Dysfunctional Uterine Bleeding and Amenorrhea Flashcards
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
What are the three phases of a normal menstrual cycle?
menses (day 0-8)
proliferative phase (follicular) (day 8-14)
Secretory/luteal (day 14)
Which hormone predominates during proliferative?
estrogen
Which hormon predominates during the secretory?
progesterone
What is menorrhagia?
normal intervals, but prolonged or excessive
What is metrorrhagia
irregular and more frequent intervals, amount is variable
What is menometrorrhagia?
prolonged and variable amounts occurring irregularly and more frquently than normal
What is oligomenorrhea?
menses at intervals greater than 35 days
What is polymenorrhea?
menses at intervals less than 21 days
What is intermenstrual bleeding?
bleeding between regular periods
What is midcycle spotting and why does it happen?
spotting just prior to ovulation due to declining estrogen
What is postmenopausal bleeding?
bleeding in a woman at least 1 year after cessation of cycles
this is abnormal!
What is amenorrhea?
lack of bleeding for 6 months or longer
What is the overal prevalence of amenorrhea not related to pregnancy, lactation or menpause?
3%
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
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
What are the organ sources of secondary amenorrhea?
ovary - 40% hypothalamus - 35% pituitary - 19% uterus - 5% other - 1%
Secondary amenorrhea has a higher prevalence in what subgroup of women?
competitive athletes
What are the 4 causes of disorders of the outflow tract leading to amenorrhea?
imperforate hymen
ashermans syndrome
mullerian anomalies
testicular feminization (androgen insensitivity)
WHat is Ashermans syndrome?
destruction of endometrium with scarring preventing bleeding - due to D&C, ablation, severe infection
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.
What is turners syndorme
46,X)
their follicles undergo apoptosis resulting in high FSH, and low estrogen
so don’t have a cycle
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
