Dysfunctional Uterine Bleeding and Amenorrhea Flashcards by Emily Prazak

Describe normal menses

2-7 days
80 ml (2.5 oz)
cycle length 24-35 days
change pad/tampon over 3 hours
use fewer than 21 pads per cycle
seldom need to change pad overnight
clots less than 1 inch in diameter

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What are the three phases of a normal menstrual cycle?

menses (day 0-8)
proliferative phase (follicular) (day 8-14)
Secretory/luteal (day 14)

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Which hormone predominates during proliferative?

estrogen

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Which hormon predominates during the secretory?

progesterone

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What is menorrhagia?

normal intervals, but prolonged or excessive

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What is metrorrhagia

irregular and more frequent intervals, amount is variable

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What is menometrorrhagia?

prolonged and variable amounts occurring irregularly and more frquently than normal

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What is oligomenorrhea?

menses at intervals greater than 35 days

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What is polymenorrhea?

menses at intervals less than 21 days

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What is intermenstrual bleeding?

bleeding between regular periods

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What is midcycle spotting and why does it happen?

spotting just prior to ovulation due to declining estrogen

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What is postmenopausal bleeding?

bleeding in a woman at least 1 year after cessation of cycles

this is abnormal!

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What is amenorrhea?

lack of bleeding for 6 months or longer

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What is the overal prevalence of amenorrhea not related to pregnancy, lactation or menpause?

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What is primary amenorrhea?

no spontaneous utering bleeding by age 14 in the absence of secondary sexual characteristics or by age 16 with otherwise normal development

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What is secondary amenorrhea?

the absence of menstrual bleeding for 6 months in a woman with prior regular menses or for 12 months in a woman with previous oligomenorrhea

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What are the organ sources of secondary amenorrhea?

ovary - 40%
hypothalamus - 35%
pituitary - 19%
uterus - 5%
other - 1%

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Secondary amenorrhea has a higher prevalence in what subgroup of women?

competitive athletes

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What are the 4 causes of disorders of the outflow tract leading to amenorrhea?

imperforate hymen
ashermans syndrome
mullerian anomalies
testicular feminization (androgen insensitivity)

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WHat is Ashermans syndrome?

destruction of endometrium with scarring preventing bleeding - due to D&C, ablation, severe infection

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What are the potential causes of disorders of the ovary leading to amenorrhea?

turner syndrome
mosaicism
gonadal agenesis/dysgenesis
resistant ovary syndrome
premature ovarian failure - prematur menopause
radiation/chemo
17 alpha hydroxylase def.

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What is turners syndorme

46,X)
their follicles undergo apoptosis resulting in high FSH, and low estrogen

so don’t have a cycle

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What are the possible causes of disorder to the Anterior PItuitary resulting in amenorrhea?

pituitary adenoma - prolactinoma
empty sella syndrome
sheehans syndrome
hypopituitarism
hypothyroid
infiltrative damage from sarcoid or hemochromatosis
medications like opiates and phenothiazines

What are the possible causes of disorder to the hypothalamus leading to amenorrhea?

tumors
craniopharyngiomas
stress leading to increased cortisol and decreased FSH/LH
hypothalamic amenorrhea with high corticotropin releasing hormone which inhibits GnRH

What are the general causes of that thypothalamic amenorrhea?

eating disorders, weight loss, exercise, Kallmanns syndrome, diseases, psychosocial stress

What is Kallmann syndrome?

congenital GnRH deficiency

What labs do you do for evaluation of amenorrhea?

hCG - rule out pregnancy! Prolactin FSH TSH add total testosterone, 17-hydroxyprogesterone and DHEA-S if there are signs of hypogonadism

Describe the progesterone withdrawl bleed test.

you give methylprogesterone 10 mg for 10 days. when it stops, they SHOULD have a withdrawal bleed. If they don't, there's something wrong

What imaging might you do for amenorrhea?

Head CT or MRI to rule out tumor or pituitary issue

If they have a normal withdrawl bleed after progesterone , with a normal prolactin and normal TSH, where is the issue?

the ovary - anovulation

Normal withdrawl bleed, low FSH/TSH?

hypothalamic amenorrhea

Normal withdrawal bleed with high FSH/LH?

ovarian failure

What is the main cause of abnormal bleeding?

pregnancy!!! | including ectopic, miscarriage, placenta previa, gestational trophoblastic disease (molar)

What is the second most common cause of abnormal bleeding?

steroids, thyroid meds, hromones, anticoagulations, SSRIs, some herbs like ginko, ginseng, and soy

What are some benign genital tract pahtology causing abnormal bleeding?

Myoma, Adenomyosis, Endometriosis, Endometrial/cervical polyp, PID, Infection, Trauma, Vascular abnormality, Foreign body

What are some malignant genital tract pathology leading to abnormal bleeding?

Carcinoma of the reproductive tract, Endometrial hyperplasia (pre- malignant changes)

What are some systemic diseases that can cause abnormal bleeding

Adrenal changes, blood dyscrasias, coagulopathies, hepatic disease, PCOS, pituitary adenoma, Renal, Thyroid

What are the main iatrogenic cuases of abnormal bleeding?

IUD | Inplanon

What would be some causes of heavier ovulatory bleeding?

increased rate of blood loss resulting from vasodilatiln of vessels physical lesions like polyps or fibroids decreased tone related to prostaglandins infeciton bleeding disorders!! factor deficiencys, leukemia, platelet disorders, VwF def

What is the most common disease affecting ovulation?

PCOS - 6% of women

Unovulatory bleeding is more concenring than ovulatory bleeding. WHat does it suggest?

a hormonal issue - usually progesterol deficient/estrogen dominant more common in the extremes of reproductive years you build up your lining until it becomes unstable and then sheds whenever it wants to.

When should you evaluate an adolescents?

if consistently more than 3 months between cycles irregular cycles for more than 3 years (should start getting regular within 2 years of start)

When should you evaluate an adult woman with issues?

suspected recurrent ANOVULATORY cycles

WHen should you evaluate a perimenopausal woman?

increased volume or duration of bleeding periods more oten than every 21 days intermenstrual spotting (can be a sign of endometrial cancer) poistcoital bleeding (usually means a functional pathology)

What hsould you do on physical exam for this?

``` height weight vitals body fat distribution tanner staging thyroid palpation bruising jaundice pelvis exam - tenderness, masses, bleeding, trauma, irritation, discharge, polyps ```

What labs should you do for abnormal bleeding?

preg test pap smear STD screening CBC, PTT, INR, platelets prolactin if oligomenorrhea or galactorrhea androgen levels if other signs of virilization endometrial biopsy

What imaging can you do for abnormal bleeding?

pelvic US

What are the risks for endometrial cancer?

``` obesity nuliparity previous tamoxifen therapy unopposed estrogen therapy diabetes increased with age ```

WHen should you consider an endometrial biopsy in an adolescent?

obese with 2-3 years of utnreated anovulatory bleeding

When should you consider an endometrial biopsy in a woman less than 35 with risk factors?

``` chronic anovulation diabetes family history fo colon cancer infertility nulliparity obesity tamoxifen use ```

Endometrial biopsy can miss up to what percent of focal lesiosn?

18%

If you find hyperplasia, what shoul dyou do? If you find atypia, what should you do?

hyperplasia - cycle with progestins and recheck atypia - refer to GYN

What tests would be more specific for leiomyoma and focal masses than endo biopsy?

endometrial ultrasound

What can you influse into the uterus to improve the US sensitivity?

saline

Endometrial lining should be less than what size?

less than 5 mm

If they're having acute, heavy bleeding, what is the first step?

make sure they are hemodynamically stable - IV lfuids, high dose IV estrogen, blood products if needed, consider D&C to stop bleeding

If they're hemodynamically stable, what are the options?

meds - OCPs, NSAIDS, tranexamic acid - which is an antifibrinolytic, GnRH agonist, Antifibrinolytic agents