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Endocrine > Endometriosis and Amenorrhea > Flashcards

Endometriosis and Amenorrhea Flashcards

1
Q

What is the clinical presentation of Endometriosis?

A
  1. Chronic Pelvic Pain
  2. Accompanied by infertility 30-50% patients
  3. Definitive diagnosis requires surgical visualization (laparoscopy).
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2
Q

What does laparoscopy confirm in terms of Endometriosis?

A

Presence of endometrial tissue outside uterus.

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3
Q

What are the characteristics of chronic pelvic pain?

A
  1. May be cyclic or acyclic
  2. May include painful intercourse
  3. May include dysmenorrhea
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4
Q

What is the incidence of Endometriosis in reproductive age women?

A

6-10%

  • 35-50% of women w/ chronic pelvic pain
  • 38% of women w/ infertility.
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5
Q

Is there a genetic component to Endometriosis?

A

6 fold greater incidence in women w/ mother or sister w/ disease.

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6
Q

What is the Etiology of Endometriosis?

A
  1. Retrograde menstrual flow (most pop.)
  2. Vascular/Lymphatic spread
  3. Immunologic disorder
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7
Q

What is the pathophysiology of Endometriosis?

A
  1. Lesions usually restricted to pelvic cavity.
  2. Lesions generate local inflammation
  3. Adhesions form between organs.
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8
Q

During endometriosis when there is generation of local inflammation, what is that a response to?

A
  1. Estrogen and Progesterone.

2. Pain can be greatest during menstruation.

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9
Q

During endometriosis when there is adhesions between organs, what does that do?

A

Restricts movement of uterus, intestines causes pain w/ intercourse and bowel movements.

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10
Q

How is the severity of endometriosis classified?

A

Stages I-IV. BUT does not relate to pain, infertility, or therapeutic outcomes.

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11
Q

What are the 3 surgical laparoscopy methods?

A
  1. Implants excised
  2. Implants burned away
  3. Implants removed w/ laser.
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12
Q

Which surgical laparoscopy method yields the best results?

A

Excision of lesions –> reduction in pain.

Recurrence rate 20% at 2 yrs, 40-50% 5yrs

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13
Q

Which surgical laparoscopy method is preferred in restoring fertility?

A

Excision of lesions.

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14
Q

Which is the only method that eliminates the problem of endometriosis?

A

Ovarectomy +/- hysterectomy.

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15
Q

What are the 5 pharmacological treatments of endometriosis?

A
  1. NSAIDs
  2. CHCs
  3. Progestins
  4. GnRH agonists
  5. Danazol
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16
Q

What is the primary goal of pharmacological therapy in endometriosis?

A
  1. Reduce Pelvic Pain.
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17
Q

What is the first choice in pharmacological treatments of Endometriosis and what are the limitations?

A
  1. NSAIDs and CHCs

2. Do no eradicate lesions or improve fertility.

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18
Q

Why are CHCs a treatment for Endometriosis?

A
  1. Establishing hypoestrogenic (cyclic CHCs) or Anovulatory (continuous CHCs) state.
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19
Q

Why are Progestins a treatment for Endometriosis?

A
  1. Establish anovulatory state w/ amenorrhea, but may result in prolonged infertility.
  2. Well tolerated, but can cause breakthrough bleeding, weight gain, fluid retention, mood changes.
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20
Q

Which progestins are effective for endometriosis?

A
  1. Oral and Depot medroxyprogesterone
  2. Norethindrone
  3. Levonorgestrel IUD
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21
Q

Why are GnRH agonists a treatment for endometriosis?

A
  1. Establish an anovulatory/menopausal state by inhibition of FSH and LH release from anterior pituitary.
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22
Q

What is the normal administration of GnRH agonists?

A

Normally administered for 6 months.
85-100% effective but recurrence >50% 5yrs.
Bone loss is reversible up to 6 months.

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23
Q

What are the adverse effects of GnRH agonists?

A

Bone loss, vasomotor symptoms, vaginal dryness, insomnia.

Addback therapy decreases AE.

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24
Q

What should patients supplement with while taking GnRH agonists?

A

Calcium
0.5-1 g/d
AND exercise.

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25
Q

When is GnRH agonists contraindicated?

A

For Adolescents due to propensity to cause bone loss.

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26
Q

What are the 3 GnRH agonists and their formulations?

A
  1. Leuprolide - IM q3months
  2. Goserelin - SQ monthly
  3. Nafarelin - Intranasal BID
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27
Q

Why is Danazol a treatment for endometriosis?

A

It is a steroid w/ weak androgenic effects that suppress FSH and LH release.

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28
Q

What other effect does Danazol have that may not be good?

A

Immunosuppresive activity.

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29
Q

What is the efficacy of Danazol?

A

treatment of 6 mo, 80-90% symptom relief.

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30
Q

What are the limitations of Danazol?

A

Androgenic effects cause:

  1. weight gain, acne, hot flashes, hirsutism.
  2. Increased LDL
  3. Teratogenic
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31
Q

When is Danazol contraindicated?

A

In women with hyperlipidemia or liver disease.

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32
Q

What is Amenorrhea?

A

Absence of menses.

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33
Q

How is primary amenorrhea characterized?

A

NO Previous menses (

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34
Q

How is secondary amenorrhea characterized?

A

Absence of menses for 6 mo (up to 4% of women)

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35
Q

When is secondary amenorrhea most common?

A
  1. Women
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36
Q

What are the main etiologies of Amenorrhea?

A
  1. Unrecognized pregnacy.
  2. Hypothalamic/pituitary suppression.
  3. Anovulatory amenorrhea.
  4. Premature ovarian insufficiency.
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37
Q

What is the most common cause of amenorrhea?

A
  1. Unrecognized pregnancy.
38
Q

How is hypothalamic/pituitary suppression involved in Amenorrhea?

A
  1. tumor
  2. anorexia, excessive exercise, obesity
  3. Thyroid disease
  4. Hyperprolactinemia.
39
Q

What is hyperprolactinemia?

A

When excess prolactin suppresses GnRH release which decreases FSH/LH.

40
Q

What are causes of Anovulatory amenorrhea?

A
  1. PolyCystic Ovarian Syndrome (PCOS)
  2. Ovarian tumors
  3. Congenital Adrenal Hyperplasia
41
Q

What is Polycystic Ovarian Syndrome (PCOS)?

A

Most common endocrine disorder in reproductive age women 5-10%.
Androgen Excess.

42
Q

What is congenital adrenal hyperplasia?

A

Excessive androgen production.

43
Q

What are characteristics of premature ovarian insufficiency?

A
  1. Genetic, Idiopathic, autoimmune
  2. LOW estrogen, HIGH FSH
    Affects 1% of women before 40.
44
Q

What Progestins can be used to identify cause of amenorrhea?

A

Oral (preferred) or IM MPA for 10-14 days.

45
Q

When progestins are given to identify cause of amenorrhea what happens when estradiol levels >50pg/ml?

A

Withdrawal bleeding will occur upon cessation.

1. Ammenorrhea is “anovulatory” - PCOS

46
Q

When using progestins to identify cause of amenorrhea: what is indicated when there is a failure to induce menses?

A

Low Estrogen Levels.

  1. Ovarian dysfunction/Premature menopause (low estrogen)
  2. Hypothalamic/Pituitary dysfunction, hyperprolactemia (Low FSH/LH)
47
Q

When using progestins to identify cause of amenorrhea: what do uterine problems indicate?

A

Asherman’s syndrome - uterine adhesions, outflow problems.

NORMAL estrogen levels

48
Q

How do you treat Hypothalamic amenorrhea?

A

aka hypoestrogenic

  1. Estrogen +/- Progestins
    - OCs, Conjugated equine estrogen, Estradiol patch.
    - Reduces risk of osteoporosis and other signs of insufficient estrogen.
49
Q

What level of blood prolactin indicates hyperprolactinemia?

A

> 100 ng/ml indicates pituitary adenoma (prolactinoma)

50
Q

What are other causes of Hyperprolactinemia?

A

OCs, Antipsychotics, antidepressants.

-Antagonize dopamine release/effect - disinhibiting prolactin release.

51
Q

Examples of dopamine receptor blockers that can cause hyperprolactinemia are?

A
  1. Risperidone
  2. Chlorpromazine
  3. Haloperidol
52
Q

Examples of Imipramines & SSRIs that cause hyperprolactinemia are?

A
  1. Amitriptyline

2. Fluoxetine

53
Q

Other drugs that can cause hyperprolactinemia?

A

alpha-methyldopa
opiates
H2 antagonists.

54
Q

What do you treat hyperprolactinemia with?

A

Dopamine agonists

1. Cabergoline preferred twice wk.

55
Q

What is the mechanism of Cabergoline?

A

Prolactin increases DA secretion in hypothalamus, which suppresses Prl secretion from anterior pituitary. (Feedback inhibition)

56
Q

What is PolyCystic Ovarian Syndrome (PCOS) also known as?

A
  1. Stein-Levanthal Syndrome
57
Q

What can PCOS present as?

A

Amenorrhea
Menorrhagia
Anovulatory Bleeding

58
Q

What is Menorrhagia?

A

Excessive bleeding >80ml or >7days

59
Q

What is Anovulatory bleeding (non-cyclical)?

A

Corpus luteum does not form
Progesterone not secreted.
Unopposed production of estradiol
Overgrowth of endometrium

60
Q

What is PCOS considered to be a disorder of?

A

Androgen Excess

61
Q

What is PCOS a risk factor for?

A
  1. Metabolic syndrome
  2. Type 2 diabetes
  3. Dyslipidemia
  4. CVD
62
Q

What are characteristics of PCOS?

A
  1. Menstrual abnormalities.
  2. Infertility
  3. Hyperandrogenism/virilization
  4. Obesity (40-50%)
  5. Symptoms of diabetes/IR
  6. Acanthosis nigricans
  7. Polycystic ovaries.
63
Q

What is the most frequent cause of anovulatory infertility?

A

PCOS

64
Q

What are risk factors for PCOS?

A

Family history of PCOS

Central Obesity

65
Q

How is PCOS diagnosed?

A
  1. Elevated LH/FSH ratio >2:1 is often present.

2. Elevated Plasma testosterone

66
Q

What does elevated LH/FSH do?

A
  1. Increased ovarian androgen production.
  2. arrest follicular development - cysts
  3. Adipose cells contribute to androgen aromatization to estrogen.
    - elevated estrogen - suppresses FSH.
67
Q

What does elevated plasma testosterone do?

A
  1. Total T may be normal but FREE T is 2X in PCOS.
  2. Lowered sex hormone binding globulin (SHBG)
  3. Must exclude androgen-secreting tumors.
68
Q

What are the goals of treatment for PCOS?

A
  1. Reduce ovarian androgen secretion and restore normal hormonal cycle.
    - normalize endometrium
    - Restore fertility
  2. Reduce Insulin Resistance
    - weight loss
    - Metformin
69
Q

What is the first choice treatment for PCOS?

A

COCs.

70
Q

What do COCs do for PCOS?

A
  1. restore normal hormonal cycle
  2. Increase SHBG to decrease free T.
  3. Reduce ovarian hormone production
  4. Decrease hyperandrogenima, hirsutism, and T by 50%
71
Q

What are contraindications for using COCs for PCOS?

A

Not appropriate if prego is goal.
Not appropriate if estrogens containdicated.
Androgenic Progestogens should be avoided (desogestrel preferred)

72
Q

When is estrogens contraindicated?

A

Breast/Uterine/endometrial/ovarian cancer, CV disease.

73
Q

How can Progesterone only treatment help PCOS?

A
  1. Suppresses ovulation and prevents endometrial hyperplasia.
  2. Fewer adverse effects than COCs
74
Q

When is progesterone only treatment for PCOS especially appropriate?

A

Menorrhagia b/c can cause amenorrhea

75
Q

What progesterone only treatments are used for PCOS?

A
  1. Oral MPA (NOT FDA Approved)

2. Levonorgestrel IUD

76
Q

What is to be noted when Oral MPA is used for PCOS?

A
  1. taken 12-14 days to induce withdrawal bleeding
  2. Prevents endometrial hyperplasia and reduces risk of endometrial cancer.
  3. Does NOT provide contraception
  4. Has some androgenic activity (hirsutism)
77
Q

What can Metformin/TZDs do for PCOS?

A
  1. Improve insulin sensitivity
  2. Increase SHBG levels
  3. Increase ovulatory rates
  4. Pioglitazone and rosiglitazone are prego C
78
Q

What Anti-androgens are used in PCOS?

A

Glucocorticoids, Sprionolactone, flutamide

NOT FDA APPROVED

79
Q

How can Glucocorticoids help PCOS?

A
  1. Suppress adrenal androgen production

2. Does NOT restore fertility.

80
Q

How can Spironolactone and Flutamide help PCOS?

A
  1. Androgen receptor antagonists
  2. Used in conjunction with COCs
  3. Flutamide more effective (but hepatic tox)
81
Q

What are the treatments for Infertility due to PCOS?

A
  1. Clomiphene

2. Metformin

82
Q

How can Clomiphene help infertility in PCOS?

A
  1. Estrogen receptor antagonist (SERM) increases FSH and LH induce ovulation.
  2. 50mg/d for 5 days, on day 3-5
  3. Typically after MPA treatment to induce WB
  4. Dose can be 250 mg/d
  5. **Increases chance of twins 1-10%
83
Q

How can metformin help infertility in PCOS?

A
  1. Increases ovulatory rates but is less effective than clomiphene.
  2. effective in clomiphene resistant patients
  3. Use during prego decreases miscarriage rates.
84
Q

What is Premature Ovarian Insufficiency (POI)?

A
  1. Sex steroid deficiency, amenorrhea, and infertility in women under 40.
85
Q

What are characteristics of POI?

A
  1. Affects 1% of women under 40

2. >4 mo amenorrhea, FSH >40 IU/L (Normal

86
Q

What does POI increase risk for?

A

Osteoporosis and CVD

87
Q

Is POI early Menopause? and WHY?

A

NO

Menopause - follicle depletion
POI - follicles often present sex steroids low

88
Q

What are causes of POI?

A

Autoimmune disease, genetic (Turner syndrome, Fragile X)

89
Q

What are clinical indications of POI?

A
  1. Hx of Oligomenorrhea (light) or Anovulatory bleeding (Prodromal POI)
  2. Hot flashes, night sweats, mood change
90
Q

What is the treatment for POI?

A
  1. Begin w/ low dose estrogen ramping up to1.25 mg/d CEE. (Transdermal ok)
  2. Progestogens added fro 12-14 d/mo
  3. T replacement may also be appropriate.
91
Q

Does replacement of estrogen or OCs prevent ovulation in women with elevated gonadotropins? (FSH+LH)

A

NO

Endocrine (9 decks)

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