid disease Androgen-producing Tumors Asherman’s Syndrome (infection/ miscarriage/ termination of pregnancy/ post-partum hemorrhage curettage too aggressive --> endometrium collapses on itself)- give high doses of estrogen, put in IUD
Cervical stenosis
Secondary amenorrhoea – Clinical evaluation
History: Life events Weight/Exercise history Pregnancy Drugs Galactorrhoea Hot flushes (premature ovarian failure) Headaches/Vision
Examination: Height/Weight BP 2ary Sexual characteristics Hirsutism/Virilisation Visual fields Galactorrhoea Genital tract oestrogenisation Cervical stenosis
Secondary amenorrhoea - primary tests
FSH LH E2 TSH PRL Androgens Ultrasound pelvis Visual fields Progesterone challenge test
Secondary Tests: CT Pituitary Other pituitary hormones Dexamethasone suppression HydroxyPROG Hysteroscopy or HSG Laparoscopy & ovarian biopsy
young lady with amenorrhea/ irregular periods
(obese, acanthosis nigricans, acne, etc. as well)
DDX
Pregnancy PCOS Hyperprolactinemia Premature ovarian failure Hypo/Hyperthyroid Hypopituitarism (usually tumor related) Hypothalamic amenorrhea (2/2 stress, weight changes, exercise) Endometrial scarring (Asherman’s syndrome) Anorexia nervosa Anabolic steroid use Other endocrine
US shows “string of pearls” multiple immature follicles
consistent with PCOS
Rotterdam Criteria
(2/3 of criteria met)
Oligoovulation/anovulation
Excess androgen activity (clinical or lab)
Polycystic ovaries on ultrasound
AND other causes are excluded
Pathophysiology of PCOS
Increased daily levels testosterone and androstenedione, higher levels of estrogen (mostly from peripheral conversion of androstenedione to estrone)
Increased estrone levels causing augmented response by the pituitary to GnRH and increased LH production
Also with hypothalamus directly aromatizing androgen to estrogen, raising local levels estrogen in anterior hypothalamus and stimulating positive feedback mechanism of LH
Elevated estrone also causing Negative feedback mechanism for LH resulting in low/low-normal levels.
Since FSH level is not totally depressed, follicular growth continuously stimulated but not to point of full maturation and ovulation
Follicles surrounded by hyperplastic thecal cells, luteinized in response to high LH levels (producing androgens)
Follicles last several months in immature phase then undergo atresia.
Tissue post atresia is also sustained by steady state of hormones and contributes to stromal tissue (producing androgens
Androgen peripherally converted to estrogen, causing augmented pituitary response to GnRH
Ultimately resulting in elevated LH and depressed FSH
Causes of PCOS
No definitive cause known, some likely factors:
Excess insulin- causing increased androgen production by the ovaries
Chronic low grade inflammation- eating certain foods in predisposed people
Genetics- having a first degree relative with PCOS makes it more likely
Exposure to excess androgens during fetal development- may cause male-pattern abdominal fat, increased insulin resistance, low grade inflammation
Complications of PCOS
Abnormal uterine bleeding
Infertility (secondary to anovulation)
Increased risk endometrial cancer
(from continuously high levels estrogen)
Increased CRP (cardiovascular dz marker)
Metabolic syndrome with increased risk cardiovascular disease
Higher incidence Type 2 DM, HTN, HLD
Increased risk NASH (nonalcoholic steatohepatitis)
OSA-(obstructive sleep apnea)
Treatment of PCOS: Irregular bleeding
Needing contraception? Oral contraceptives
Does not desire contraception? Provera daily x 5 days q2months to effect endometrial shedding (decreased risk endometrial hyperplasia and adenocarcinoma from unopposed estrogen)
treatment of PCOS: hirsutism
Oral contraceptive suppress ovarian and adrenal production of androgens and decrease hirsutism
Can also use corticosteroids for same result
Treatment of PCOS: desired pregnancy
Evaluate for other causes
Clomiphene (risk of ovarian hyper stimulation)
Second line can use purified human FSH
Endometriosis is:
Ectopic endometrium i.e. “internal menstruation”
Requires laparoscopy +/- biopsy for diagnosis
Activity is more important than appearance
Symptoms do not always correlate with grading
Symptoms of Endometriosis
The Classic Triad…
Dysmenorrhoea
Dyspareunia
Infertility
But consider also…
Pre menstrual staining Pain with defaecation during menstruation Intermenstrual pain Disordered cycles Family history
Diagnosis of Endometriosis
A Careful History (The most important) Rule out other Causes of Symptoms (The next most important) Examination (not much help) Ultrasound (of little value) MRI (useful for rectovaginal deposits) Laparoscopy (The gold standard) Serum CA125 (Lacks sensitivity) Iridology (a good guess!)
Differential Diagnosis when endometriosis is suspected
Primary Dysmenorrhoea
Irritable Bowel Syndrome
Ovulation Pain
Pelvic Inflammatory Disease
Psychosexual Problems
Aetiology of endometriosis
Two Main Theories:
Retrograde menstruation
Peritoneal metaplasia
Predisposing Factors: Familial predisposition Disordered immunity Environmental toxins Recurrent ovulation Infertile partner Obstructed menstrual flow
Principles of Management - endometriosis
When the Problem is Pain – Use Medical Rx
When the Problem is Infertility – Use Surgical Rx
When there is no Problem – Use no Rx
Medical Therapy Options for endometriosis
Progestins
COC (best in continuous form)
Provera or Norethisterone
The Mirena IUS
Danazol & Gestrinone
GnRH agonists +/- Add Back Therapy
A question of side effects
Cochrane Conclusions- endometriosis
Oral & rectal Chinese Herbal Medicine better than Danazol in both pain reduction and shrinkage of masses
Auricular acupunture effective in pain relief
Inconclusive evidence that NSAIDs are any better than pacebo
But side effects certainly can occur
COC as effective as GnRHa in control of dysmenorrhoea 6m after therapy but GNRHa better in terms of dyspareunia
Oral Provera 100 mg daily more effective than placebo (but not Dyhydrogesterone). IM route no better
GnRHa are no more effective than Danazol and side effects are more frequent
Laparoscopy with diathermy is more effective than just laparoscopy
For up to 12m after for pain
For conception (OR 1.66, CI 1.09-2.51)
There is no advantage from pre operative medical Rx but one small trial showed less pain if a Mirena is provided after surgery (OR 0.14, CI 0.02-0.75)
There is a risk of symptom recurrence if HRT with E2 is used after pelvic clearance
What is Infertility?
After 12 months of regular sex without contraception…
85 – 90% of couples will achieve pregnancy
Another 5% will be pregnant in the next 12 months
The age of the woman has a major influence
most “infertility” is really subfertility Or failing to conceive when the couple expect to
They expect to “switch on” fertility in the same way that contraception switches it off
Principal Causes of Infertility
Ovulation problem Sperm Problem Tubal problem Cervical factor Endometriosis
infertility- Taking the history
Do not ask “How long have you been trying to get pregnant”
Ask instead: “How long have you been in your current relationship”
What methods of contraception or avoiding pregnancy have you used and…
When did you stop using it?
Have you ever been pregnant?
Or tried in any previous relationship?
Have you ever fathered a pregnancy before (or tried in any other relationship).
Has that person subsequently proven fertile (become pregnant or fathered a pregnancy) in any subsequent relationship(s)?
Infertility Questions
Have you ever been treated for inflammation of the pelvis or tubes? Chlamydia?
A sexually transmitted infection?
Genital Herpes? Wart virus? Pre-cancer of the cervix?
Do you know if any of your partners have been treated or suffered from any of these conditions?
Have you ever used an intra uterine contraceptive device?
When you say your periods are “irregular” does that mean that they are coming more or less often than once in each four weeks?
How much earlier? How much later?
Most patients with “regular” cycles will be ovulating normally
How often is intercourse occurring?
This is better than…
How often are you trying each month!
Do either of you have any problems?
Coital problems are rarely a cause of infertility
But impotence is a common problem in older males
Who may have some difficulty admitting to this problem
Tests of Ovulation
A basal body temperature chart (BBT)
- Accurate body temperature measured once daily after >8 hours at rest
- Progesterone (released only after ovulation) raises BBT by 0.3 – 0.50C
S Progesterone luteal phase of the cycle
- Preferably 7 days before menstruation
LH surge in urine
- False positives can occur
Endometrial biopsy 2nd half of the cycle
- Look for secretory changes on histology
Tests of Tubal Patency
Hysterosalpingogram
- Passage of radio-opaque dye from the cervix with pressure and fluoroscopy or still images
Laparoscopy with dye studies
- The best test because it involves direct observation
- And the only way of diagnosing endometriosis
All of these tests have potential for therapy if there is minor tubal obstruction
- And diathermy of minimal endometriosis reduces “reproductive toxins”
Testing the Cervical Factor
Requires careful cycle timing
Because it has to be done when the cervical mucous is receptive
This is Day 12 or 13 in a 28 day cycle
Take a sample of the mucous 4 – 20 hours after intercourse…
And examine microscopically for evidence of progressively motile sperm
This is a good backup test for men who cannot or will not produce a semen sample
Semen Analysis
Requires 48 – 72 hours of abstinence
Must collect the whole semen sample
Must be examined within 1-2 hours kept at room temperature
Count
- Should be > 20 million/ml
Motility
- Should be >50%
Morphology
- Should be >15% completely normal
If abnormal it should be repeated
